The findings of the re-licensure survey conducted 12/05/22 through 12/07/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 re-visit to the re-licensure survey of 12/07/22, conducted 05/23/23 through 05/25/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 12/07/22, conducted 04/15/24 through 04/17/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 third re-visit to the re-licensure survey of 12/07/22, conducted 09/16/24 through 09/19/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

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 area:

OAR 411-054-0300 (11-13): Call System

The facility put an Immediate Plan of Correction in place during the survey.

The findings of the fourth re-visit to the re-licensure survey of 12/07/22, conducted on 11/25/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the second revisit to the re-licensure survey of 12/07/22, conducted 04/15/24 through 04/17/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations.

Refer to the deficiencies identified in the report.

Licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility.

1.Actions related to specific residents are addressed with the corresponding tags.

2.Corrections and systems implemented will be addressed with the corresponding tags.

3.Corrections and systems implemented will be monitored through weekly audits for a minimum period of 3 months. Many audits will be an ongoing part of the Quality Program.

4.Administrator will be responsible to see that the corrections are monitored and completed.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to:

During the third revisit to the re-licensure survey of 12/07/22, conducted 09/16/24 through 09/19/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on severity of repeat citations.

Refer to the deficiencies identified in the report.

Licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility.

1.Actions related to specific residents are addressed with the corresponding tags.

2.Corrections and systems implemented will be addressed with the corresponding tags.

3.Corrections and systems implemented will be monitored through weekly audits for a minimum period of 3 months. Many audits will be an ongoing part of the Quality Program.

4.Administrator will be responsible to see that the corrections are monitored and completed

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

During the survey, conducted 04/15/24 through 04/17/24, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.

Refer to the deficiencies in the report.

Quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be  ineffective.

1. All residents have the potential to be affected by ineffective Quality Improvement oversight.

2.  Facility will implement a comprehensive Quality Improvement Program. The administrator and consultant will oversee and assist each department head in developing quality benchmarks and Quality Committee will review and incorporate CoreQ Survey data into the facility Quality Improvement Program.

3. Monthly or as needed ongoing quality audits will be completed by department heads and administrator to monitor performance and progress. Administrator will review each department's monthly audits. Quality Committee will meet quarterly to review and discuss results.

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

Based on observation and interview, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. This is a repeat citation. Findings included, but are not limited to:

During the survey, conducted 09/16/24 through 09/19/24, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.

Refer to the deficiencies in the report.

Quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.

1. All residents have the potential to be affected by ineffective Quality Improvement oversight.

2.  Facility will implement a comprehensive Quality Improvement Program. The administrator and consultant will oversee and assist each department head in developing quality benchmarks and Quality Committee will review and incorporate CoreQ Survey data into the facility Quality Improvement Program.

3. Monthly or as needed ongoing quality audits will be completed by department heads and administrator to monitor performance and progress. Administrator will review each department's monthly audits. Quality Committee will meet quarterly to review and discuss results.

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

Based on interview and record view, it was determined the facility failed to promptly investigate injuries of unknown cause to rule out abuse/neglect, document all required areas of an investigation, and notify the local SPD office when abuse/neglect could not be ruled out for 1 of 1 sampled resident (#5) reviewed with injuries of unknown cause. Findings include, but are not limited to:

Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease.

Resident 5's current service plan identified s/he was "mostly unable to verbalize his/her needs."

A review of the resident's record including charting notes, dated 01/28/24 through 04/09/24, identified the following:

* A chart note dated 03/21/24 indicated the resident was found with "purple bruises on both arms and two [on] both side[s] of [his/her] chest and a bump on the right side of [his/her] head...[Staff 4 (Memory Care Director)] and [Staff 9 (Director of Facility Operations)] was notified."

This incident represented an injury of unknown cause that required an immediate investigation.

On 04/16/24 at 9:43 am, survey requested an investigation of the injuries. At 3:43 pm, Staff 9 reported there wasn't an investigation completed, nor had the facility reported to the local SPD office when abuse/neglect could not be ruled out.

The need to investigate injuries of unknown cause to rule out suspected abuse and/or report to SPD if unable to reasonably rule out suspected abuse was discussed with Staff 3 (Health Services Director/RN), Staff 4 and Staff 9 on 04/16/24. They acknowledged the findings.

Facility failed to promptly investigate injuries of unknown cause to rule out abuse/neglect, document all required areas of an investigation, and notify the local SPD office when abuse/neglect could not be ruled out for 1 of 1 sampled resident (#5) reviewed with injuries of unknown cause.

1. Incident regarding resident 5 was investigated and abuse was ruled out.

2. All staff will complete Abuse Reporting and Investigation Training. Health Services Director or Administrator or designee will complete investigations according to the guidelines in the Abuse Reporting and Investigation Guide for Providers. Incidents will be reviewed by the team at daily stand-up meetings to ensure abuse has either been ruled out or reported.

3. Incidents will be audited weekly to ensure Investigations are completed for all incidents.

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

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 12/05/22 at 9:40 am, the facility kitchen was observed. The following deficiencies were identified:

* Main entryway walls, door and door frame to the kitchen were dirty, had chipped paint and moulding in need of repair or replacement;

* Convection oven, gas range, stainless steel tables and cabinet interiors had surfaces with layers of debris and food splatter on them;

* Caulking around the sink in the food preparation area had a black substance on its surface and was porous, deeming the surface non-cleanable;

* Floor throughout the kitchen including the walk-in refrigerator had a black substance on it;

* On 12/05/22 at 9:46 am, a surveyor observed Staff 21 (Dietary Cook) and Staff 27 (Dietary Dishwasher) preparing food without wearing proper hair restraints; and

* In interview on 12/05/22 at 12:37 pm, Staff 20 (Dietary Manager) failed to produce a current Oregon Food Handlers Card when requested.

The need to ensure the kitchen was clean and in good repair in accordance the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Interim Administrator) and Staff 20 on 12/07/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:

There were no scheduled or unscheduled activities observed on the memory care community on 12/05/22 (10:00 am - 4:00 pm) , 12/06/22 (9:00 am - 3:00 pm), and 12/07/22 (9:00 am - 10:00 am). On those days residents were observed in their rooms, watching TV on the unit, or sitting in common areas.

In an interview on 12/06/22, Staff 3 (RN Director of The Cottages) acknowledged the lack of organized group activities in the MCC.

On 12/07/22 the need for an organized activity program was discussed with Staff 1 (Interim Administrator) and Staff 3. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 2019 with diagnoses including Chronic Obstructive Pulmonary Disorder, shortness of breath, and cardiovascular disease.

A review of the resident's clinical record, and interviews with staff and Resident 1 identified the following:

The service plan dated 06/29/22 and noted as reviewed on 10/05/22 had not been updated and/or lacked clear instructions to staff in the following areas:

* Resident smoking status;

* Use of manual wheelchair or powered wheelchair; and

* Presence of pressure ulcer and pressure relief interventions.

The need to ensure service plans were completed, updated, and were accessible to staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 04/2020 with diagnoses including vascular dementia, emphysema and hypertension.

A review of the resident's clinical record and interviews with staff indicated the following deficiencies:

a. The most recent service plan, dated 07/19/22 had not been updated quarterly; and

b. The service was not reflective of current status and/or lacked clear instructions for staff in the following areas:

* Fall interventions/precautions;

* Denture status;

* Activities plan; and

* Elopement prevention.

On 12/07/22 the need to ensure service plans were completed quarterly, were reflective of current resident status, and provided clear instruction for staff was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were completed upon move-in, updated within 30 days of move-in and quarterly thereafter, were accessible to staff, reflective of the resident's current status, care needs and preferences, and provided clear instruction regarding the delivery of services for 3 of 6 sampled residents (#s 1, 3 and 6), whose service plans were reviewed. Findings include but, are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including atrial fibrillation, congestive heart failure and anxiety.

