The findings of the re-licensure survey, conducted 04/29/24 through  05/02/24, 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 and Home and Community Based Services Regulations 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

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

A situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following areas:

OAR 411-054-0025 (4): Reasonable Precautions; and

OAR 411-054-0040 (1-2): Change in Condition and Monitoring.

The facility put an Immediate Plan of Correction in place during the survey and the situation was abated.

Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to:

During the re-licensure survey, conducted 04/29/24 through 05/02/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

1. Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:

OAR 411-054-0025 (4): Reasonable Precautions; and

OAR 411-054-0040 (1-2): Change in Condition and Monitoring.

The facility put immediate plans of correction in place during the survey and the situation was abated.   

2. Refer to deficiencies in the report.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to:

The facility was toured on 04/30/24. The following was not posted as required:

* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility.

In an interview with direct care staff on duty at 8:20 pm on 05/01/24, staff were unable to determine who was in charge and stated the person in charge was a staff that was not currently on duty in the facility.

The need to ensure all required items were posted was reviewed with Staff 1 (ED) on 05/02/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

1. A group interview was conducted on 04/30/24 at 1:00 pm. Multiple alert and oriented residents provided information on services received in the community. Residents expressed concerns in areas including, but not limited to long delays for call light response times, inadequate training for staff, frequent unscheduled changes to the dining menu and poor quality of food, residents and visitors being locked out of the building during night hours, and a consistent lack of scheduled activities. Responses included:

* " It's not uncommon to wait 30 minutes or more for a call light to be answered";

* " I had an appointment out of the facility and returned after 6:00 pm and could not get back in the building because no one answered the doorbell";

* " Another resident was knocking on my window late at night because s/he couldn't get back in";

* "We don't get enough protein and the alternative menu items are often not available"; and

* "The activities on the calendar don't happen because we don't have an activity director."

Call light reports were requested on 05/01/24, however, Staff 1 (ED) and Staff 5 (Environmental Services Director) confirmed the facility system was not able to produce a report that could be reviewed to determine call wait times. Staff 1 stated the facility was planning to get a new call system that would address the information needed. Staff 5 reviewed the staff pagers that received call light signals and showed the call history on the pager was limited and could not show a record to review facility response times.

2. The "Resident Meeting Notes" dated 01/30/24 and 03/19/24 were reviewed. Comments included:

* On 02/27/24 - residents made multiple suggestions for activities the group would enjoy and expressed concern that "there aren't enough activities going on because [activity staff] never show up.";

* On 03/05/24 - residents offered menu changes to the kitchen and expressed concern regarding portion sizes and out of stock items; and

* On 03/19/24 - residents expressed concern for what to do if the elevator stopped working and requested instructions be posted.

Documentation of the facility's method of responding to and resolving resident complaints was requested on 05/01/24. Staff 1 provided two "concerns/grievances/compliment" forms dated 05/2023 and 06/2023. There was one hand written letter dated 04/2023. The forms were left blank under "results of investigation" and "resolution/follow-up" and none of the forms were signed by facility staff or Administration.

On 05/02/24, Staff 1 stated he was not sure if residents were currently aware of how to submit concerns to the facility or the location of the forms used to document communication.

The need to ensure the facility implemented effective methods of responding to and resolving resident complaints was discussed with Staff 1, Staff 2 (RN/Health Services Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 04/29/24 through 05/02/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

Refer to the deficiencies in the report.

Based on observation, interview, and record review it was determined the facility failed to ensure reasonable precautions were taken to protect against any condition that could threaten the health, safety, or welfare of residents. Resident 3 was lost in the community on at least three occasions and unable to find his/her way home. On two of those occasions the resident was returned home to the ALF by the local police. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.  

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 02/13/24, and progress notes, dated 08/01/23 to 04/25/24, were completed.

The resident's service plan indicated s/he was independent with ADLs and noted the resident "does not remember how to use call system, after many instructions." The resident was additionally noted to enter other residents' apartments, open doors, and involve himself/herself in other resident emergency situations. The resident was identified to be an average risk of elopement on the service plan related to a history of exit seeking and increased cognitive decline due to Alzheimer's disease. No exit seeking behavior occurred during the previous evaluation period. The resident was noted to have a history of falls.

Review of the resident's 08/01/23 to 04/25/24 progress notes showed the following:

A progress note dated 08/05/23 at 8:54 pm, indicated the resident was "dropped off this afternoon 6:00 pm by police." The resident had wandered out and was picked up near a pub. The resident told police officers s/he wanted to be dropped off at his/her home but gave the wrong location. Police officers contacted the resident's family and were given the correct location of resident's home at the facility. Resident was given food and drink upon his/her return, walked to his/her room and it was noted staff would "...keep an eye on..." the resident.

A progress note dated 08/06/23 at 2:27 pm, indicated a call was received from a local car dealership stating the resident was at their dealership, and the resident was unsure how to get back to the facility. A caregiver on shift was sent to pick up the resident and returned to the facility.

