The findings of the re-licensure survey, conducted 04/01/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with H refer to the Home and Community Based Services Rules OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 04/04/24, conducted 08/26/24 through 08/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 04/04/24, conducted on 10/18/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 01/20/24 service plan, 01/07/24 through 04/01/24 progress notes, physician communications, and incident investigations were completed.

The resident was noted to be independent with most ADLs and ambulated on his/her own. The resident was unsteady on his/her feet and did have occasional falls. The resident could make some needs known and answer simple questions.

Review of the resident's records showed the following:

* An incident report dated 01/06/24 indicated the resident was in another resident's apartment and was hit with a shoe;

* An incident report dated 01/23/24 indicated the resident was found on the floor naked, s/he stated their shoulder was painful, and an abrasion was noted to the right shoulder; and

* An incident report dated 03/27/24 indicated the resident was found in the apartment of his/her companion resident. Resident 6 was found with a skin tear to the arm and a red mark under his/her left eye.

There was no additional information regarding the incidents and no reports were made to the local SPD unit.

Staff 1 (Administrator) was asked to report the incidents and provided confirmation of the reports prior to survey exit.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to promptly investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office, if abuse could not immediately be ruled out, for 3 of 5 sampled residents (#s 3, 4 and 6) with incidents or injuries of unknown cause. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia.

Interviews with staff and review of the resident's clinical record were completed, including most recent service plan dated 03/15/24, temporary service plans (TSPs), incident reports and progress notes.

The following was identified:

* An incident report was completed on 02/15/24 at 11:30 am indicating Resident 4 was found with a skin tear to the left forearm. Staff stated "we are not sure how she acquired this skin tear". When asked, the resident could not explain how the injury occurred.

There was no documented evidence the facility immediately reported the injury of unknown cause to the local SPD office. At the request of the survey team, the facility reported the incident to the local SPD and a confirmation was provided to the survey team prior to exit.

The need to ensure all injuries of unknown cause were reported to the local SPD office, unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 09/2020 with diagnoses including dementia.

The resident's clinical record was reviewed, including progress notes dated 01/05/24 through 03/27/24, incident reports, and temporary service plans, and staff were interviewed.

In a 02/18/24 progress note, written at 1:02 pm, staff documented "a red bruised area on the left side of the residents [sic] chin area" was noticed during breakfast. At that time staff wrote it was "unknown at this particular time how it occurred."

On 02/20/24 the bruise on the resident's face was investigated by Staff 2 (RN). She noted, "Caregivers on noc [overnight] shift heard and raced to a commotion and saw [resident] standing not too far from [another resident]. They report not seeing any physical activity upon arrival." She documented, "It is possible however inconclusive that [the other resident] hit [Resident 3] prior to the noc caregivers' arrival to the scene." Staff 2 documented abuse and neglect were ruled out.

There was no documented evidence the possible resident-to-resident altercation was reported to the local SPD office.

On 04/03/24 Staff 1 (Administrator) was directed to immediately report the possible resident-to-resident altercation to the local SPD office, and confirmation of the report was received on 04/03/24 at 10:39 am.

The need to ensure all incidents of abuse or suspected abuse are immediately reported to the local SPD office and promptly investigated to rule out abuse was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Resident #4, 6 and 3 were reported to the local SPD unit during survey.  All Incident Reports will be promptly investigated and reported when abuse or neglect can not be ruled out per regulation.  I.R.s will be reviewed M-F daily at morning meeting with RCC, RN, and Admin.  RN will investigate all I.R.s and document in electronic medical record.   Admin will report if abuse and neglect can not be ruled out.  Additionally, all staff will be inserviced on incident reporting policy.

Facility will conduct weekly I.R. meetings weekly for 5 weeks, bi-weekly for 4 weeks and then monthly continuosly.  

Administrator is responsible to monitor that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:

During the survey, 04/01/24 through 04/04/24, observations of the facility showed bingo was conducted daily, a bus ride was offered on Tuesday, and ball bounce was played on Wednesday afternoon. No additional activities were observed during survey. Multiple residents were observed throughout the day wandering the halls, asleep in the living room, or watching TV in the living room.