A review of the resident's clinical record, and interviews with staff and Resident 3 identified the following:

a. The initial service plan was not completed and a 30 day update had not been completed and made accessible to staff.

b. The service plan review that had been completed was not reflective and/or lacked clear instructions to staff in the following areas:

* Ability to use call light;

* Medication management;

* Behavior management including depression and interventions;

* History of falls and fall interventions;

* Assistance with daily weights;

* Ability to eat independently;

* Use of adaptive equipment (shower chair, toilet riser and hospital bed);

* Preferred activities (watching football, basketball, pets and reading the daily newspaper);

* Skin checks and monitoring for bed sores;

* Use of home health PT services that were provided;

* Reminders to lock brakes on walker prior to sitting;

* Reminders to use incentive spirometer (manual machine for lung exercises); and

* Encourage to walk halls BID, drink water and eat regularly.

The need to ensure service plans were completed and updated within 30 days of move-in and provided clear instructions for staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 06/2016 with diagnoses including diabetes and fibromyalgia.

Observation and interview with the resident, interviews with staff, and review of the current service plan during the survey, from 05/23/23 through 05/24/23, revealed Resident 7's service plan was not updated quarterly, was not reflective of the resident's status and lacked clear instructions in the following:

* Use of bilateral half side rails;

* Management of ongoing pain; and

* Elderplace services.

On 05/24/23 the service plan was discussed with Staff 9 (Facility Administrator). She acknowledged the service plans were not reflective of the resident's status and lacked clear instructions.

2. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.

On 05/23/23, the copy of Resident 5's quarterly service plan available for caregivers to review was dated 10/24/22.  On 05/24/23, a copy of the service plan dated 05/05/23 was printed.

A review of the resident's clinical record, and interviews with staff identified the following was missing or did not provide clear instructions for staff:

* Side rail use;

* Home Health and Hospice;

* Pressure alarm and fall interventions; and

* Use of a wheelchair and gait belt.

The need to ensure service plans were updated quarterly and provided clear instructions to staff was discussed with Staff 1 (RCC) on 05/24/23 and Staff 9 (Facility Administrator) on 05/23/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, were reflective of the resident's current status, care needs and preferences, and provided clear instruction regarding the delivery of services for 3 of 3 sampled residents (#s 5, 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety.

A review of the resident's clinical record, and interviews with staff and Resident 8 identified the following:

The service plan with most recent updates dated 10/27/22 was not updated quarterly, was not reflective and/or lacked clear instructions to staff in the following areas:

* Use of modified utensils for eating;

* Use and safety instructions for the transfer pole including placement of furniture to remain in the same location to ensure proper body mechanics when transferring;

* Use of hospital bed and ensure resident elevating HOB/FOB;

* Preference to sleep with head at foot of bed;

* Use of bilateral 1/2 length side rails, risks, precautions and who was to monitor and how often to monitor the side rails functioning and the residents' ability to continue safely using the side rails;

* Use of oxygen and nebulizer, including instructions related to infection control and monitoring oxygen saturation levels;

* Application and cleaning instructions for compression socks/wraps; and

* Current falls and fall interventions.   

The need to ensure service plans were updated quarterly and provided clear instructions to staff was discussed with Staff 1 (RCC) on 05/24/23 and Staff 9 (Facility Administrator) on 05/23/23. 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 resident's current status and care needs, provided clear instruction regarding the delivery of services and were implemented for 1 of 5 sampled residents (#5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease and depression.

A review of the resident's clinical record, including a review of the service plan dated 01/24/24, temporary service plans, interviews with staff and observations of the resident's care was conducted during the survey.

a. The following areas were not reflective of the resident's current status and care needs and did not provide clear instructions for staff:

* The use of over-the-counter pain medications;

* Ability to communicate symptoms of depression; and

* History of weight loss and interventions.

b. The following service-planned care needs were not implemented:

* Toileting and brief changes every two hours;

* Repositioning every two hours when in bed or geri-chair;

* Safety checks every two hours when napping in bed; and

* Daily one-on-one activities.

The need to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services and were implemented was discussed with Staff 3 (Health Services Director/RN), Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/17/24. They acknowledged the findings.

Facility failed to ensure service plans were reflective of the resident's current  status and care needs, provided clear instruction regarding the delivery ofservices and were implemented for 1 of 5 sampled residents (#5) whose service plans were reviewed.

1.Resident 5's service plan was reviewed and updated to reflect her current condition and needs

2.The interdisciplinary team (IDT) consisting of ADM, RN, & RSD will meet no less than once per week to go over the on-going needs and service planning of all residents on a rotating basis. RSD will use a checklist addressing all areas of concern to ensure that it is reflected accurately on the service plan. RSD to collaborate with RN to ensure all care and health needs are an accurate reflection of resident's needs and preferences. Service plans will clearly instruct staff on resident needs and preferences.

3.Consultant will perform weekly audits of service plans to monitor compliance and communicate results to the IDT.

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

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 2 sampled memory care residents (#s 5 and 6) whose service plans were reviewed.  Findings include, but are not limited to:

The most recent service plans for Residents 5 and 6 lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 12/07/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages). They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, that interventions were resident-specific, interventions were monitored for effectiveness, and weekly progress noted until the condition resolved for 2 of 6 sampled residents (#s 2 and 5) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.

In an acuity interview on 12/05/22, Staff 1 (Interim Administrator) identified Resident 5 was a "high fall risk."

The resident's service plan, dated 10/24/22, progress notes, dated 09/05/22 through 12/05/22, temporary service plans, and incident reports were reviewed.

The records indicated Resident 5 experienced the following four falls from 09/08/22 through 10/31/22:

* 09/08/22- another resident pushed Resident 5, causing him/her to fall in hallway;

* 09/21/22- Resident 5 slid on wet grass in courtyard and fell;

* 10/09/22- the resident slid out of recliner and landed on floor; and

* 10/31/22- Resident 5 tripped and fell in hallway.

Temporary service plans were created for these falls, but lacked resident-specific interventions, evidence of new interventions being tried, or evaluation of those interventions for effectiveness.

On 12/07/22 the need to implement resident-specific interventions following changes of condition, and to evaluate those interventions for effectiveness was discussed with Staff 1 and Staff 3 (RN Director of The Cottages). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 2021 and was noted to experience urinary tract infections frequently.

Review of the resident's TSPs (Temporary Service Plans), Incident Reports and progress notes dated 09/07/22 through 12/02/22, indicated the resident experienced the following short-term changes of condition:

* 09/07/22 - Fall;

* 09/12/22 - Fall;

* 09/12/22 - Emergency room visit (for dehydration);

* 09/13/22 - Fall;

* 09/13/22 - Fall;

* 09/14/22 - Fall;

* 09/14/22 - Urinary tract infection;

* 10/22/22 - Edema and pain to bilateral lower extremities; and

* 11/29/22 - Fall.

The facility lacked documented evidence it determined resident-specific interventions or actions, communicated the interventions or actions to staff on all shifts, and monitored the conditions with progress noted at least weekly through resolution for each of Resident 2's short-term changes of condition.

Short-term changes of condition and monitoring was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 06/2016 with diagnoses including diabetes.

The resident's progress notes dated 02/22/23 through 03/10/23, and temporary service plans were reviewed. The following short term change of condition was identified:

* 03/01/23 - Change in medications.

There was no documented evidence the facility determined what action or intervention was needed and communicated to staff on each shift.

The need to ensure resident specific actions or interventions were determined and communicated to staff was discussed with Staff 9 (Facility Administrator) on 05/24/23. She acknowledged the findings.

2. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.

The resident's service plan, dated 05/05/23, progress notes dated 02/06/23 through 05/23/23, temporary service plans, and incident reports were reviewed.

The records indicated Resident 5 experienced the following falls from 02/06/23 through 05/23/23:

* 02/21/23 - fell out of wheelchair in dining room;

* 02/22/23 - found on floor in room;

* 02/26/23 - found on floor in room;

* 03/13/23 - fell onto floor;

* 03/14/23 - three falls in one day;

* 03/17/23 - found on floor;

* 03/20/23 - found on floor in room;

* 03/23/23 - fell in room;

* 04/01/23 - found on floor in room;

* 04/03/23 - fell to floor;

* 04/25/23 - fall in dining room;

* 05/04/23 - fell in hallway;

* 05/07/23 - found on floor;

* 05/10/23 - fell in another resident room;

* 05/17/23 - fell out of wheelchair;

* 05/21/23 - fell in courtyard; and

* 05/23/23 - found on floor.

Temporary service plans were created for the falls, but lacked resident-specific interventions, evidence of new interventions being tried, or evaluation of those interventions for effectiveness.

On 05/24/23 the need to develop and implement resident-specific interventions following changes of condition and to evaluate those interventions for effectiveness was reviewed with Staff 1 (RCC), Staff 35 (RN), and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, ensure interventions were resident-specific, interventions were monitored for effectiveness, and weekly progress noted until the condition resolved for 3 of 3 sampled residents (#s 5, 7 and 8) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety.

Review of the resident's Temporary Service Plans (TSP's) and progress notes dated 02/23/23 through 05/23/23 were reviewed during the survey and identified the following changes in condition:

* 02/23/23 - "missed inhaler medication. Inhaler was empty and no extra inhalers could be found. Inhaler on order";

* 03/26/23 - missed pain medication (oxycodone);

* 04/04/23 - fall with rib pain;

* 05/08/23 - injury fall with left dislocated index finger;

* 05/08/23 - "return to facility + new medications"; and

* 05/16/23 - shortness of breath.

There was no documentation the missed respiratory medication and pain medications were communicated to staff or there was no monitoring through resolution.

There was no documented evidence the facility reviewed fall interventions for effectiveness and new interventions were implemented in order to mitigate the potential for future falls and there was no documented evidence the 05/08/23 fall was communicated to staff.

There was a TSP for the 05/08/23 return to facility; however, the TSP lacked clear monitoring instructions related to additional care needs to include: "buddy taping" fingers. The TSP lacked clear monitoring instructions including the name of the new medications and for what the staff should monitor.

There was no documented evidence monitoring instructions or interventions for the resident's shortness of breath and low oxygen saturation level were communicated to staff.

The need to ensure the facility determined resident-specific interventions or actions, communicated the interventions or actions to staff on all shifts, and monitored the conditions with progress noted at least weekly through resolution was discussed with Staff 1 (RCC) and Staff 9 (Facility Administrator) on 05/23/23 and 05/24/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition and ensure weekly progress noted until the condition resolved for 1 of 5 sampled residents (#5) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease.

A review of the resident's clinical record, including charting notes dated 01/28/24 through 04/09/24, temporary service plans for the same time period and interviews with staff was conducted during the survey.

Resident 5 had the following changes of condition that lacked documentation of what action or intervention was needed, the determined action or intervention communicated to staff on each shift, and the condition monitored with weekly progress noted until the condition resolved:

* 02/22/24 - 4 cm x 3 cm bruise to left upper arm;

* 02/06/24 - Discoloration to buttock area;

* 03/21/24 - Bruises on both arms and a bump on the right side of the head;

* 03/24/24 - Pressure sore; and

* 04/08/24 - Bruise to the back of the left hand.

The need to ensure the facility determined and documented what action or intervention was needed for a resident following a change of condition, communicated the actions or interventions to staff and ensured weekly progress noted until the condition resolved was discussed with Staff 3 (Health Services Director/RN), Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/16/24. They acknowledged the findings.

Facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition and ensure weekly progress noted until the condition resolved for 1 of 5 sampled residents (#5) who experienced changes of condition.?

1.RN has assessed resident 5 and implemented, and communicated all interventions related to her change in condition to care staff.  Service plan was updated to reflect changes.

2.Staff will complete training on monitoring residents, recognizing and reporting Changes of Condition and Documentation. Facility will review and update communication systems as needed to ensure timely communication of changing care needs. Nursing will review the 24-hour report daily at stand up to monitor and follow up on any changes of condition.

3. Administrator or designee will perform weekly audits of residents with Change of Condition to verify appropriate follow up has taken place.

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

Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed for 1 of 1 sampled resident (#5) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.

Progress notes between 02/06/23 and 05/23/23 were reviewed along with Resident 5's service plan, Temporary Service Plans (TSPs), physician orders and MAR. The following issues were identified:

On 04/05/23 a progress note documented a meeting including two facility staff and Resident 5's daughter regarding:

* Decline in ADL ability;

* 15 falls in 90 days;

* 4% unexplained weight loss in one month;

* Increased sleep patterns;

* Little to no verbal communication; and

* Admission to hospice.

The changes in ADL ability, frequent falls, unexplained weight loss, decreased communication, and admission to hospice constituted a significant change of condition.

There was no documented RN assessment of Resident 5's change of condition with findings, resident status, and interventions made as a result of the assessment. The service plan was not updated until one month later, on 05/05/23.

The need to ensure conditions that represent significant changes of condition are assessed timely by the facility RN was discussed with Staff 1 (RCC), Staff 35 (RN), and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 12/05/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Delegation records for Staff 11, 12 and 22 (MTs), reviewed on 12/06/22 and 12/07/22, lacked documentation in the following areas:

* An RN assessment of the resident's condition;

* Rationale that the task could be safely delegated to the CG;

* Rationale for how frequently the client should be reassessed by the RN; and

* Rationale for how frequently the unlicensed person(s) should be supervised and reevaluated based on the competency of the MT.

The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22.  They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#7) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 05/23/23, Resident 7 was identified to be administered insulin injections by non-licensed staff.

Delegation records and staff interviews revealed the following:

* Lack of an RN assessment of the resident's condition;

* Only insulin preparation was delegated and not administration; and

* Resident was self-administering the insulin with the assistance of the unlicensed staff.

The need to ensure the resident was assessed by the RN, staff completed all the components of insulin administration and not just a portion and staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 9 (Facility Administrator) on 05/24/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 1 of 1 sampled resident (#12) who received insulin injections by a unregulated assistive person (UAP). This is a repeat citation. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the UAP, teaching the task, and observing the staff demonstrate the task.

During the acuity interview on 04/15/24, Resident 12 was identified to be administered insulin injections by UAPs.

Resident 12's MARs dated 03/01/24 through 04/14/24 and delegation records were reviewed with Staff 3 (Health Services Director/RN) on 04/16/24.

a. An RN assessment of the resident's condition failed to document the following:

* The frequency of resident assessment deemed necessary by the RN to determine the ongoing stability and predictability of the resident's responses to their condition; and

* The resident's responses to other actual or potential health problems that may impact their responses to the condition for which the nursing procedure was ordered.

b. The RN re-evaluation of the UAP failed to document the following:

* The nursing procedure delegated;

* Whether the RN had authorized the same UAP to perform the same nursing procedure previously;

* The length of time the RN had worked with the UAP as a health care team member;

* Evaluation of the UAP's documentation of performance of the nursing procedure;

* Address questions or concerns the UAP and client may have;

* Direct observation of the UAP in their performance of the nursing procedure on the client; and

* Documentation of the length of the UAP's authorization period with data supporting the decision.