A progress note dated 04/07/24 at 1:08 pm, indicated the front desk received a call from County 911 that officers were headed to make contact with the resident. The resident was not in the facility but had been found at a local hotel approximately half a mile from the facility. Police transported the resident back to the facility and family was contacted about the incident.

There was no indication or documentation the facility implemented interventions to prevent the resident from leaving the facility unsupervised to ensure his/her safety.

Observations of the resident between 04/29/24 and 05/02/24 showed the following:

* The resident was seen walking throughout the facility, both indoors and outdoors.

* The resident was observed on at least four occasions going out the front door with no indication staff saw the resident leave, that the resident had signed out on the log provided, or that staff had signed the log on the resident's behalf prior to the resident leaving the building.

* On 05/01/24 at approximately 4:45 pm, the resident exited the front door and left the area in front of the facility. The resident headed towards the cross walk near the highway at the corner of the campus. Staff 22 (Front Desk) was aware the resident went out but then lost sight of him/her. The surveyor informed Staff 22 of the resident's whereabouts, and Staff 22 contacted care staff to go get the resident. The resident was found in the flower bed/border of the facility, around the corner nearest the crosswalk side, picking a flower.

* An evening visit to the facility was conducted at approximately 8:15 pm on 05/01/24. The safety log which was implemented on 04/30/24, to monitor the resident's whereabouts, was located on the medication cart and was pre-filled with safety check times completed through 10:00 pm.

The need to ensure the resident's incidents of being lost in the community were monitored, interventions were evaluated, and changes implemented and communicated with staff was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director) and Staff 3 (RCC) on 04/30/24 and 05/01/24.

An immediate plan of correction was requested on 04/30/24 to ensure resident safety, related to leaving the facility grounds unsupervised. An initial plan was received on 04/30/24 at 6:45 pm and the situation was abated. Additionally, an updated plan was provided on 05/02/24 at 12:15 pm.  

Refer to C 270, example 1.  

2. During a group interview on 04/30/24, multiple residents expressed concern for residents getting "locked out of the building at night." Group participants explained the front door of the facility was locked at 6:00 pm every night and there was a doorbell to ring "after hours" however, "staff do not respond to the door bell" and residents are out in the cold and often freezing temperatures with no way to get in." One resident stated another resident recently woke him/her "in the middle of the night" by knocking on the resident's window to be let in.

a. The front entrance of the facility was observed on 04/30/24. Staff 4 (Business Office Manager) confirmed the door was locked nightly at 6:00 pm. A doorbell was visible to the left of the entrance door behind decorative trim. There were no instructions posted directing staff, residents, or visitors on how to reach staff after hours when the door was locked. Staff 4 stated "there used to be a sign, but it must have fallen off". A sign directing visitors to use the door bell and the phone number for the facility was replaced on 04/30/24 at 4:30 pm.

b. On 05/01/24 at 8:14 pm, surveyors approached the facility and the front door was locked. Surveyors rang the door bell. At 8:17 pm a staff person walked past the door. At 8:18 pm another staff opened the front door to allow emergency services to enter the building. Staff 29 (MT) was interviewed at 8:20 pm regarding the door bell. Staff 29 checked the pager and showed surveyors the screen and said "the door bell doesn't work, it doesn't alert the pager."

c. Resident 8 moved into the facility in 06/2023 with diagnoses including dementia. A review of Resident 8's progress notes documented on 05/01/24 that the "resident was found outside the building at 0300 after another resident called to notify staff that someone was outside banging on their window. When asked what [s/he] was doing outside at this time resident said, "I went out to pick some flowers and got locked out."

The findings regarding the door bell and residents and visitors being locked out of the building and the need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents were discussed with Staff 1 (ED) and Staff 5 (Environmental Services Director) on 05/01/24. They acknowledged the findings.

3. During a group interview on 04/30/24, multiple residents expressed concern regarding a door that was used to access the interior courtyard area from the dining room. Resident's stated when the "handicap access door pad" was pressed to open the door from outside, the door would "open into you if you don't get out of the way quickly" causing a risk of falling. In addition, residents stated a rock placed in the walkway was used to "prop the door open" and was causing a tripping hazard.

On 05/01/24, a surveyor toured the area with Staff 5 (Environmental Services Director). Observations confirmed the door, when the handicap access pad was depressed from the outside, would result in the door opening into the user. The rock was visible near the door causing a tripping hazard. Staff 5 stated the door was "designed wrong" and stated the access pad could be moved to provide safer access.

The findings regarding the door access and a large rock causing risk of falls and the need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents were discussed with Staff 1 (ED) and Staff 5 on 05/01/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a resident's right to exercise individual rights that do not infringe upon the rights or safety of others. Findings include, but are not limited to:

In a group interview, conducted 04/30/24, multiple alert and oriented residents expressed concern that it was "very difficult to get permission to be allowed to keep over the counter medications." Residents explained that facility staff instructed them they were not allowed to keep "over-the-counters" in their rooms, even if they were locked up and if found, staff would remove them.

