The findings of the re-licensure survey, conducted 04/22/24 through 04/25/24, 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 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter 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 the letter H refer to the Home and Community Based Services 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

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 revisit to the re-licensure survey of 04/25/24, conducted 09/03/24 through 09/05/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for 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

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 second re-visit to the re-licensure survey of 04/25/24, conducted 12/04/24 through 12/05/24, are documented in this report. It was determined the facility was in compliance with the 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect for one unsampled resident and to receive services in a manner that protected privacy and dignity for 1 of 2 sampled residents (#4) for whom incontinence care was observed. Findings include, but are not limited to:

a. Resident 4 was admitted to facility in 05/2021 with diagnoses including Alzheimer's disease.

The current service plan, dated 04/07/24, and Interim Service Plans from 01/29/24 through 04/19/24 identified the resident had the following care needs:

* Two-person assist for all toileting needs and transfers; and

* Physical assistance with dressing.

Observations of Resident 4's room in the Oregon City unit revealed s/he shared a room with another resident. Staff 17 (CG) and Staff 23 (CG) were observed providing incontinence care to Resident 4 on 04/23/24 while his/her roommate was in the room. There was no observable barrier between the two sides of the room that provided privacy and dignity during ADL cares.

During an interview at 9:45 am on 04/24/24, Staff 17 and Staff 23 acknowledged that Resident 4 did not have a privacy screen in his/her room.

b. On 04/24/24 at 11:55 am, multiple residents were gathered at tables in the Oregon City unit dining room waiting for lunch to be served. A staff member standing in the kitchenette was observed to speak to another staff member across the dining room in a loud voice, saying "[Resident] yelled at me. Do you want to try a change of face and see if [s/he] wants to eat?"

On 04/25/24, the need to ensure residents' right to be treated with dignity and respect and to receive services in a manner that promoted privacy and dignity was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 5 (LPN) on 4/25/24. They acknowledged the findings.

Refer to H1510 and H1517.

Tag C200-OAR 411-054-0027 Resident Rights and Protection.

Facility will provied training on ensuring that the resident dignity and privacy is protected during each interaction. Training will be provided on the correct procedure for providing personal care in a shared apartment and not discussing with others in common areas. Privacy screens will be made available to use in shared rooms when the resident is not able to move to a private space for personal care. Managers will round throughout the day to ensure that these policies and procedures are followed and any additional training neds identified in regards to this will be provided. The Executive Director will be responsible for maing syre that the training is provided to all direct care staff at the next inservices until confident that the staff is following the  proper procedures.

2. Resident 12 was admitted to the facility in 03/2020 with diagnoses including dementia.

On 09/04/24 during lunch meal service, Resident 12 was observed in the facility's dining room with Staff 35 (CG) and 16 other residents. At 12:02 pm, Resident 12 began to call out the first name of Staff 35 three times. Staff  35 responded in a loud voice, "I heard you" and "You crazy lady."

The need to ensure residents are treated with dignity and respect was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 09/04/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect and/or receive services in a manner that protected privacy and dignity for 2 of 2 sampled residents observed (#'s 7 and 12). This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to facility in 05/2021 with diagnoses including dementia and Parkinson's disease.

Interviews with staff, observations of the resident, and review of the resident's current service plan, dated 08/07/24, and Interim Service Plans from 06/24/24 through 09/03/24, identified the following:

* The resident was not able to communicate his/her needs verbally; and

* The resident required one-person assist for dressing, incontinence care, transfers and mobility.

Observations of Resident 7's room in the Oregon City unit revealed a large picture window which looked out onto a walking path around the outside of the unit. On 09/05/24 at 10:06 am, Staff 40 (CG) assisted Resident 7 to his/her room via wheelchair. The blinds on the picture window were open and an unsampled resident was walking back and forth along the walking path which brought him/her directly outside Resident 7's window. Staff 40 proceeded to assist Resident 7 with a clothing change including removal of pants and shirt, leaving the resident sitting in his/her brief for approximately three minutes while the unsampled resident continued to walk on the path outside of Resident 7's window. Resident 7 observed the unsampled resident outside his/her window and shook his/her fist at the unsampled resident.  