The need to ensure the resident was assessed by the RN and the UAP was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 3, Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/16/24. They acknowledged the findings.

Facility failed to ensure delegation was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 1 of 1 sampled resident (#12) who received insulin injections by a  unregulated assistive person (UAP).

1.RN assessed resident 12 and updated delegations to reflect OSBN Div 47 rules.

2.RN educated on OSBN Div 47 regulations regarding delegation. All residents with delegation audited, delegations updated as needed to reflect OSBN Div 47 rules.  Tracking system will be implemented for monitoring delegations and maintaining currency for all staff.

3.Administrator or Consultant will perform monthly audits of delegation documentation.

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

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers, ensure staff were informed of new interventions, the service plan was updated and reporting protocols were in place for 1 of 2 sampled residents (#3) who was reviewed with outside service providers. Findings include but, are not limited to:

Resident 3 was admitted to the facility in 10/2022 with diagnoses including atrial fibrillation and congestive heart failure.

A review of the service plan, temporary care plans and outside provider notes reviewed during the survey identified the following recommendations were not communicated to staff, nor was the service plan updated and followed related to:

* Behavior support plan and interventions;

* Daily weights;

* Encourage resident to get out of bed;

* Encourage resident to walk halls BID;

* Remind resident to use incentive spirometer TID (manual machine for lung exercises); and

* Remind resident to lock brakes on walker prior to sitting down on it.

During an interview on 12/06/22, Staff 11 (MT) reported the facility didn't take the resident's weight. The resident was only weighed when s/he moved in.

During an interview on 12/06/22 at 1:45 pm, Staff 1 (Interim Administrator) confirmed the facility's process was to communicate the recommendations to staff on a temporary care plan. She acknowledged their were no temporary care plans for the above recommendations.

Based on interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as required in OAR 411-054-0050 Infection Prevention and Control. Findings include, but are not limited to:

In an interview on 12/06/22, Staff 1 (Interim Administrator) reported Staff 2 (Corporate Director of Nursing) was the facility's designated Infection Control Specialist.

Review of Staff 2's infection control training revealed she had not completed the required specialized, Department-approved training in infection prevention and control protocols for an Assisted Living Facility Infection Control Specialist.

The need to ensure the designated Infection Control Specialist completed all required training was reviewed with Staff 1 and Staff 2 on 12/07/22. They acknowledged training had not been completed as required.

2. Resident 2 was admitted to the facility in 2021 with diagnoses including diabetes. Review of 10/14/22 physician's orders, 11/01/22 through 12/05/22 MAR and 09/07/22 through 12/02/22 progress notes identified the following deficiency:

According to the records, facility staff administered CBG testing to Resident 2 on the following dates:

* 09/16/22;

* 10/01/11;

* 10/02/22;

* 10/05/22;

* 11/26/22; and

* 11/30/22.

The facility lacked a signed physician's order to administer CBG testing for Resident 2.

The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility administered was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's record for all medications and treatments that the facility was responsible to administer and medication and treatment orders were carried out as prescribed for 2 of 6 sampled residents (#s 2 and 3) whose records were reviewed. Findings include but, are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses of atrial fibrillation and congestive heart failure.

A review of the 12/2022 MAR and current physician orders dated 10/17/22 identified the following:

Resident 3 was prescribed furosemide, give one tablet as needed, for weight gain of three pounds overnight/five pounds in a week and potassium chloride as needed, for weight gain of three pounds overnight/five pounds in a week.

During an interview on 12/06/22, Staff 11 (MT) reported the facility wasn't taking the resident's weight.

The need to ensure the facility followed signed physician orders as prescribed was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 4 of 6 sampled residents (#s 2, 3, 4 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2018 with diagnoses including diabetes and dementia.

Resident 4's 12/01/22 through 12/05/22 MAR was reviewed and identified the following:

* PRN oxycodone and PRN Tylenol for pain with no clear direction to staff regarding which to give first;

* Lantus (for diabetes) without resident-specific parameters of when to hold;

* Novolog (for diabetes) lacked clear parameters for low CBGs; and

* Warfarin (anticoagulant) lacked reason for use.

On 12/07/22, the need to ensure MARs were accurate was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing). They acknowledged the findings, and no further information was provided.

2. Resident 6 was admitted to the facility 04/2020 with diagnoses including vascular dementia, emphysema and hypertension.

Review of Resident 6's MAR, dated 12/01/22 to 12/05/22, identified the following:

*The MAR listed the following PRN bowel medications for constipation:  Milk of Magnesia, senna, bisacodyl suppository and polyethylene glycol. The MAR lacked parameters for these medications, to direct the sequential order of use.

*The MAR listed the following PRN medications for pain:  acetaminophen, morphine sulfate and trolamine salicytate.  The MAR lacked parameters for these medications, to direct the sequential order of use.

On 12/07/22 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescribe and administered by the facility was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages). They acknowledged the findings.

3. Resident 2 was admitted to the facility in 2021 with diagnoses including diabetes.

The resident's 11/01/22  through 12/05/22 MAR and 11/07/22 through 12/05/22 Medication Administration History records were reviewed and revealed the following:

* An order for sucralfate one gram tablet (stomach pain), take one gram to two grams by mouth twice daily, lacked resident-specific parameters and instructions for staff on when to give one tablet versus two tablets, or if the resident could self-direct the medication; and

* On multiple occasions, the facility failed to record the dosage of sucralfate administered to Resident 2.

The need to ensure MARs were accurate, and included dosage and resident-specific parameters and instructions, was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 10/2022 with diagnoses including atrial fibrillation and congestive heart failure.

A review of the 12/2022 MAR identified the following inaccuracies:

* On four occasions the 12/2022 MAR lacked initials of the person who administered simethicone (antacid chewable);

* Polyethylene glycol and sennosides, as needed (both for bowel care), lacked resident specific parameters including instructions of which medication to administer first; and

* Atorvastatin calcium, finasteride, simethicone and Ambien lacked reason for use.

The need to ensure MARs were accurate and included initials of the person who administered the medications, parameters for multiple PRN medications used to treat the same condition, and had reason for use for all medications was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 06/15/23 with diagnoses including diabetes and fibromyalgia.

Resident 7's 05/01/23 through 05/23/23 MAR was reviewed and identified the following:

* PRN Tylenol (for pain) and PRN oxycodone (for pain) lacked resident-specific parameters for which to use first.

* Staff initialed on the MAR they administered insulin, however, the resident administered it.

On 05/24/23, the need to ensure MARs had clear parameters for unlicensed staff to follow and staff were not initialing for medications they did not administer was discussed with Staff 9 (Facility Administer). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 3 sampled residents (#s 7 and 8) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety.

A review of the 05/01/23 through 05/23/23 MAR and current physician orders dated 04/05/23 identified the following deficiencies:

* An order for Zofran (for nausea) every 6 hours, as needed was not transcribed onto the MAR.

* A physician order instructed staff to administer 4 to 6 LPM (liters per minute) by nasal cannula for comfort to maintain saturation between 92% and 95%. The MAR indicated to administer the oxygen as needed, staff were not initialing the MAR for oxygen administration and staff failed to document oxygen saturation levels.

* The MAR lacked parameters for PRN milk of magnesia and PRN polyethylene glycol powder, both used to treat constipation.

* The MAR was initialed by unlicensed staff indicating staff applied tubi-grip socks on the residents lower extremities on 05/23/23 and 05/24/23. During observations on both days the resident was not wearing tubi-grip socks. There was no documented evidence on the MAR that the resident had refused the treatment.

The need to ensure MARs included all prescribed medications transcribed accurately on the MAR, treatment refusals were accurately documented on the MAR and parameters for multiple PRN medications used to treat the same condition were discussed with Staff 1 (RCC) and Staff 9 (Facility Administrator). They acknowledged the findings.

2. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.

Review of Resident 5's clinical record indicated the following:

The 05/01/23 through 05/23/23 MAR, indicated staff administered the PRN psychotropic medications:

* Diazepam 5 mg 12 times;

* Lorazepam 0.5 mg 1 time; and

* Quetiapine 25 mg 1 time.

There was no documented evidence the staff attempted and documented non-drug interventions with ineffective results prior to administering the medication.

The need to ensure non-pharmacological interventions were attempted and, documented with ineffective results prior to administering the medications was reviewed with Staff 1 (RCC), Staff 35 (RN), and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication specific instructions were included on the MAR and non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications, for 2 of 2 sampled residents (#s 5 and 8) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety.

Review of Resident 8's clinical record indicated the following:

* Resident 8 was prescribed hydroxyzine 50 mg capsule, as needed, three times daily (to treat anxiety);

* The 05/01/23 through 05/23/23 MAR lacked clear medication specific instructions regarding how long to wait before administering the next dose; and

* The 05/01/23 through 05/23/23 MAR, indicated staff administered 21 doses of PRN hydroxyzine. There was no documented evidence the staff attempted and documented non-drug interventions with ineffective results prior to administering the medication.

The need to ensure medication specific instructions and non-pharmacological interventions were attempted and, documented with ineffective results prior to administering the medications was reviewed with Staff 1 (RCC) and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions had been tried and documented with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#5) who was prescribed a PRN psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease and depression.

Review of MARs dated 03/01/24 through 04/15/24 and charting notes for the same time period identified the following:

Resident 5 was prescribed diazepam 5 mg every four hours PRN for anxiety, and

unlicensed staff administered the PRN psychotropic medication on 03/29/24, 04/06/24 and 04/10/24.

There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medication.

The need to ensure non-pharmacological interventions were attempted and documented with ineffective results prior to administering the medications was reviewed with Staff 3 (Health Services Director/RN), Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/16/24. They acknowledged the findings.

Facility failed to ensure non-pharmacological interventions had been tried and documented with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#5) who was prescribed a PRN psychotropic medications.

1.Resident 5 PRN use of antipsychotic medication reviewed and non-pharmaceutical interventions put in place. Staff educated on how to use non-pharmaceutical interventions prior to PRN medications.

2.Psychotropic Policy will be put in place. Staff will be trained on policy. All resident charts for PRN psychotropic medications being reviewed. Any resident orders for PRN psychotropic medications will be updated to include non-pharmaceutical interventions. Service plans will be updated as needed. Staff will be educated on updated orders and Service Plans. Initial and quarterly assessments will identify PRN medication, non-pharmacological interventions, frequency of use, effectiveness, and need for scheduled dose vs PRN.

3.Administrator and/or RN will perform weekly audits of MARs to ensure that every PRN psychotropic medication has non-pharmacological interventions listed and that documentation demonstrates staff are following the Psychotropic Medication Policy and attempting interventions prior to using PRN psychotropics.

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

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who utilized a supportive device with potentially restraining qualities was informed of the risks and benefits of the device, there was documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use and precautions related to the device, and the use of the device was included in the service plan for 1 of 3 sampled residents (#2) who had bi-lateral quarter-length side rails on their bed. Findings include, but are not limited to

Resident 2 was admitted to the facility in 2021 with diagnoses including arthritis.  

On 12/05/22 at 11:45 am, the resident was observed to have bi-lateral quarter length side rails on his/her bed.

On 12/05/22, review of  the "Supportive Device With Restraining Characteristics Assessment and Review" form dated 09/30/22 lacked documented evidence of the following:

*  Other less restrictive alternatives were evaluated prior to the use of the device;

*  Resident 2 was informed of risks and benefits associated with use of the device;

* Caregivers were instructed on the correct use and precautions related to the device; and

* The use of the device was included in the resident's service plan.

Requirements regarding the use of devices with potentially restraining qualities were discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to select and implement an Acuity-Based Staffing Tool (ABST), complete an ABST assessment for each resident, and develop the facility's staffing plan based on the ABST. Findings include, but are not limited to:

In an interview on 12/07/22, Staff 1 (Interim Administrator) stated the facility had not implemented an ABST to use in developing the facility staffing plan.

On 12/07/22, the requirement to complete an assessment of each resident and implement an ABST was discussed with Staff 1. She acknowledged the lack of an ABST.

Based on interview and record review, it was determined the facility failed to fully implement an Acuity-Based Staffing Tool (ABST), complete an ABST assessment for each resident, and develop the facility's staffing plan based on the ABST. This is a repeat citation. Findings include, but are not limited to:

In an interview on 05/23/23, Staff 9 (Facility Administrator) stated the facility had not yet assessed each resident and entered the assessment information into the ABST. As a result, the ABST was not generating information regarding the staffing levels needed which could be used to develop a facility staffing plan.

On 05/23/23, the requirement to complete an assessment of each resident and implement an ABST was discussed with Staff 9. She acknowledged the lack of an ABST.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 29, 30 and 8) completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 12/06/22. The following deficiencies were identified:

Staff 29 (CG) was hired 08/16/22, Staff 30 (MT) was hired 09/16/22 and Staff 8 (CG) was hired 09/24/22. There was no documented evidence Staff 29, 30 and 8 completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure staff completed all required training as specified in the rules was reviewed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired direct care staff (#33) completed First Aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 05/24/23. The following deficiencies were identified:

Staff 33 (MT) was hired 01/24/23. There was no documented evidence Staff 33 completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure newly-hired direct care staff completed all required training as specified in the rules was reviewed with Staff 9 (Facility Administrator). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC), ensure alternate exit routes are used during fire drills, ensure staff know the designated point of safety outside the building and provide fire and life safety training to staff on alternate months. Findings include, but are not limited to:

Fire drill and Fire and Life Safety training records for the six months prior to the survey were requested and reviewed on 12/06/22. The following deficiencies were identified:

1. The facility was not conducting fire drills every other month. The only fire drills documented within the last six months were conducted on 10/26/22 and 10/27/22.

a. The fire drill records lacked the following documentation:

* Time of day (the record did not indicate "am" or "pm");

* The escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Number of occupants evacuated; and

* There was no evidence alternate exit routes were used during fire drills to react to varying potential fire origin points.

b. In interviews on 12/06/22, Staff 8 (CG) and Staff 19 (MT) stated they did not know and had not been trained on the designated point of safety outside the building.

2. In an interview on 12/06/22, Staff 1 (Interim Administrator) stated staff completed one online Fire and Life Safety course annually. The facility did not provide fire and life safety instruction to staff on alternate months as required in the rule.

The need to ensure fire drills and fire and life safety training for staff were provided per the rule was reviewed with Staff 1 on 12/07/22 at 1:40 pm. She acknowledged the findings. The surveyor provided her a copy of OAR 411-054-0090.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC), ensure alternate exit routes were used during fire drills, ensure staff know the designated point of safety outside the building and provide fire and life safety training to staff on alternate months. This is a repeat citation. Findings include, but not limited to:

Fire drill and Fire and Life Safety training records for the six months prior to the revisit survey were requested and reviewed on 05/23/23. The following deficiencies were identified:

1. In an interview on 05/23/23, Staff 9 (Facility Administrator) stated the facility did not conduct fire drills every other month. The only fire drills documented within the last six months were actual fire alarm events.

Review of the fire event documentation indicated the "Fire Emergency Drill Checklist" form the facility used for fire drills lacked space to document the following required information:

* The escape route used; and

* Problems encountered, comments related to residents who resisted or failed to participate in the drills.