In an interview on 05/01/24, an un-sampled resident explained s/he had agreed to have facility staff administer his/her prescription medications and paid for that service, however had asked to keep his/her non-prescription (over the counter) medications in his/her locked drawer in his/her apartment. The resident explained his/her doctor had no concerns about it and "I had to be very firm and insist this be allowed. I worry they will take them away."  A review of the resident's service plan and evaluations showed no contraindication by the physician or by resident evaluation for the resident's ability to safely keep over the counter medications.

In an interview on 05/01/24, Staff 6 (MT) was asked about over the counter medications in resident units. Staff 6 stated when staff find these in resident rooms, unless they are approved to self-administer their medications, staff will take them and let the resident know they cannot keep those in their room and they "can ask staff for anything they need".

On 05/02/24, the need to ensure a resident's right to exercise individual rights that do not infringe upon the rights or safety of others was discussed with Staff 1 (ED), Staff 2 (RN/ Health Services Director), and Staff 3 (RCC). No additional information was provided.

Based on observation, interview, and record review, 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, 04/29/24 through 05/02/24, multiple unsampled residents expressed concern over a lack of activities. Observations over four days showed a coloring activity was offered once and two group activities, which consisted of a visiting musician and youth singing group, were conducted.

The facility posted Activity calendar for April was reviewed and included the following scheduled daily activities:

April 30, 2024:

10:30 am morning meeting

11:00 am 1:1 Activity (activities staff)

1:00 pm afternoon meeting

1:00 pm gardening with eldergrow

1:30 pm Lifelong Learning

2:00 pm Arts and Crafts

None of the posted activities were conducted. There was no activity calendar available for the month of May 2024.

In an interview on 05/01/24, Staff 1 (ED) indicated the facility did not currently have an activity director and there were plans to have the position filled in the near future. The facility did not have a current plan to conduct activities during the absence of an activity director.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 on 05/02/24. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care, were available for care staff review and services, and were consistently implemented by staff for 6 of 7 sampled residents (#s 1, 3, 5, 6, 7 and 8) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease and migraine.   

Observations of the resident, interviews with staff, and review of the service plan, dated 02/13/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and was not implemented in the following areas:

* Entering other apartments;

* Private caregiver;

* Safety devices including air tag;

* Redirection away from emergent events;

* Confusion, cognitive impairment, and safety awareness; and

* Exiting the facility, becoming lost in the community, and police involvement.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2  (RN/Health Services Director) and Staff 3 (RCC) on 04/30/24 and 05/01/24. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 02/2024 with diagnoses including edema and vision impairment.  

Observations of the resident, interviews with staff, and review of the service plan, dated 02/21/24, located in the service plan binder, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and was not implemented in the following areas:

* Oxygen use and concentrator vs. tank use;

* Assistance with ambulation outside the apartment;

* Vision impairment and assistive devices;

* Edema and daily weights; and

* Shower assistance.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director) and Staff 3 (RCC) on 04/30/24 and 05/01/24. The staff acknowledged the findings.

3. Resident 1 was admitted to the facility in 05/2019 with diagnoses including neuropathy.

Resident 1's bed was observed with a bilateral 1/2 side rail in the up position on the right side of the bed.

A pelvic and back brace was noted on the floor in Resident 1's apartment.

On 04/29/24, Resident 1 explained s/he had fallen and fractured his/her pelvis and back and the brace was to be used when walking. Resident 1 stated staff were not aware of how to apply the brace.

Resident 1's service plan did not provide direction for:

* The bilateral 1/2 side rail, including the risks and precautions; and

* The use of a brace for walking, following fractures.

The need for service plans to provide clear direction regarding the delivery of services was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/29/24 and 05/01/24. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 03/2022 with diagnoses including hypertension, presence of cardiac pacemaker, and Alzheimer's disease.

Interviews with the resident and staff, and review of the current service plan, dated 02/19/24, revealed Resident 6's service plan was not reflective of his/her current needs and lacked clear instructions to staff in the following areas:

* Number of staff needed to assist with activities of daily living;

* Hearing and use of assistive devices;

* Mobility and assistive devices;

* Instructions on specific changes of condition to report to hospice;

* Instructions on proper maintenance of air mattress used for pressure ulcer prevention;

* Nutrition habits and fluid preferences;

* Instructions on fall prevention;

* Instructions on what types of skin impairments to report and to whom;

* Incorrect reference to resident not requiring assistance with mobility;

* Instructions on edema management; and

* Pacemaker precautions, instructions for proper maintenance, and how to monitor malfunctions.

The facility made service plans available to staff by storing them in a binder located in the medication room on the floor where the resident resided. However, Resident 6's service plan was not included in the binder and not available to facility staff at the time of the survey.

The need to ensure service plans were readily available to staff,  reflected the resident's current needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings. No further information was provided.