The need to ensure residents' right to be treated with dignity and respect and to receive services in a manner that promoted privacy and dignity was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) at 11:55 am on 09/05/24. They acknowledged the findings, and no additional information was provided.

C200

Conduct dignity and privacy training weekly for 4 weeks reviewing new Privacy Protocol for Resident Care. Protocol posted in every neighborhood. New protocol for Respectful Communication reviewed at All Staff and posted in each neighborhood. Protocols emailed to each employee. RCMs to conduct weekly audits of each neighborhood for demonstration of Protocol comprehension. RCMs report to Executive Director weekly during QA audit results and POC fr corrections needed. Disciplinary action will be taken for staff with reoccuring violations of these protocols.

2. Resident 2 moved into the memory care community in 06/2021 with diagnoses including mixed Alzheimer's and vascular dementia with behavior disturbance.

The resident's 04/17/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Resident-to-resident altercation and interventions;

* Caregiver instructions for pacing and wandering;

* Weight loss and meal monitoring instruction;

* Implementation of snacks and hydration;

* Frequency of supplement and who was responsible for administering;

* Outside service visits including frequency, responsibilities, and recommendations made by the agency; and

* Current skin condition and treatment for feet.

Observations of the resident on 4/23/24 and 4/24/24 showed staff inconsistently implemented service-planned interventions in the following areas:

* Meal textures; and

* Meal assistance.

The need to ensure service plans were reflective of the resident's current status, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/25/24. They acknowledged the findings.

3. Resident 3 moved into the memory care community in 11/2023 with diagnoses including dementia, paranoia, and schizophrenia.

The resident's 04/10/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Use of glasses;

* Recent falls and interventions to minimize further incidents;

* Instructions to staff regarding the resident's preferred meal and sleeping schedule;

* Toileting assistance and level of care the resident needed;

* Caregiver instructions for pacing and wandering;

* Weight loss and meal monitoring instruction;

* Implementation of snacks and hydration; and

* Frequency of supplement and who was responsible for administering.

The need to ensure service plans were reflective of the resident's current status and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the residents' needs, provided clear direction regarding the delivery of services, and/or services were implemented for 3 of 6 sampled residents (#s 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to facility in 05/2021 with diagnoses including Alzheimer's disease.

The current service plan, dated 04/07/24, and Interim Service Plans from 01/29/24 through 04/19/24 were reviewed, observations were made, and interviews with staff were conducted. The service plan was not reflective of the resident's current status, did not provide clear direction to staff, and/or was not being implemented in the following areas:

* Fall precautions including floor mat and bed height;

* Skin treatments including prevention of possible skin tears;

* Barrier cream following incontinence care;

* Feeding assistance;

* Non-drug interventions for pain; and

* Speech Language Pathologist recommendations regarding "smaller meals" five to six times per day.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were implemented was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 5 (LPN) on 4/25/24. They acknowledged the findings.

Tag C260-OAR 411-054-0036 Service Plan General Service Plans for specified residents were updated immediately to ensure they were reflective of residents' current state and all care needs were addressed. Service plans will be updated per regulation and a meeting will be offered to the resident's responsible party to review the service plan and provide any additional information. Resident Care Managers, Assistant Executive Director and Administrator will be responsible for ensuring that all Service Plans are up to date and reflective of resients needs. ED and AED will be responsible for ensuring required changes are made during weekly IDT meetings and will ensure said changes are clearly communicated to staff during shift huddles daily.

2. Resident 8 was admitted to the facility in 08/2023 with diagnoses including behavioral disorders associated with dementia.

The resident's service plan, dated 08/07/24, Behavior/Safety Plan, dated 07/18/24, and Interim Service Plans, dated 07/08/24 through 09/01/24 were reviewed. Resident 8 was observed, and interviews with staff were conducted.

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

* Food and beverage preferences;

* Finger foods;

* Interventions for administering medications and treatments;

* Conflicting information relating to behavioral triggers;

* Communicated by whispering;

* Non-drug interventions for pain;

* Safety checks;

* Environmental factors that impact the resident's behavior; and

* How the resident expressed wanting to be around others.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) at 1:15 pm on 09/05/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff for 2 of 6 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 05/2021 with diagnoses including dementia and Parkinson's disease.