2. In an interview on 05/23/23 Staff 9 (Facility Administrator) stated the facility was providing staff fire and life safety training upon hire and once annually. The facility did not provide fire and life safety instruction to staff on alternate months as required in the rule.

The need to ensure fire drills and fire and life safety training for staff were provided per the rule was reviewed with Staff 9, Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23 at 12:50 pm. They acknowledged the findings.

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

On 04/16/24, this surveyor requested fire drill and fire and life safety training records from Staff 9 (Director of Facility Operations). She stated she did not know where the records were, the employee who kept those records had been on leave, and she would attempt to get in touch with that employee to locate the records.

On 04/17/24, Staff 9 reported she had still been unable to locate the records. Review of the facility's "2024 Inservice Calendar" indicated fire and life safety training for employees was only scheduled twice during the year, not every other month as required in the rule.

The facility failed to provide documentation it was conducting fire drills every other month per the OFC and providing fire and life safety training to staff on alternate months.

The need to ensure fire drills and fire and life safety training was provided and documented was reviewed with Staff 9 and Staff 3 (Director of Health Services/RN) on 04/17/24. They acknowledged the lack of records.

Facility failed to conduct and record fire drills according to the Oregon Fire Code (OFC) every other month and provide fire and life safety instruction to staff on alternate months.

1.Maintenance Department to provide fire life and safety training to all staff.

2.Initiate use of a fire drill form with all required elements for compliance. Fire and Life Safety drills to be conducted every other month in different shifts. Maintenance Director will develop a system to track and monitor completion of fire drills and fire and life safety training on alternate months.

3.Administrator will review and monitor completion of fire drills and life safety training with Maintenance Director on a monthly basis.

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

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures. Findings include, but are not limited to:

On 12/06/22, Staff 1 (Interim Administrator) was asked to explain the facility's process for providing residents with instruction on fire and life safety procedures upon admission and annually. Staff 1 reported a new resident was given a copy of the Resident Handbook which contained information about the facility's fire and safety drills. She acknowledged the facility had not been providing annual re-instruction on fire and life safety procedures to residents.  

Review of the Resident Handbook indicated "Office personnel will explain fire and life safety drill procedures to you."

On 12/07/22, Staff 4 (Assistant to the Administrator) reported a new resident was given a copy of the Resident Handbook but acknowledged the resident was not provided any further instruction from the facility. She also confirmed that the facility was not providing annual re-instruction.

The need to ensure residents received fire and life safety training within 24 hours of admission and annually was discussed with Staff 1 on 12/07/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures. This is a repeat citation. Findings include, but are not limited to:

On 05/23/23 at 2:45 am, Staff 9 (Facility Administrator) was asked to explain the facility's process for providing residents with instruction on fire and life safety procedures upon admission and annually. Staff 9 stated a new resident was given a copy of the Resident Handbook which contained information about the facility's fire and safety drills. Staff 9 acknowledged the resident was not provided any further instruction. Staff 9 also stated the facility did not provide annual re-instruction.

The need to ensure residents received fire and life safety training within 24 hours of admission and annually was discussed with Staff 9, Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23 at 12:50 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures, and kept a written record of fire safety training including the content and residents attending. This is a repeat citation. Findings include, but are not limited to:

On 04/17/24 at 11:20 am, this surveyor asked Staff 9 (Director of Facility Operations) about the facility's process for instructing new residents on fire and safety procedures following admission and reinstructing them annually. Staff 9 stated she was unsure as to whether the facility had developed a new process to meet the rule.

Multiple sampled residents' service plans included the following statement: "Fire evacuation procedures have been reviewed with [resident]." However, Staff 9 stated she intended to implement a process that included the resident's acknowledgment of that training and their signature to ensure the instruction was provided.

The need to ensure the facility had a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures was reviewed with Staff 9 and Staff 3 (Director of Health Services/RN) on 04/17/24. They acknowledged the findings.

Facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures, and kept a written record of fire safety training including the content and residents attending.

1. The Resident Services Director will provide fire life and safety training to all current residents and new residents within 24 hours of admission.

2. Fire and Life Safety Training will be added to the new admission checklist to ensure it is completed as part of the admission process. On an ongoing basis, all residents will be invited to a bi-annual in-service regarding fire, life, and safety with the maintenance department.

3. New admission records will be audited weekly by administrator or designee to ensure Fire and Life Safety training occurred within 24 hours of admission. During quarterly reviews resident charts will be reviewed to determine training of status for each resident. Training will be provided as needed for residents who choose not to attend the bi-annual life safety training with the maintenance department.  

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

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 C260, C270, C282, C310, C 330, C361, C372, C420, C422, C610, C613, C615, C645, C655, Z155 and Z164.

Based on observation, interview and record review, it was determined the facility failed to submit a plan of correction that satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260, C 270, C 282, C 330, C 420, C 422, C 455, C 610, C 613, C 615, and C 655.

It was determined the facility failed to submit a plan of correction that satisfied the Department.

1. The facility has a new administrator and hired a consultant to assist in developing the plan of correction for each citation.  

2. The new administrator and consultant will work together to develop an acceptable plan of correction for each citation.

3. All areas of the plan of correction will be reviewed by the consultant prior to submission, this will occur at any time a plan is required for submission.  

4. Administrator and Consultant are responsible to see that the plan of correction meets acceptable standards.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include but are not limited to:

Refer to C 150, C 156, C 610, and C 655.

It was determined the facility failed to submit a plan of correction that satisfied the Department.

1. The facility has hired a consultant to assist in developing the plan of correction for each citation.  

2. The administrator and consultant will work together to develop an acceptable plan of correction for each citation.

3. All areas of the plan of correction will be reviewed by the consultant prior to submission, this will occur at any time a plan is required for submission.  

4. Administrator and Consultant are responsible to see that the plan of correction meets acceptable standards

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and all chemicals were secure. Findings include, but are not limited to:

The exterior areas of the facility were toured on 12/05/22 at 1:00 pm. The following were identified:

1a. In the MCC courtyard, there were drop-offs of up to two inches, measured from the concrete to the planting bed surface. These areas created potential hazards for residents.

b. In the ALF patio, there were drop-offs of up to two inches along the sidewalks surrounding the rose beds and around five 12" by 12" square areas near multiple arbor support posts. These areas created potential hazards for residents.

2. The interior areas of the MCC were toured on 12/05/22 at 11:00 am. The following deficiencies were identified:

a. Utility closets in both MCC units were unlocked and contained toxic chemicals. This presented potential risks to residents who resided on the units.

b. MCC unit resident room 119's lockable medicine cabinet was unlocked. It contained the resident's inhaler and a bottle of mouthwash which contained alcohol. These items presented potential risks to that resident.

In an interview on 12/05/22 at 12:10 pm, Staff 15 (MT) acknowledged she was unaware of the items left unsecured in the resident's medicine cabinet and stated she was sure the inhaler should not have been stored there; she was unsure of the facility's policy regarding MCC residents' access to mouthwash or other potentially dangerous chemicals. Staff 15 removed the resident's inhaler from the room.

The exterior areas were toured with Staff 1 (Interim Administrator) and Staff 23 (Maintenance) on 12/05/22 at 2:55 pm. They acknowledged the drop-offs. The interior of the MCC was also toured and the need to ensure chemicals were secure was discussed. They acknowledged chemicals needed to be stored securely.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and all chemicals were secured. This is a repeat citation. Findings include, but not limited to:

The exterior areas of the facility were toured on 05/23/23 at 11:00 am. The following were identified:

1a. In the MCC courtyard, there were drop-offs of up to two inches, measured from the concrete to the planting bed surface. These areas created potential hazards for residents.

b. In the ALF patio, there were drop-offs of up to two inches along the sidewalks surrounding the rose beds and around five 12" by 12" square areas near multiple arbor support posts. There were also drop-offs along the pathways leading from the rear exit (near the raised planter boxes). These areas created potential hazards for residents.