5. Resident 7 was admitted to the facility in 06/2020 with diagnoses including hypertension, cystitis, and hypocoagulable disorder.

Interviews with the resident and staff, and review of the current service plan, dated 02/10/24, revealed Resident 7's service plan was not reflective of current needs and lacked clear instructions to staff in the following areas:

* Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety;

* How a person expressed memory loss;

* Instructions on edema management;

* Use of assistive devices;

* Instructions on compression therapy; and

* How the continuous positive airway pressure ventilation device was to be used and monitored for safety.

The facility made service plans available to staff by storing them in a binder located in the medication room on the floor where the resident resided. However, Resident 7's service plan was not included in the binder and not available to facility staff at the time of the survey.

The need to ensure service plans were readily available to staff, reflected the resident's current needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings. No further information was provided.

6.  Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.   

Observations of the resident, interviews with staff, and review of the service plan, dated 01/26/24, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Behavior of exiting the facility at night and knocking on windows to be let in.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff when behaviors occurred was discussed with Staff 1 (ED), Staff 2  (RN/Health Services Director) and Staff 3 (RCC) on 05/02/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure incidents were evaluated to determine the effectiveness of current interventions, determine additional interventions needed, communicate resident specific interventions to staff, and that short term changes had monitored progress weekly through resolution for 4 of 5 sampled residents (#s 3, 6, 7 and 8). Resident 3 exited the facility and was lost in the community on three separate occasions, two of which s/he was returned to the facility by police. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.  

During the acuity interview on 04/29/24, Staff 3 (RCC) identified the resident as confused and could get lost when s/he left the campus. In a later interview, Staff 3 indicated the resident had told her s/he was approaching the opposite gender while s/he was out walking and expressed his/her interest to them. Staff 3 stated she was concerned about this because the resident did not have the ability to make this type of decision and the facility was unaware who the resident might be approaching.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 02/13/24, and progress notes dated 08//01/23 to 04/25/24, were completed.

The resident's service plan indicated the resident had a diagnosis of Alzheimer's disease. The resident was noted to be independent with ADL care but did require stand by assistance for showers. The service plan noted the resident "does not remember how to use call system, after many instructions." The resident was additionally noted to enter other residents' apartments, open doors, and involve himself/herself in other resident emergency situations. The resident was identified to be an average risk of elopement on the service plan related to a history of exit seeking, increased cognitive decline due to Alzheimer's disease. No exit seeking behavior occurred during the last evaluation period. The resident was also noted to have a history of falls.

Review of the resident's 08/01/23 to 04/25/24 progress notes showed the following:

A progress note dated 08/05/23 at 8:54 pm, indicated the resident was dropped off at 6:00 pm by police. The resident had wandered out and was picked up near a pub.

A progress note dated 08/06/23 at 2:27 pm, indicated a call was received from a local car dealership stating the resident was at their dealership and the resident was unsure how to get back to the facility. A caregiver on shift was sent to pick up the resident and returned to the facility.

A progress note dated 08/08/23 at 7:26 pm, indicated the resident stated to Staff 3 (RCC) that while the resident was on walks outside the community s/he was "seeking companionship from opposite gender." The resident stated while on walks s/he had come across companions and expressed interest to these people.

A progress note dated 03/30/24 at 9:34 am, indicated the resident entered the facility kitchen "upset" with his/her toast. The resident was asked to leave the kitchen and became agitated with staff. The resident indicated the MT argued with him/her so the resident threw his/her toast.

A progress note dated 04/07/24 at 1:08 pm, indicated the front desk received a call from County 911 that officers were headed to make contact with the resident. The resident was not in the facility but had been found at a local hotel approximately half a mile from the facility. Police transported the resident back to the facility and family was contacted about the incident.

There were no investigations or monitoring of the incidents to evaluate existing interventions, determination of new interventions that may be needed, communication of resident specific interventions to staff, and implementation of interventions and safety measures to prevent reoccurrence. There was no documentation to determine if the existing service planned interventions were in place or effective related to the resident's time while out of the facility.

Observations of the resident between 04/29/24 and 05/02/24 showed the following:

* During the survey, the resident was seen walking throughout the facility both indoors and outdoors.

* The resident was observed in common areas and within his/her apartment. The resident entered the survey work room to greet the team. The resident placed his/her fingers in a container of vegetables in front of a team member. The surveyor went upstairs to the resident's apartment approximately 15 minutes later and the resident did not recall the previous interaction. Five additional meetings with the resident occurred between 04/29/24 and 04/30/24 without any recognition.

* The resident was observed on the second floor near the elevators unable to locate his/her apartment down the hall. The resident could not recall apartment number or what direction to go. Staff 15 (MT/CG) assisted the resident to locate his/her apartment and gave him/her the apartment number. The resident was escorted to his/her apartment. Approximately 20 minutes later the resident exited his/her apartment and became disoriented near the elevators as to where home was. Staff 15 again assisted the resident to locate his/her apartment.