The resident's clinical record was reviewed, including service plan dated 08/07/24, progress notes and Interim Service Plans dated 06/24/24 through 09/03/24, the resident was observed, and interviews with staff were conducted.

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

* Fall mat;

* Pressure relieving mattress;

* Hospital bed;

* Incontinence products including specific type of brief;

* Ability to communicate pain verbally;

* Interventions for behaviors; and

* Meal assistance including level of hands-on assistance required, assistance required for cleaning face after meals, and use of clothing protector during meals.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) at 11:55 am on 09/05/24. The findings were acknowledged. No further documentation was provided.

c260

Executive Director to audit each completed Service Plan weekly, during ABST completion. Any discrepencies or additional instructions needed will be immediately entered into an ISP and placed in neighborhood 24hr binder. IDT meeting is currently conducted each Wednesday to complete due Service Plans and Change of Condition Plans; each present member of IDT will review Comprehensive Service Plan Checklist to ensure each section is address and is reflective of the residents' current needs. This will be confirmed and entered into Bluestep by Assist Executive Director weekly, as part of weekly QA process.

Based on observation, interview, and record review, it was determined the facility failed to monitor residents based on their evaluated and service-planned needs for 2 of 6 sampled residents (#s 2 and 3) who experienced changes of condition requiring monitoring. Findings include, but are not limited to:

1. Resident 2 moved into the MCC in 06/2021 with diagnoses including mixed Alzheimer's and vascular dementia with behavior disturbance.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 04/10/24, interim service plans (ISPs), and progress notes dated 01/22/24 through 04/19/24 were completed.

The resident experienced a significant weight loss on 03/22/24. A significant change of condition ISP identified the following interventions for weight loss:

* "Monitor how much [resident] is eating at meals, how much [resident] is drinking of [his/her] nutritional shakes, is [resident] sleeping or walking during meals."; and

* "Offer food items that are easy for [resident] to eat on the go such as sandwiches, wraps, cookies, fruit, chips."

The resident was observed pacing and wandering through the hallways during the survey. The resident often moved along the handrails and walls, bumping his/her walker into doorframes throughout the unit. When staff redirected the resident to sit down for meals, the resident could feed himself/herself. During lunch on 04/22/24 and 04/23/24, observations showed the resident nodded off intermittently, and at times his/her face almost touched the plate.

Staff interviews between 04/22/24 and 04/24/24 revealed staff did not document the resident's meal intake, nor did staff document how much the resident drank of his/her nutritional shakes.

There was no documented evidence the facility monitored whether the interventions were being implemented, whether the interventions were evaluated for effectiveness, or if new interventions needed to be developed.

In an interview on 04/25/24, Staff 5 (LPN) acknowledged that the interventions lacked documentation that they were being followed and monitored.

The need to ensure service plan interventions were implemented and monitored for effectiveness was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/25/24. They acknowledged the findings.

2. Resident 3 moved into the memory care community in 11/2023 with diagnoses including dementia, paranoia, and schizophrenia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 04/17/24, interim service plans (ISPs), and progress notes dated 01/22/24 through 04/16/24 were completed.

On 04/09/24, Resident 3 was identified as having lost 13.4 pounds in three months, or 10.72% of his/her total body weight, which constituted a severe weight loss for three months. In response to the severe weight loss an ISP was initiated the same day that included the following interventions:

* "How much is [resident] eating at meals.";

* "Is [s/he] attending meals.";

* "Is [s/he] getting distracted during meals.";

* "Is there any specific foods [resident] likes to eat."; and

* "Is [resident] having increased behaviors/activity."

The facility failed to include staff instructions on what to monitor and document. There was no documented evidence the facility monitored whether the interventions were being implemented or whether the interventions were evaluated for effectiveness.

On 4/16/24, Staff 5 (LPN) evaluated the resident's weight and documented in an ISP new interventions: "give items that are easy to eat on the move such as, cookies, ice cream bars, chocolate, bananas, [and] half sandwiches."

During the survey, the resident was observed sleeping in his/her room while breakfast was being served on 04/24/24 and 04/25/24. Interviews with staff indicated the resident often missed breakfast and sometimes lunch. Staff further indicated they were unaware they should be providing snacks. The facility failed to ensure new interventions were communicated to staff, implemented, and monitored.