Review of the activity calendar showed three to five scheduled activities a day. All scheduled activities noted on the calendar were not observed during survey. Daily activities included snack and hydration pass and men's facial care. The men's facial care was observed to include shaving of male residents while in the living room.  

In an interview on 04/01/24, Staff 1 (Administrator) indicated the position of the activity aide was recently vacated and they were working to fill the opening.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings.

Activity calendar has been updated with social and recreational activities based on resident's individual and group interests.   Additionally, lobby bookcase has been utilized for holding textile activity books, games and fidget toys/books for carestaff to use when a resident does not want to participate in the group actvities.  These areas will be available for residents to enjoy at their leisure or with care staff assistance.   The Administrator will review the calendar monthly with the Activity Director prior to it being published.  Administrator will also monitor daily the activity calendar versus actual activity performed and the activity schedule for the day will be discussed at standup.  Administrator is responsible to see these corrections are completed and monitored.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, provided clear direction for staff, and were consistently implemented by staff for 3 of 6 sampled residents (#s 1, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 03/14/24, and progress notes, dated 01/22/24 to 03/26/24, were completed. Staff indicated the resident was dependent on staff for ADL care and required two staff for transfers.

The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not followed by staff in the following areas:

* Falls and safety interventions;

* Behaviors during care;

* Gait belt use and 1 person vs. 2 person transfers;

* Toileting;

* Activities;

* Grooming; and

* Mental health diagnoses.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/20/24, and progress notes, dated 01/07/24 to 04/01/24, were completed. Staff indicated the resident was able to complete several of his/her ADLs on his/her own. The resident required stand-by assist with bathing and occasionally toileting. The resident was able to ambulate and transfer on his/her own.

The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not implemented  by staff in the following areas:

* Falls and safety interventions;

* Resident-to-resident altercations;

* Relationship with room 9;

* PRN assistance with ADLs;

* Activities;

* Shower assistance; and

* Agitation, exit seeking for a "gig," and behaviors related to room 9.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 03/15/24, and progress notes, dated 01/03/24 through 04/01/24, were completed. Staff indicated the resident was dependent on staff for ADL care and required three staff for transfers.

The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not implemented by staff in the following areas:

* Three-person transfer assistance;

* Two-person assist for bed mobility, dressing, and hygiene cares;

* Tilt in space wheelchair with calf support strap;

* Pressure reducing boots on both feet at all times;

* Rolled blanket next to resident on open side of bed;

* Pressure reducing cushion in wheelchair;

* Arm protectors on at all times;

* Push fluids all shifts;

* Daily Foley catheter care instructions;

* Elevate heels/feet with pillows in bed;

* Ability to use call system;

* Straw in drinks;

* Fall history; and

* Location of pain.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.

Resident #1 care plan has been updated with resident specific direction for staff regarding falls and safety interventions, behaviors during care, gait belt use with 2 staff transfer, toileting, activities, and mental health diagnosis.

Resident #6 care plan has been updated with safety interventions and falls,res-to-res altercations, behaviors with room #9, relationship with room #9, PRN assistance with ADLs, activities, shower assistance and agitation, exit seeking and what it looks like when he has to "get to a gig".

Resident #4 care plan has been updated to accurately reflect residents needs in 2 person transfer, 2 person bed mobility, tilt-n-space wheelchair with calf support strap, pressure reducing boots on both feet at all times, elevate feet with pillows in bed, rolled blanket next to resident on open side of bed, pressure reducing cushion in wheelchair, arm protectors at all times, push fluids all shifts, daily catheter care instructions, ability to use call light system, fall history and location of pain.   Administrator will audit all care plans when completed to ensure a reflection of resident's current care needs using QAPI audit tool.   The results of the audit will be brought to the next 3 QAPI meetings.  Administrator is responsible to see the corrections are completed and monitored. RN Consultant to audit the service plans of 2 residents per month.  

3. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 03/14/24, and progress notes, dated 01/22/24 through 03/26/24, were completed.

a. The resident experienced multiple short-term changes of condition without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas:

* New move in;

* Injury and non-injury falls;

* Wheelchair changes;

* Red marks to the face; and

* Medication changes.

b. Staff indicated the resident had increased confusion and weakness when s/he first came to the facility. The resident came after hip surgery and repeatedly attempted to get up out of the geri chair s/he was seated in. The resident had poor safety awareness and required full assistance with ADL care and transfers. Review of incident reports and investigations showed the following:

* An incident report dated 01/24/24 indicated the resident slid out of the chair and was found yelling for help. No injury was noted.

* An incident report dated 02/13/24 indicated the resident was found on the floor, with no injuries noted.

* An incident report dated 03/02/24 indicated the resident scooted out of the chair and tipped forward. The resident repeatedly attempted to get out of the chair on that day. There were no injuries noted.

* An incident report dated 03/14/24 indicated the resident was found on the floor in the lobby. The resident fell out of the wheelchair, no injury was noted. A new cushion for the wheelchair would be ordered to help keep the resident from scooting forward.

* An incident report dated 03/19/24 indicated the resident was found on the floor in another resident's apartment. There was no injury noted, and staff were able to assist the resident out the apartment.

* An incident report dated 03/21/24 indicated the resident was found on the floor in his/her room, next to the bed. The bed was in the low position, and no injuries were noted to the resident.

There was no documentation in the resident's record the facility had completed investigations of the incidents to determine the cause, minimize reoccurrence, develop and implement interventions and to re-evaluate existing interventions for appropriateness and effectiveness.

In interview on 04/01/24, the resident was unable to answer questions regarding the falls.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, interventions were evaluated for effectiveness and provided clear resident-specific directions to staff was discussed with Staff 1, Staff 2, and Staff 3 (RCC) on 04/03/24 and 04/04/24. The staff acknowledged the findings.

4. Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/20/24, and progress notes, dated 01/07/24 through 04/01/24, were completed.

The resident experienced multiple short-term changes of condition without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas:

* Resident-to-resident altercations;

* Body aches;

* Sexual behaviors in common areas;

* Relationship and agitation with another resident; and

* Medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia, cerebral vascular accident, and post-polio syndrome.

The resident's clinical record, including progress notes, dated 01/13/24 through 04/01/24, and incident reports, were reviewed, and interviews with staff were conducted. The following was identified:

* An incident report dated 02/12/24 reported Resident 4 had a fall from bed and sustained a skin tear to the left elbow and a red mark on his/her left cheek bone. A rolled blanket intervention was determined to be placed on the side of the resident to help remind him/her of where the edge of the bed was; and

* An incident reported dated 03/14/24 reported the resident had sustained a skin tear to the left leg during a transfer from bed to the wheelchair.

There was no documented evidence staff had evaluated the effectiveness of interventions and/or determined if additional actions or interventions were indicated, communicated actions or interventions to staff on all shifts, or monitored progress and effectiveness of  interventions weekly through resolution.

The need to ensure interventions were evaluated  for effectiveness, additional actions or interventions were determined as indicated and communicated to staff on all shifts, and any new interventions were monitored for effectiveness weekly through resolution for short-term changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure there was documented monitoring at least weekly to resolution for short-term changes of condition, interventions were evaluated for effectiveness, and resident-specific interventions were determined, communicated to staff on all shifts, and implemented for 4 of 6 sampled residents (#s 1, 4, 5, and 6) reviewed with changes of condition.

1. Resident 5 was admitted to the facility in 01/2024 with diagnoses including dementia.

The resident's service plan, dated 02/16/24, progress notes, dated 01/02/24 through 04/01/24, temporary service plans, and incident reports were reviewed. Staff were interviewed. The following was identified:

The resident experienced multiple changes of condition:

* 01/04/24 and 01/05/24 - multiple medications refused;

* 01/11/24 - new diet;

* 01/17/24 - report of a person entering his/her room when s/he was sleeping, laying next to him/her on the bed, and having "fought" the person;

* 01/21/24 - medication refusals;

* 02/16/24 - placed on alert charting upon returning to the facility the morning following an overnight visit with family;

* 02/26/24 - medication change; and

* 03/04/24 - medication changes.

There was no documented evidence these short-term changes of condition were monitored through resolution.