* The resident was observed on at least four occasions during the survey going out the front door with no indication staff saw the resident leave or had signed the resident out prior to the resident leaving the building.

* An immediate plan of correction was requested related to the resident being lost in the local community on multiple occasions. The plan was received on 04/30/24 to address the resident's confusion and impaired safety awareness when leaving the community. On 05/01/24 at approximately 4:45 pm, the resident left out the front door for a walk and left the area in front of the facility. The resident headed towards the cross walk near the highway at the corner of the campus. Staff 22 (Front Desk) was aware the resident went out but then lost sight of him/her. The surveyor informed the front desk staff of the resident's whereabouts, and she contacted care staff to go get the resident. The resident was found in the flower bed/border of the facility, around the corner nearest the cross-walk side, picking a flower.

* On 05/01/24 at approximately 10:00 am, Staff 15 (CG) was able to show the surveyor the newly implemented safety log, which was located on the medication cart. Staff 15 indicated she had no idea why they were tracking the resident's location or why it mattered. The tracking log was not labeled with any information.

* An evening visit to the facility was completed at approximately 8:15 pm on 05/01/24. The safety log put in place to monitor the resident's whereabouts was located on the medication cart and was pre filled with safety check times through 10:00 pm.

Interviews with staff were conducted between 04/29/24 and 05/02/24 and revealed the following:

Staff 2 (RN/Health Services Director) indicated the resident had confusion and was lost in the community on a few occasions. Staff 2 stated the resident usually returned without assistance and usually took shorter walks. There was no particular pattern to indicate when the resident would leave campus vs. walk within the property. Staff 2 further indicated there were no additional interventions put in place after being lost and no restriction to the resident's movement outside the facility because the resident had the right to leave. The resident had a tracking device in his/her wallet supplied by the family so they could check and see where the resident was if a concern arose. Staff 2 stated the facility did not have access to view the data from the tracking device or the resident's location.

Staff 6, 11, 12, 15 and 17 (MT/CGs), indicated the resident was confused with moments when s/he seemed more alert. Staff 12 stated he did not work with the resident often, but s/he typically seemed lost as s/he "wandered" around the building and looked in windows. Staff 6, 11, and 17 indicated the resident was independent with his/her ADLs but could become confused and disoriented when out walking. Staff 15 stated the resident had confusion and forgetfulness. Staff 15 noticed recently the resident seemed more confused. The staff all further indicated they did not restrict the resident from going for walks outside the building, nor did they track when the resident left.  

Staff 1 (ED) indicated the resident did have a few occurrences when s/he needed escorted back to the building. He was aware of one of the incidents when the police returned the resident. He was unaware the resident was seeking out the opposite gender when out on walks to declare his/her interest. Staff 1 indicated the front desk staff attempted to catch the resident as s/he exited to sign out or they would sign out for him/her. Staff 1 acknowledged this was not consistently occurring.

Staff 18 and 22 (Front Desk Staff/Concierges) indicated they were new to the facility. They were both aware that the resident went out for walks frequently. They were not aware of anything special they were to do related to the resident and did not track when the resident left. Staff 18 indicated sometimes she saw the resident go out and sometimes she did not. She would encourage the resident to sign out or sign out on behalf of the resident if she saw the resident leave. Staff 18 further stated the resident sometimes would just stand in the entryway and look in the windows and then come back inside.

The need to ensure the resident's incidents of being lost in the community were monitored, interventions were evaluated, and changes implemented and communicated with staff was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director and Staff 3 (RCC) on 04/30/24 and 05/01/24.

An immediate plan of correction was first requested on 04/30/24 to ensure resident safety, related to leaving the facility grounds unsupervised. An initial plan was received on 04/30/24 at 6:45 pm and the situation was abated. Additionally, an updated plan was requested and provided on 05/02/24 at 12:15 pm.

3. Resident 6 was admitted to the facility in 03/2022 with diagnoses including hypertension, presence of cardiac pacemaker, and Alzheimer's disease.

Clinical records, including the resident's current service plan and charting notes from 01/30/24 through 04/27/24, were reviewed, and interviews with the resident and facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved.

Charting notes recorded the following:

* 02/04/24 - Resident admitted to hospice;

* 02/06/24 - "Resident was dyspneic at rest ... feels 'nervous/worried' with upset stomach.";

* 02/09/24 -  "Nausea reported when eating.";

* 02/12/24 - " 3 stage 2 pressure injuries noted to inner buttocks.";

* 02/16/24 -  "...resident is dyspneic with rapid RR [respiratory rate] after moving around in bed...";

* 02/19/24 - "Lungs sounds diminished w/shallow breathing.";

* 02/26/24 -  "edema in ankles and below calves.";

* 03/01/24 -  resident had a fall with injury;

* 03/05/24 -  " ...lethargic and difficulty [sic] to arouse [possibly over medicated ...]";

* 03/08/24 -  " ...resident was seen to be laying in  ...bed unresponsive while staring at the upper right corner of ...ceiling.";

* 03/09/24 -  " ...daughter administered expired hydralazine at visit. Resident missed AM med's d/t dysphasia.";

* 03/13/24 -  " ...very lethargic.";

* 03/22/24 -  " ...+3 pitting edema on BLE [bilateral lower extremities] ankle/feet.";

* 03/36/24 -  " ...bed sore on buttocks.";

* 04/20/24 -  " ...resident very restless and anxious today.";

* 04/22/24 -  " ...resident stated [he/she] was lonely."; and

* 04/27/24 -  " ...resident is increasingly anxious and confused."