The need to ensure service plan interventions were implemented and monitored for effectiveness was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/25/24. They acknowledged the findings.

Tag C270-OAR 411-054-0040 Change of Condition and Monitoring

Facility will ensure that interventions that are implemented are tracked and documented for efficacy. Facility will ensure that all changes ISPs are communicated to staff during shift huddles to address any changes and provide guidance. Facility Nurse conducted training regarding meal monitoring specific weight change interventions. Diagrams where provided within each neighborhood's 24 hour binder, providing guidance to track and document intake of food and supplemental shakes. Meal Monitor log has ben implemented withing each neighborhoods for residents who are currently being monitored for weight concerns in the 24hr binder to notify staff of monitoring requirement and instruction for documentation. RCMs and Nurses to ensure that this is up to date during weekly IDT meetings.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols for incontinence care for 2 of 2 sampled residents (#s 3 and 4) whose care was observed. Findings include but are not limited to:

Observations made during the survey on 04/22/24 through 04/25/24 determined the facility failed to adhere to universal precautions for infection control in the following area:

1. Resident 2 moved into the MCC in 06/2021 with diagnoses including mixed Alzheimer's and vascular dementia with behavior disturbance. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care needs.

On 04/24/24 at 3:58 pm, Staff 32 (CG) provided ADL incontinence care for Resident 2. Staff 32 removed the resident's soiled brief, provided perineal care, and proceeded to put a clean brief on the resident without removing the soiled gloves or performing hand hygiene. When Staff 32 was finished with incontinence care, she removed her gloves but did not perform hand hygiene.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/25/24. They acknowledged the findings.

2. During an ADL observation on 04/23/24 at 10:45 am, the following was observed:

* Two caregiving staff donned gloves without performing hand hygiene first and assisted the resident with incontinence care, which included physical assistance with rolling, perineal care, and repositioning;

* Both staff assisted in removing the soiled brief;

* One staff provided perineal care that included using wipes to clean off stool, followed by applying barrier cream. Both staff then touched a clean incontinence brief, the resident's legs and torso, and the comforter, all while wearing the soiled gloves. The staff who cleaned the peri-area and applied the barrier cream then used the controls to lower the bed; and

* Both caregivers removed the soiled gloves and then performed hand hygiene after leaving the resident's room.

The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 5 (LPN) on 4/25/24. They acknowledged the findings.

Tag C295 OAR 411-054-0050 Infection Prevention & Control

Facility has conducted Infection Prevention & Control training with specific guidace regarding proper hand hygiene and glove use at caregiver inservice 5/09/2024. This topic will be address at every monthly All Staff meeting moving forward until procedure is being followed. Laminated signs have been posted in each neighborhood servery providing reminders and guidance to staff for proper glove use. Resident Care Managers will remind and review the proper use of hand hygiene and glove use during daily rounding and shift huddles until procedure is being followed.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols for incontinence care for 1 of 1 sampled resident (#7) who received incontinence care at bedside. This is a repeat citation. Findings include, but are not limited to:

Resident 7 moved into the facility in 05/2021 with diagnoses including dementia and Parkinson's disease. Observations and interviews with staff on 09/04/24 and 09/05/24 identified s/he required one person assist for incontinence care and dressing.

On 09/04/24 at 1:05 pm, Staff 18 (CG) provided ADL incontinence care for Resident 7. After removing the resident's soiled brief, Staff 18 placed the soiled brief directly onto the carpeted floor next to the resident's wheelchair. Staff 18 provided perineal care, and proceeded to put a clean brief on the resident without removing the soiled gloves or performing hand hygiene.

On 09/05/24 at 10:06 am, Staff 40 (CG) provided dressing assistance for Resident 7. Staff 40 donned gloves and proceeded to remove the shirt and the resident's pants which appeared heavily soiled. She did not perform hand hygiene or remove her soiled gloves before assisting the resident to dress in a clean shirt and pants.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) at 11:55 am on 09/05/24. They acknowledged the findings.