In addition, the resident experienced a severe weight gain, which was identified on 02/15/24. The significant change of condition was assessed by the facility RN, who determined the resident would be weighed weekly to monitor the weight gain.

There was no documented evidence weekly weights were implemented for the resident.

The need to implement determined interventions and monitor changes of condition through resolution, with progress noted at least weekly, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Short term change of conditions will be reviewed daily during the clinical meeting Monday-Friday and audited weekly by RCC to ensure monitored through resolution.   Med Tech staff will be inserviced on 24 hour report and alert charting policies.  RCC will obtain weights and implement interventions with RN managing assessments. RN and RCC will evaluate at the end of each month to ensure all interventions and documentation has been monitored through resoultion. RN will be responsible to see that the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure they staffed based on their Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to:

Review of the ABST, the March and April 2024 staffing schedule, and the posted staffing plan was completed on 04/01/24 and 04/02/24. The facility was not staffing to or exceeding the indicated number of staff calculated by the tool for the day and evening shifts.

The need to ensure the facility was staffed according to the ABST generated staff hours was discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings.

ABST was updated to accuratley reflect residents needs.  RN and RCC will update all residents monthly and at the time of a significant change.  After each update RCC will calculate care staff needs for each shift, day and staff based on those numbers. This will be evaluated monthly for 3 months and brought to next two Q.A.P.I. meetings.  Administrator is responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted on alternating months, for all shifts, and that all required components were documented on the fire drill form in accordance with the Oregon Fire Code. Findings include, but are not limited to:

Fire and life safety records, reviewed between 10/2023 and 03/2024, showed documentation was lacking in the following areas:

* The escape route used;

* Problems encountered;

* Evidence of alternate routes used;

* Evacuation time-period needed; and

* The number of occupants evacuated.

The fire drills were not completed at least every other month on alternating shifts.

The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months, for all shifts, was discussed with Staff 1 (Administrator) and Staff 17 (Maintenance Director) on 04/02/24. The staff acknowledged the findings.

TELs documentation has been updated to include the following; escape route used, problems encountered, evidence of alternate routes used, evacuation time period needed and the number of occupants evacuated.  All Fire and Life Satey Fire Drills will be evaluated for 6 months, then brought to quarterly Q.A.P.I. meetings.

Maintenance Director is responsible to see that this process is completed.  

Administrator to review documentation monthly.

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months of fire drills or conduct fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records, reviewed between 06/03/24 and 08/26/24, revealed the following:

* Fire and life safety instruction was not consistently provided to staff on alternating months; and

* There had been no fire drills completed between 06/03/24 and 08/26/24.

In an interview on 08/26/20, Staff 17 (Maintenance Director) and Staff 1 (Administrator) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months and fire drills were not conducted according to the OFC.

On 08/27/24 at 3:59 pm Staff 17 conducted a fire drill which included documentation of all required components.

Fire drills will be happening monthly for nine months and fire and life safety instructions every other month. All fire and life safety drills will be evaluated monthly for nine months and brought to quarterly Q.A.P.I. meetings.   Maintenance Director is responsible to see that this is completed.  Administrator to review documentation monthly.    

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 04/02/24. There was no documentation of annual training conducted with residents related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire.

In an interview on 04/02/24, Staff 1 indicated the facility had not been conducting annual training with residents. She acknowledged there were residents currently in the facility who would be able to participate with fire and life safety training. Staff 1 further indicated they would implement a plan to address annual training with the residents who were able to understand.

TELs has been updated to include annual training in June conducted with residents related to general fire and life safety procedures, evacuation methods, responsiblities, and designated meeting places inside or outside the building in the event of a fire.  This will be evaluated annually at Q.A.P.I. and Safety Meeting following training .  Maintenace Director is responsible to see that the corrections are completed and monitored.

Administrator to ensure annuall training has occurred.  

Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 420.