The need to ensure the facility evaluated the resident, documented the change, and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was discussed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings. No further information was provided.

4. Resident 7 was admitted to the facility in 06/2020 with diagnoses including hypertension, cystitis, and hypocoagulable disorder.

Clinical records, including the resident's current service plan and observation notes from 02/08/24 through 04/27/24, were reviewed, and interviews with the resident and facility staff were conducted.

The following significant change of condition lacked documentation the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed:

* 04/2024: severe weight loss consisting of a 24.4 pound loss, or 11.38% of his/her total body weight, in three months (01/2024 through 04/2024).

The need to ensure the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed for a significant change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved, was discussed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings. No further information was provided.

Refer to C 280, example 1.

2. Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.

The resident's current service plan and charting notes from 02/05/24 through 05/01/24, were reviewed and showed the following:

* 04/27/24: resident placed on alert after getting up four times throughout the night, disoriented. "Last time [s/he] got up was at 3:40 am and went outside at the front of the building and started banging on residents' windows..."; and

* 05/01/24: "resident found outside the building at 0300 ...".

The clinical record lacked documented evidence the resident's behavior and disorientation were evaluated and the facility had determined and documented what action or intervention was needed for the resident, the determined action or intervention was communicated to staff on each shift, and staff instructions or interventions were provided and made part of the resident record with weekly progress noted until the condition resolved.

The need to ensure the facility evaluated residents with changes of condition and determined actions or interventions needed for the resident and residents were monitored until the condition resolved, was discussed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2023 with diagnoses which included neuropathy.

Observations and interviews with the resident from 04/29/24 to 05/02/24 revealed the resident used a back brace and a walker for mobility. Resident 1 explained s/he had fallen and fractured his/her back and pelvis.

On 04/29/24 Staff 3 (RCC) reported the resident had a fall which resulted in fractures of the pelvis and back.

A 3/16/24 facility Charting Notes indicated "Resident on alert due to injury fall...resident claims [s/he] lost balance while making bed...medics called and [s/he] was taken to urgent care...daughter came by and let staff know [s/he] will not be returning ...has a fractured pelvis and T-10 [vertebrae]..."

The new diagnosis of the pelvic and vertebrae fractures represented a significant change of condition for the resident.

Resident 1 returned to the facility on 04/25/24 with increased care needs and equipment following the fractures.

On 05/01/24 Staff 2 (RN/Health Services Director) acknowledged there was no documented evidence of an RN assessment of Resident 1's significant change in condition, including documentation of findings, resident status, and interventions made as a result of the assessment.

The failure to conduct an RN assessment following a significant change in condition was discussed with Staff 1 (ED) on 05/01/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 3 sampled residents (# 1 and 7) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 06/2020 with diagnoses including hypertension, cystitis, and hypocoagulable disorder.

The following weights were recorded by the facility:

* 11/2023 - 203.4 pounds;

* 12/2023 - 211.0 pounds;

* 01/2024 - 214.4 pounds;

* 02/2024 - 200.6 pounds;

* 03/2024 - 201.8 pounds;

* 04/2024 - 190.0 pounds; and

* 05/01/24 -192.8 pounds. (Resident was weighed per surveyor request.)

The resident experienced a 24.4 pound weight loss, or 11.38% of his/her total body weight, in three months (01/2024 through 04/2024). This represented a significant change of condition.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

During an interview on 05/01/24, Resident 7 stated "I am glad I lost weight. I gained a lot because of a carbs [carbohydrates] diet. Also, I have been sick lately [hospitalization related to pneumonia], don't have much of an appetite." The resident also confirmed a family member had been bringing Ensure drink supplements since the resident's recent hospitalization.

On 05/01/24, the resident stated, "My goal is to go to the dining room for lunch. Social interaction helps me to eat more." Resident 7 was observed eating lunch in the dining room. During observation of meals on 05/01/24 and breakfast 05/02/24, Resident 7 consumed 100% of meals.

During an interview with Staff 2 (RN/Health Service Director) and Staff 3 (RCC) on 05/01/24, they acknowledged they were aware of Resident 7's weight loss. Both stated while reviewing weights they "take into account when someone is overweight" and "190 [pounds] for [Resident 7] is a healthy weight."  