C295

All staff that have not completed the 2 Hour "Pre-Service Infection Prevention" Oregon Care Partners online class, within the last 90 days must do so by 10/20/24. Mountain Park Infection Control Specialist to observe incontinence care and hand hygiene within each neighborhood weekly and report finding in during weekly QA to Executive Director and Resident Care Manager. Disciplinary actions for staff members with reoccuring violations.

Based on interview and record review, it was determined the facility failed to ensure adequate direct care staff were present at all times based on resident acuity and facility structural design and to ensure a minimum of two direct care staff were scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to:

During the acuity interview at 9:15 am on 04/23/24, Staff 2 (Assistant ED) stated the facility was designed with five separate units, each containing 18-20 residents. He further identified two residents who needed two staff members for transferring, one in the Oregon City unit and one in the West Linn unit.

The facility's 04/01/24 through 04/23/24 night shift schedule was reviewed with Staff 1 (ED) and Staff 2 at 11:30 am on 04/24/24. The schedule showed one CG assigned to each of the five units, and one MT assigned to the entire building. Staff 2 confirmed the Oregon City unit and the West Linn unit did not have two direct care staff scheduled and available at all times.

The need to ensure adequate direct care staff were present and available at all times, including a minimum of two direct care staff scheduled and available when a resident required the assistance of two direct care staff for scheduled and unscheduled needs, was discussed with Staff 1 and Staff 2 on 04/25/24. They acknowledged the findings.

Tag C260 OAR 411-054-0070 Staffing Requirements and Training

Facility will ensure that we are staffed according to residents scheduled and unscheduled needs. Facility will schedule and ensure that two staff members are scheduled and available when a resident requires two people for transfers or any care needs on all shifts within all neighborhoods. RCMs, AED and ED will track and ensure that appropriate coverage is provided to meet all residents needs each day.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) with significant changes of condition and to include the amount of staff time needed to provide care for activities of daily living and other tasks related to care for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6). Findings include, but are not limited to:

Resident 2, 3, 4, 5, and 6's ABST's were reviewed and found to be deficient in one or more of the following areas:

* Updated with a significant change of condition;

* Eating assistance;

* Providing treatments;

* Laundry services;

* Nail care;

* Morning bathroom escort;

* Transferring into or out of bed;

* Time spent on ambulation, escorting to and from meals or activities; and

* Responding to call lights.

During an interview at 11:55 am on 04/24/24, Staff 1 (ED) stated the facility was working on a system to capture all needed scheduled and unscheduled care minutes for each resident's ABST.

The need to ensure residents' ABST was updated with significant changes of condition and included the amount of staff time needed to provide care was discussed with Staff 1 and Staff 2 (Assistant ED) on 04/25/24. They acknowledged the findings.

Tag 361 OAR 411-054-0037 Acuity Based Staffing Tool

Facility will ensure that ABST is updated with Change of Conditions completed for residents, and will capture all aspects of resident needs requiring staff assistance, including but not limited to; eating assistance, providing treatments, laundry services, nail care, escorts, transfers and responding to call lights. Administrator will ensure that all ABSTs are updated upon move in, within 30 days, quarterly and upon change of condition. These changes will be communicated to staff during shift huddle during review of 24hr binders.

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

Refer to C 200, C 260 and C 295.

C455

Executive Director and Assistant Executive Director to meet weekly and document in weekly QA ovesight of previous and current POC to ensure that all required correction are being consistently followed.

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

Throughout the survey, conducted 04/22/24 through 04/25/24, there was a pervasive, unpleasant urine odor in the dining room area and hallways near the dining room in the Oregon City neighborhood. The odor did not dissipate during the survey.

The need to maintain the interior of the facility and all equipment and surfaces free from unpleasant odors was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 4/25/24. They acknowledged the findings.

Tag C513 OAR 411-054-0200 Doors, Walls, Elevators, Odors

Facility will conduct daily manager walk throughs using the Manager Rounding Tool to audit within all neighborhoods. Staff are to report any and all environmental concerns to the Maintenance Director, AED and/or ED. Odor concerns will be addressed immediately and if/when odors persists a plan will be implemented to address/correct the odor within a reasonable timeframe such as arranging for carpet cleaning or flooring replacement, and increased housekeeping in apartments. Odor concerns will be tracked. Carpets have been cleaned in the neighborhood of concern and applicable apartments are being mopped daily.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

A tour of the facility, on 04/23/24 at 9:15 am, with Staff 2 (Assistant ED) revealed the following:

* The hot water in two of five sampled residents' bathroom sinks was between 121 and 144 degrees Fahrenheit.