Refer to C 420

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

Observations of the facility on 04/01/24 showed the following areas in need of cleaning or repair:

* Multiple walls, doors, and door frames in the living room, dining room, and activity room had scrapes, dings, chips, missing pieces of plaster, spills, and/or black streaks;

* A cupboard in the Jacuzzi room was damaged and the side was pulled apart, and a wall was scraped and chipped;

* Walls in the laundry room had scrapes, splatters, and dings. The flooring in the east laundry room had a large section of missing linoleum around the drain. The west laundry room had small pieces of linoleum that were chipped and/or missing;

* Numerous black scratches, deep gouges, and dings were noted on the flooring in the living room near the fireplace area;

* Multiple areas of the laminate floor throughout the two front halls were pulling apart at the seams, creating a gap in the flooring. Several entry ways to bedrooms had no transition between the hall and bedroom flooring, which created a large gap between the two flooring types;

* Numerous chairs located in the dining room, activity room, and hallway had missing vinyl, which left an exposed fabric layer. A sofa in the entryway of the building had a large tear in the left arm rest, with exposed stuffing. A recliner chair near the dining room had food spills and debris and dining room chairs had spills and debris on the seats and lower arms;

* Window sills in the dining room had splatters, debris, and dead insects;

* Strong, pervasive urine odors were present in Room 7 and the nearby hallway and alcove; these odors did not dissipate during the survey;

* Courtyard doors and the facility's front door had significant scrapes and dings to the lower portions of the door; and

* Two unused nurse's stations had scrapes, splatters, chips, and dings on the outer walls, inner walls, and/or corners were chipped with pieces of missing plaster.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings.

Walls, doors, and door frames in the living room, dining room and activity room fixed and/or cleaned.  Jacuzzi room cupboard fixed and wall repaired.  Both laundry room walls repaired and /or cleaned.   The flooring in both laundry rooms will be replaced after hoppers are moved to dirty side of laundry and dryers to clean side. Quotes and plan for work to be completed will be done by the date of compliance.  Laminate floors throughout two front halls where pulling apart at the seams, creating a gap are to be replaced along with the black deep scratches and dings noted in the lobby by the fireplace area.  Entry ways to bedrooms have been fixed with transition pieces.  New dining room chairs have been ordered and will arrive May 23rd.   Other chiars with damage have been cleaned, repaired or replaced.  Window sills in dining room have been cleaned.  Room 7 has been shampooed and is now on a shampooing schedule to twice a week to help odor control.  Doors to the courtyards and front doors have been repaired and  fixed with metal kick boards to help prevent scrapes and dings. Nurse's stations on East and West sides have been repaired and cleaned.   Maintenance Director will will do rounds daily of facility to identify issues that need attention and repair/clean as nessasary.   Administrator and Maintenace Director will do Facility rounds weekly for 6 weeks, then monthly for 3 months and then quarterly continuously. Maintenance Director is  reponsible to see these corrections are monitored.   

Technical assistance was provided in the following area:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Technical assistance was provided in the following area related to H1518:

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C231, C242, C361, C420, C422, and C513.

Refer to C231, C242, C361, C420, C422, and C513.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 420.

Refer to C 420

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 3, 13, and 20) completed all required pre-service orientation and dementia training topics; 3 of 3 staff (#s 13, 16, and 20) demonstrated competency in all assigned job duties within 30 days of hire; 2 of 2 long term staff (#s 4 and 14) completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training on dementia care; and 2 of 2 long term non-care staff completed annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 04/03/24. The following was identified:

1. There was no documented evidence Staff 3 (RCC), hired 02/22/24, Staff 13 (CG), hired 01/31/24, and Staff (20), hired 01/11/24, completed one or more of the following pre-service orientation and dementia training topics:

* Infectious Disease Prevention;

* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach;

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

2. There was no documented evidence Staff 13 (CG), hired 01/31/24, Staff 16 (MT), hired 08/08/23, and Staff 20 (CG), hired 01/11/24, demonstrated competency in one or more of the following areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

3. There was no documented evidence Staff 4 (CG), hired 07/31/20, and Staff 14 (MT), hired 04/07/21, had completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training related to dementia care.

4. There was no documented evidence Staff 5 (Dietary Aide), hired 09/21/18, and Staff 19 (Dietary Manager), hired 11/16/15, completed the required annual infectious disease training.