The need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2, and Staff 3 on 05/02/24. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 6 sampled residents (#6 and 7) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 03/2022 with diagnoses including hypertension, presence of cardiac pacemaker, and Alzheimer's disease.

Resident 6's current facility records and MARs from 04/01/24 to 04/29/24 were reviewed.

Resident 6's current facility records included a physician order to "administer torsemide 20 mg one tablet by mouth every day as needed for edema or fluid retention of three pounds weight gain in one week."

Review of MARs showed the following:

* Resident refused to be weighted on 04/08/24, 04/22/24, and 04/29/24; and

* Torsemide 20 mg was administered on one occasion on 04/03/24.

Due to the fact that the resident's weight was not taken at least weekly, there was no documented evidence the facility properly determined whether administration of torsemide was required per the order.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings. No further information was provided.

2. Resident 7 was admitted to the facility in 06/2020 with diagnoses including hypertension, cystitis, and hypocoagulable disorder.

Resident 7's current facility records and MARs from 04/01/24 to 04/29/24 were reviewed.

Resident 7's current facility records included a physician order to "administer hydralazine 10 mg one tablet by mouth four times daily as needed for blood pressure above 160 systolic or 90 diastolic."

Review of MARs showed the following:

* Resident's systolic blood pressure from 04/01/24 to 04/29/24 was above 160 on 12 occasions; and

* There was no documented evidence hydralazine 10 mg was administered as ordered.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a legally recognized prescriber for 1 of 3 sampled residents (#7) who were receiving oxygen. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 06/2020 with diagnoses including hypertension, cystitis, and hypocoagulable disorder.

Resident 7's MAR from 04/01/24 through 04/29/24 and physician orders were reviewed and revealed the order for continuous oxygen at two liters per minute via nasal cannula while sleeping until continuous positive airway pressure (CPAP) mask is refitted, was not documented on the MAR.

The need to ensure residents' MARs were accurate and included all medications ordered by a legally recognized prescriber was reviewed with Staff 1 (ED), Staff 2 (RN/Health Service Director), and Staff 3 (RCC) on 05/02/24. They acknowledged the findings. No further information was provided.

Based on interview and record review, the facility failed to have a defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs, and to have staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

The facility was home to 72 residents housed on three separate floors of the facility at the time of the re-licensure survey. During the acuity interview on 04/29/24, the facility identified multiple residents with behavior concerns and high ADL care needs, three of whom required a minimum of two direct care staff to assist with transfers/mobility and ADL care.

1. Review of the facility Acuity Based Staffing Tool (ABST) identified five residents that were not entered into the tool.

Not accounting for all resident care needs in the creation of the staffing plan was reviewed with Staff 3 (RCC) on 04/29/24 and 05/01/24. She acknowledged not all residents were entered into the ABST thus affecting the staffing plan generated by the tool.

The need to have a defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs was reviewed with Staff 1 (ED) on 05/01/24.  He acknowledged the findings.

2. A group interview was conducted on 04/20/24 at 1:00 pm. Multiple alert and oriented residents provided information on services received in the community. Residents expressed concerns related to having enough staff available to respond to call lights, including:

* " It's not uncommon to wait 30 minutes or more for a call light to be answered."

On 05/02/24, a call light on the first floor was pushed and the response time was recorded. The resident re-set and pushed the call light after approximately 19 minutes, stating the wait time was too long. Staff responded to the call light 20 minutes and 37 seconds after it was initially activated.

The resident's concerns and need to ensure qualified, awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 1 (ED) on 05/02/24. He acknowledged the findings.

Refer to C 154 example 1.

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) that met the regulation. Findings include, but are not limited to:

The ABST must address all the required activities of daily living for each resident and the amount of staff time per resident needed to provide care.

The facility staffing tool was reviewed with Staff 3 (RCC) on 04/29/24 and 05/01/24.

Review of the facility ABST identified five residents that were not entered into the tool, including sampled Resident 5.

Residents 1 and Resident 6's evaluated care needs were not accurately reflected in the ABST to generate an adequate staffing plan.

The need to accurately addressed the amount of staff time needed to provide care for residents and to ensure all residents were entered into the ABST was discussed with Staff 1 (ED) on 05/01/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training completed by each employee. Findings include, but are not limited to:

During a review of staff training records on 04/30/24 and 05/01/24, Staff 4 (Business Office Manager) was unable to provide documented evidence that sampled staff administering medications and providing personal care had completed pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned before working independently with residents, and sampled long term staff had completed annual training including:

* Staff 20 (CG) hired 01/16/2024, Staff 23 (CG) hired 02/27/24, and Staff 24 (CG) hired 01/23/24, had no documented evidence of pre-service orientation requirements, pre-service dementia training completed before beginning job duties, or demonstrated competency within 30 days of hire; and

* Long term Staff 14 (MT), Staff 17 (CG) and Staff 25 (CG) had no documented evidence of annual training, including infectious disease training based on anniversary date of hire.