2. The interior areas of the MCC were toured on 05/23/23 at 10:45 am.

A utility closet on the South MCC unit was unlocked and contained toxic chemicals. This presented potential risks to the residents who resided on the south unit.

On 05/24/23 at 12:50 pm Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) declined a tour of the exterior areas and the interior of the South MCC unit. They acknowledged the drop-offs and the need to ensure chemicals were stored securely.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and there was locked storage for all chemicals. This is a repeat citation. Findings include, but not limited to:

The exterior areas of the facility were toured at 9:06 am on 04/15/24. The following was identified:

1a. In the MCC courtyard, there were drop-offs of up to two inches, measured from the concrete to the planting bed surface. These areas created potential hazards for residents.

1b. In the ALF patio, there were drop-offs of up to three inches along the sidewalks surrounding the rose beds and around five 12" by 12" square areas near multiple arbor support posts. There were also drop-offs along the pathways leading from the rear exit (near the raised planter boxes). These areas created potential hazards for residents.

2a. The interior areas of the MCC were toured at 9:34 am on 04/15/24. Toxic chemicals were observed in unlocked storage in the following areas:

* The housekeeping closet on the North MCC unit; and

* The cabinets above the stove in the kitchenette on the North MCC unit.

This presented potential risks to the residents who resided on the North MCC unit.

2b. The interior areas of the ALF were toured at 9:46 am on 04/15/24. Toxic chemicals were observed in unlocked storage in the following areas:

* On the counter by the sink in the public bathrooms on the 2nd and 3rd floors;

* On a storage bin to the left of the door to Room 319; and

* In the housekeeping closet on the 2nd floor.

These unlocked chemicals presented potential risks to the resident who resided in the ALF.

The need to ensure all exterior pathways and accesses were maintained in good repair and there was locked storage for all chemicals was discussed with Staff 9 (Director of Facility Operations) on 04/16/24. She acknowledged the findings.

It was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and there was locked storage for all

chemicals.

1. All potentially dangerous chemicals will be stored in locked cabinets/containers. Contracts are place for exterior maintenance and repairs for drop offs and uneven surfaces. Exterior drop offs were filled by our landscaping company on 4/23/2024.

2. Administrator and Maintenance Director will have scheduled quarterly walk through inspections of the building exterior to ensure pathways are safe and chemicals are stored safely and appropriately.

3. Administrator or designee will perform random audits, at least 2x/month to ensure chemicals are being kept in locked storage when not in use and pathway drop offs are an acceptable height.

4. Administrator is responsible to see that the plan of correction meets acceptable standards.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

On 09/17/24 and 09/18/24 the exterior of the facility was toured. The following was identified:

a. The Memory Care (MC) courtyard had drop-offs that were measured up to three and a half inches located along the paved pathway and near to resident planter boxes. These areas created potential hazards for residents.

b. The Assisted Living (AL) courtyard had drop-offs measured up to four and a half inches along the paved pathways located around the perimeter of the resident planter boxes, an AL facility exit door near the resident's planter boxes, and near the wooden benches throughout the courtyard. These areas created potential hazards for residents.

On 09/18/24 at 9:47 am, the MC and AL courtyards were toured with Staff 23 (Maintenance). He confirmed he was aware of the drop offs.

The need to ensure all exterior pathways were maintained in good repair was discussed with Staff 2 (Corporate Director of Nursing/ Administrator), Staff 23, Staff 37 (Corporate Director of Wellness), Staff 38 (Resident Services Director), Staff 39 (Director of the Cottages), and Staff 40 (LPN) on 09/18/24. They acknowledged the findings.

It was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair

1. Contracts are in place for exterior maintenance and repairs for drop offs and uneven surfaces.  

2. Administrator and Maintenance Director will have scheduled quarterly walk through inspections of the building exterior to ensure pathways are safe  

3. Administrator or designee will perform random audits, at least 2x/month to ensure pathway drop offs are an acceptable height.

4. Administrator is responsible to see that the plan of correction meets acceptable standards.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

The interior of the facility was toured on 12/05/22 at 11:00 am. The following areas needed cleaning or repair:

* Black recliner chair in the rear living room of MCC had spillage in cup holder;

* Wall vents in common area next to Resident room 132 had dust build-up;

* Ceiling light in the living area of MCC next to dining area had no cover and had a broken light fixture;

* Resident room 120's bathroom door had a hole in the middle, paint on toilet seat was worn exposing bare wood, brown debris was noted on the shower floor;

* Resident room 119's bathroom sink had a large chip, paint on toilet seat was worn exposing bare wood;

* Several wooden patio benches outside the main dining area and in the MCC courtyard were worn and rough to the touch;

* Three white round tables in the coffee area next to main dining area were noted to have damaged laminate, and the counter backsplash was warped and the laminate was coming off;

* Folding counters in the resident laundry rooms on the 1st, 2nd and 3rd floors had damaged laminate;

* Resident laundry room on the 2nd floor sink cabinet was missing right door, the rubber baseboard was peeling away from the wall; and

* Resident room 205 had pervasive urine odor in the room.

The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Interim Administrator) and Staff 23 (Maintenance) on 12/05/22. They acknowledged the areas needing cleaning and repair.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

The interior and exterior of the facility was toured on 05/23/23 at 9:40 am. The following areas needed cleaning or repair:

Memory Care Community:

* Resident room 119's bathroom sink had a large chip and paint on the toilet seat was worn exposing bare wood;

* Resident room 120's bathroom door had a hole in the middle and paint on the toilet seat was worn exposing bare wood;

* Resident room 137 was missing a door to the bathroom base cabinet;

* The handrails at the entry to the north MCC unit were gouged and had chipped paint; and

* Several wooden patio benches in the MCC courtyard were worn and rough to the touch;

Assisted Living:

* Three white round tables in the coffee area next to main dining area were noted to have damaged laminate, and the counter backsplash was warped and the laminate was coming off;

* Handrails across from the 1st floor lobby elevator and across from the mailboxes were gouged and had chipped paint;

* Folding counters in the resident laundry rooms on the 1st, 2nd and 3rd floors had damaged laminate;

* Resident laundry room on the 2nd floor sink cabinet was missing a right door, the rubber baseboard was peeling away from the wall;

* Resident room 333 had pervasive urine odor in the room; and

* Several wooden patio benches in the ALF courtyard around the large statue were worn and rough to the touch.

Assisted Living kitchen:

* The entry area, including walls, door and frame, had multiple areas that were dirty or where paint was chipped, exposing bare wood that was an uncleanable surface;

* Two lower open shelving areas under the steam table were missing laminate, exposing bare wood that was an uncleanable surface: and

* Caulking around the three-compartment sink in the food preparation area had a black substance on its surface.

The areas needing cleaning or repair were discussed with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23. They declined the surveyor's offer to tour the areas. They acknowledged the areas needing cleaning and repair.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:

The interior and exterior of the facility was toured at 9:06 am on 04/15/24. The following areas needed cleaning or repair:

A. Memory Care Community:

* The heating vents and returns throughout the North and South MCC units had a buildup of dust and dirt;

* Resident room 119's bathroom sink had a large chip, and paint on the toilet seat was worn exposing bare wood;

* Resident room 120's bathroom door had a hole in the middle, and paint on the toilet seat was worn exposing bare wood;

* The handrails at the entry to the north MCC unit were gouged and had chipped paint; and

* Several wooden patio benches in the MCC courtyard were worn and rough to the touch.