At approximately 10:30 am on 04/23/24, Staff 2 reported the facility had identified the issue, Staff 3 (Maintenance Director) had adjusted the water temperatures, and the adjustments would be monitored for effectiveness. Staff had been notified of the excessive hot water temperatures.

On 04/24/24, water temperatures were between 110 and 120 degrees Fahrenheit in the two units where the water had been over 120 degrees Fahrenheit.

The need to ensure hot water temperatures in resident units and common areas did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED) on 04/23/24. She acknowledged the findings.

Tag C545 OAR 411-054-0200 Plumbing System Facility will ensure that Hot water temperatures withing resident units maintain a range of 110-120 degrees Fahrenheit. Maintenance Director will ensure that temps are audited weekly to ensure that we are meeting this regulation at all times. If a variance outside of the listed range is identified immediate action will be taken to resolve the safety hazard and a sign will be posted until safe temperature is obtained consistently. The Maintenance Director has adjusted the water temperatures to meet regulation at this time.

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

H1510: OAR 411-004-0020(1)(c): Individual Rights Settings:  Privacy, Dignity.

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

Refer to C200.

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

H1517: OAR 411-004-0020(2)(d): Individual Privacy: Own Unit.

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

Refer to C200.

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

H1518: OAR 411-004-0020(2)(e): Individual Door Locks: Key Access.

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

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

H1519: OAR 411-004-0020(2)(f): Individual Shared Units: Roommate Choice.

(f) Individuals sharing units must have a choice of roommates.

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

H1580: OAR 411-004-0020(2)(d) to (2)(j): Limitations: Threats to health and safety.

Ensure the residential setting applies individually based limitations when conditions may not be met due to threats to the health and safety of an individual or others.

Refer to H1518 and H1519.

Based on 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: C200, C295, C360, C361, C513, and C545.

Please see POC for C220, C295, C360, C361, C513 and C 545.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.

This is a repeat citation. Findings include, but are not limited to:

Refer to C 200.

Z142

Conduct dignity and privacy training weekly for 4 weeks reviewing new Privacy Protocol for Resident Care. Protocol posted in every neighborhood. New protocol for Respectful Communication reviewed at All Staff and posted in each neighborhood. Both protocols emailed to each employee. RCMs to conduct weekly audits of each neighborhood for demonstration of Protocol comprehension. RCMs report to Executive Director weekly during QA audit results and POC for corrections needed. Discrplinary action will be taken for staff with reoccuring violations of these protocols Executive Director to audit each completed Service Plan weekly, during ABST completion. Any discrepancies or additional instructions needed will be immediately entered into an ISPand placed in neighborhood 24hr binder. IDT meeting is currently conducted each Wednesday to complete due Service Plans and Change of Condition Service Plans; each present member of IDT will review Comprehensive Service Plan Checklist to ensure each section is address and is reflective of the residents' current needs . This will be confirmed and entered into Bluestep by Assist Executive Director weekly as part of weekly QA process.   

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.

Please see POC for C260 and C270

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260.

Z162

Conduct dignity and privacy training weekly for 4 weeks reviewing new Privacy Protocol for Resident Care Protocol posted in every neighborhood. New protocol for Respectful Communication reviewed at All Staff and posted in each neighborhood. Both protocols emailed to each employee . RCMs to confuct weekly audits of each neighborhood for demonstration of Protocol comprehension. RCMs report to Executive Director weekly during QA audit results and POC for corrections needed. Disciplinary action will be taken for staff with reoccuring violations of these protocols. Executive Director to audit each completed Service Plan weekly, during ABST completion. Any discrepancies or additional instructions needed will be immediately entered into an ISP and placed in neighborhood 24hr binder. IDT meeting is currently conducted each Wednesday to complete due Service Plans and Change of Condition Service Plans; each present member of IDT will review Comprehensive Service Plan Checklist to ensure each section is address and is reflective of the residents' current needs. This will be confirmed and entered into Bluestep by Assist Executive Director weekly, as part of weekly QA process.