In an interview on 04/30/24, Staff 4 (Business Office Manager) stated she was unable to access training records for staff related to a pending change of ownership. Staff 4 stated "a few months ago we found out we couldn't access the records."

The requirement to maintain written documentation of training completed by each employee was discussed with Staff 1 (ED) and Staff 4 on 05/01/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 20, 23, and 24) completed pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to:

Staff training records were reviewed with Staff 4 (Business Office Manager) on 05/01/24. The following was identified:

There was no documented evidence Staff 20 (CG) hired 01/16/2024, Staff 23 (CG) hired 02/27/24, and Staff 24 (CG) hired 01/23/24, completed required pre-service orientation training topics and pre-service dementia training prior to beginning job duties.

The need to ensure staff completed all required pre-service orientation and training prior to beginning job duties was discussed with Staff 1 (ED) on 05/02/24. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 20, 23, and 24) had documented evidence of demonstrated competency in all required areas within 30 days of hire, and staff had sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. Findings include, but are not limited to:

a. Staff training records were reviewed with Staff 4 (Business Office Manager) on 05/01/24.

Staff 20 (CG) hired 01/16/2024, Staff 23 (CG) hired 02/27/24, and Staff 24 (CG) hired 01/23/24, lacked documented evidence they had completed all of the required training, demonstrated competency in all job duties and been trained in First Aid and abdominal thrust training, within 30 days of hire.     

b. During observations and an interview on 05/01/24, Staff 27 (CG) was observed being unable to communicate with a health care professional due to lack of language skills. Another un-sampled staff verified the staff member required assistance of other staff to effectively communicate.

The need to ensure staff completed all required training and demonstrated competency within 30 days of hire, and the need to ensure staff had sufficient communication skills was reviewed with Staff 1 (ED) on 05/02/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term direct care staff (#s 14, 17, and 25) completed a minimum of 12 hours of in-service training annually, including six hours on dementia training and 2 of 2 long term, non-direct care staff (#s 26 and 28) completed required annual infectious disease training. Findings include, but are not limited to:

Staff training records were requested on 04/30/24.

a. Staff 14 (MT) hired 08/02/22, Staff 17 (CG) hired 02/15/18, and Staff 25 (CG) hired 11/02/22, lacked documented evidence of completing a minimum of 12 hours of in-service training annually, based on date of hire, which included at least six hours of dementia care and the required annual infectious disease training.

b. Staff 26 (Cook), hired 10/04/16, and Staff 28 (Housekeeper), hired 09/18/20, lacked documented evidence of completion of annual infectious disease training based on anniversary date of hire.

The need to ensure direct care staff had a minimum of 12 hours of in-service training annually, including at least six hours of dementia training, and all staff completed the required infectious disease training, was discussed with Staff 1 (ED) and Staff 4 (Business Office Manager) on 05/01/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire drill records reviewed from 09/2023 through 02/2024 lacked documentation that drills and fire life safety training were conducted every other month on alternating shifts. No additional documentation was provided for March or April 2024.

Fire Drill documentation lacked documentation of all required elements, including the following:

* Escape route used;

* Number of occupants evacuated;

* Staff members on duty and participating;

* Evacuation time-period needed; and

* Evidence alternate escape routes were used.

There was no documentation that fire life safety training was conducted during the time period reviewed.

The need to ensure fire life safety training was conducted on alternating months and all required components were documented was discussed with Staff 1 (ED) and Staff 5 (Environmental Services Director) on 04/30/24 and 05/01/24. The staff acknowledged the findings.

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 5 (Environmental Services Director) on 04/30/24 and Staff 1 (ED) on 05/01/24. 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 05/01/24, Staff 1 indicated there was no additional information to provide related to resident training.

Based on observation and interview, it was determined the facility failed to ensure the interior of the facility was kept free from unpleasant odors. Findings include, but are not limited to:

The interior of the facility was toured on 04/30/24. A strong, pervasive odor of urine was detected on the second floor of the facility near rooms 217 and 218.

In an interview and tour on 05/01/24, Staff 5 (Environmental Services Director) was aware of the odor and stated the facility would need to further investigate the source and develop a plan to address it.

The need to ensure the interior of the facility was free from unpleasant odors was discussed with Staff 5 on 05/01/24 and with Staff 1 (ED) on 05/02/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system for security purposes and to alert staff when residents exited the building. Findings include, but are not limited to:

The facility was toured on 04/30/24 through 05/01/24. Observations and interviews with staff during the survey confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (ED) and Staff 5 (Environmental Services Director) on 05/02/24. They acknowledged the findings.

Concerns were identified and the facility was provided with technical assistance in the following areas:

(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Refer to C 200.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

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

(b) The setting is physically accessible to an individual.

Refer to C 160 example 3.

Concerns were identified and the facility was provided with technical assistance in the following areas:

(d) Each individual has privacy in his or her own unit.