The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Staff #3, #13, #20 completed all pre-service orientation and dementia training topics. All new staff pre-service training plan was created in RELIAS to have all required training.  Staff #13, #16, and #20 demonstrated compentency in role of service plans in providing individualized care, providing assistance with ADLs, changes associated with normal aging, identification, documentation and reporting of changes of condition, conditions that require assessment, treatment, observation, and reporting, and general food safety, serving and sanitation.  All new 30 days after hire Training Plan was also created in RELIAS to have all required training.  Annual Direct Care Staff Training was also updated to have all staff take the same training monthly and have an All Staff Meeting monthly to discuss and do training on course. Every June all staff will go on OCP and do 2 hour course on Infection Control for annual training.   RCC will see that all pre-service training and 30 day training is done by all new staff.   Administrator Assitant will also audit all staff training files to ensure compliance.  Administrator Assistant is responsible to monitor staff monthly to complete annual training on time.      

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 24, 25, and 26) completed all required pre-service dementia training topics and 3 of 3 staff (#s 24, 25, and 26) demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 08/27/24 with Staff 1 (Administrator). The following was identified:

1. There was no documented evidence Staff 24 (CG), hired 07/08/24, Staff 25 (CG), hired 05/23/24, and Staff (26), hired 06/21/24, completed the following pre-service orientation and dementia training topic:

* Use of supportive devices with restraining qualities in memory care communities.

2. There was no documented evidence Staff 24 (CG), hired 07/08/24, Staff 25 (CG), hired 05/23/24, and Staff 26 (CG), hired 06/21/24, demonstrated competency in one or more of the following areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

The need to ensure the required pre-service training was completed by staff in the time frames specified in the rules, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire, was discussed with Staff 1, Staff 3 (RCC) and Staff 9 (Administrative Assistant) on 08/27/24. They acknowledged the findings.

Relias pre-service dementia training has been updated to include use of supportive devices with restraining qualities in memory care communities.

The 30 day competency training was also updated to have role of service plans in providing individualized care, providing assistance with ADLs, changes associated with normal aging, identification, documentation and reporting of changes of condition, conditions that require assessment, treatment, observation and reporting, and general food safety,serving and sanitation.  This will be evaluated monthly for three months and brought to next three Q.A.P.I. meetings.  Administrator is responsible to see that the corretions are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C260 and C270.

Refer to C260 and C270.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 6 sampled residents (#s 3 and 5) whose records were reviewed. Findings include, but are not limited to:

Resident 3 and 5's current service plans, dated 03/19/24 and 02/16/24, respectively, were reviewed. Both service plans were found to be lacking information and staff instructions related to an individualized nutritional plan.

The need to develop an individualized nutritional plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Service plans for #3 and #5 were updated with more information for an individualized nutrition and hydration plan.   All residents service plans have been updated to have more information for an individualized nutrition and hydration prferences and needs.   RN is responsible to audit 20% of Care Plans monthly ensuring nutrition and hydration plans are personalized for 5 months.  Results of audits will be discussed in Q.A.P.I. for the next 3 meetings.  

Based on interview and record review, it was determined the facility failed to develop individualized activity plans from the evaluations completed, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 5 of 6 sampled residents' (#s 1, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:

A review of service plans for Residents 1, 3, 4, 5, and 6, and interviews with Staff 1 (Administrator) and Staff 21 (Activity Director) and during survey, revealed the following:

1. There was no documented evidence an individualized activity plan had been developed for Residents 1, 3, 4, 5, and 6 based on their activity evaluation that was reflective of the resident's activity preferences and needs.

2. There was no documented evidence a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate and based on the resident's evaluation.

The need to ensure the facility developed an individualized activity plan based on the evaluation for each resident, and provided daily structured and non-structured activities based on the evaluation, was discussed with Staff 1, Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Individualized activity plans for residents #1, #3, #4, #5, and #6 were updated in their service plans with daily structured and non-structured activities.  All residents service plans have been updated with daily structured and non-structured activities.  Activity Director will complete Resident Life History upon move in and update at 30 days then quarterly with Care Plans.   RCC will audit all activity plans for the next 4 months.  Results will be brought to Q.A.P.I. for next 3 meetings. Activity Director to audit all residents for completed Life Histories.   Administrator will be responsible to see that the corrections are completed.