B. Assisted Living:

* The heating vents and returns throughout the facility had a buildup of dust and dirt;

* Three white round tables in the coffee area next to main dining area were noted to have damaged laminate, and the counter backsplash was warped and the laminate was coming off;

* The handrails across from the 1st floor lobby elevator and across from the mailboxes were gouged and had chipped paint;

* The folding counters in the resident laundry rooms on the 1st, 2nd, and 3rd floors had damaged laminate rendering the surfaces uncleanable;

* The sink cabinet in the resident laundry room on the 2nd floor was missing a right door;

* Resident rooms 206 and 330 had a pervasive urine odor; and

* Several wooden patio benches in the ALF courtyard around the large statue were worn and rough to the touch.

The areas needing cleaning or repair were discussed with Staff 9 (Director of Facility Operations) on 04/16/24. She acknowledged the findings.

Facility failed to ensure all interior materials and surfaces were kept clean and in good repair and free from unpleasant odors.

1. The areas identified in the resident rooms and laundry room are being addressed and corrected through a combination of repair and replacement to ensure all surfaces are cleanable, smooth and no structural material exposed.

-heating vents and returns throughout the facility

units were cleaned as of April 23, 2024

-room 119's bathroom sink and toilet seat in process of being repaired

-room 120's bathroom door and toilet seat in process of being repaired

-handrails in facility will be audited and repainted where needed

-wooden patio benches throughout facility courtyards will audited and be sanded and re-varnished as needed.

-laminate in coffee shop will be repaired and tables being replaced

-counters in laundry room will have laminate repaired

2. The housekeeping and maintenance supervisor has implemented a written schedule to formally audit the building on a quarterly basis. Maintenance supervisor will perform monthly audits as part of the quality program.

3. Administrator or designee will perform a weekly building walkthrough audit on an ongoing basis.

4. Administrator is responsible to see that the plan of correction meets acceptable standards.

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided in each resident unit, and operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

1. During a group interview conducted by the survey team on 12/06/22 at 11:00 am, several residents reported they did not have a key to their lockable storage. Also, in an interview on 12/05/22, Resident 2 reported s/he did not have a key to the lockable storage in his/her unit.

Unsampled resident rooms 233 and 226 were inspected on 12/07/22 between 10:45 am and 11:00 am. Each room had a medicine cabinet in the bathroom that had a locking device. Both residents stated, however, they did not have a key to lock the storage space.

In an interview on 12/07/22, Staff 4 (Assistant to the Administrator) explained she was responsible for orienting new residents to the facility. She acknowledged she had not been giving new residents a key for their lockable storage, and stated existing residents may not have been given keys or lost their key.

2. The windows of four randomly-sampled rooms were inspected on 12/06/22. Each resident unit included two vertically-opening windows with sill heights less than 36 inches. Three of the four units' windows had no device which limited how much the windows could open to prevent accidental falls. The fourth unit had one window that had a small limiting device but it was not secure and did not prevent the window from being opened fully.

The need to ensure all residents had a key to the lockable storage space in their unit, and that all operable windows above the first floor were designed to prevent accidental falls was discussed with Staff 1 (Interim Administrator) on 12/07/22. She acknowledged the findings. Staff 1 reported she had staff inventory every resident that morning, and all residents would be provided a key to their storage space by the end of the day.

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided in each resident unit, and operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. This is a repeat citation. Findings include, but are not limited to:

1. Unsampled resident rooms 205, 233, 313 and 333 were inspected on 05/23/23 and 05/24/23. Each room had a medicine cabinet in the bathroom that had a locking device. Only one resident in room 313 stated they had a key to lock the storage space.

2. The windows of four randomly sampled rooms (205, 311, 313, and 333) were inspected on 05/23/23 and 05/24/23. Each resident unit included two vertically opening windows with sill heights less than 36 inches. None of the four units' windows had a device which limited how much the windows could open to prevent accidental falls.

The need to ensure all residents had keys to their locked storage space and windows above the first floor had devices to prevent accidental falls was reviewed on 05/24/23 at 12:50 pm with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided in each resident unit, and operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. This is a repeat citation. Findings include, but are not limited to:

1. Sampled and unsampled resident rooms 206, 209, 317, and 330 were inspected on 04/15/24. Each room had a medicine cabinet in the bathroom that had a locking device. All residents stated they did not have a key to the locking device when interviewed.

2. The windows of four randomly sampled rooms (207, 217, 330, and 340) were inspected on 04/15/24 and 04/16/24. Each resident unit included two vertically opening windows with sill heights less than 36 inches. None of the four units' windows had a device which limited how much the windows could open to prevent accidental falls.

The need to ensure all residents had keys to their locked storage space and windows above the first floor had devices to prevent accidental falls was reviewed on 04/16/24 with Staff 9 (Director of Facility Operations). She acknowledged the findings.

Facility failed to ensure a lockable storage space was provided in each resident unit, and operable windows were designed to prevent  accidental falls when sill heights were lower than 36 inches and above the first floor.

1.Maintenance Director will audit all resident rooms for keys for locking cabinets and windows for safety devices. Keys will be provided to any residents without a key. Safety devices will be installed on windows to prevent accidental falls.

2.Admission checklist will be modified to include offering/resident receipt of a key to the locking cabinet in their apartment. Maintenance Director will ensure every apartment has a working lock and key as part of general apartment maintenance.

Windows in all rooms will have safety devices installed to prevent potential accidental falls.

3.As part of the quarterly review process, staff will verify residents have keys to their locking cabinets.

Maintenance director will verify affected apartments have safety devices on windows during apartment turnover and scheduled quarterly inspections.

Administrator will perform random audits of resident rooms to ensure compliance.  

4.Administrator is responsible to see that the plan of correction meets acceptable standards.?

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

On 12/05/22, the surveyor measured water temperatures in occupied resident unit bathrooms and common area bathrooms throughout the assisted living and memory care units. The following were identified:

* Resident room 131 (MCC) bathroom sink water temperature was 106.0 degrees F; and

* Resident room 132 (MCC) bathroom sink water temperature was 88.4 degrees F.

On 12/05/22, the water temperatures were discussed with Staff 1 (Interim Administrator) and Staff 23 (Maintenance). They both acknowledged the findings and Staff 23 stated that he did not have a process for monitoring water temperatures regularly.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110-120 degrees Fahrenheit (F). This is a repeat citation. Findings include, but not limited to:

On 05/23/23 and 05/24/23, the surveyor measured water temperatures in occupied resident unit bathrooms throughout the assisted living and memory care units. The following were identified:

Memory Care Community:

* Resident room 132 water temperature was 94.3 F; and

* Resident room 137 water temperature was 102.4 F.

Assisted Living:

* Resident room 105 water temperature was 109.2 F;

* Resident room 237 water temperature was 122.0 F;

* Laundry room sink second floor water temperature was 124.7 F; and

* Resident room 333 water temperature was 125.1 F.

On 05/24/23 at 12:50 pm the water temperatures were discussed with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance). They acknowledged the findings. Staff 32 acknowledged they didn't have a system for monitoring water temps regularly. Staff 23 stated he monitored water temps daily at the boilers but not at the residents' sinks.

Based on observation and interview, it was determined the facility failed to ensure it provided a call system that connected resident units to the care staff, that a manually-operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exit the ALF. Findings include, but are not limited to:

1. During a group interview conducted by the survey team on 12/06/22 at 11:00 am, several residents reported their personal call pendants did not work.

Unsampled resident rooms 208, 223, 233 and 313 were inspected on 12/06/22 between 1:55 pm and 2:15 pm. The only system for connecting the resident unit to the care staff was by means of a wireless call pendant that each resident was provided.

The resident in room 223 stated his/her call pendant did not work and the resident in room 233 stated s/he did not have a call pendant.

2a. Resident rooms 208, 233 and 313 did not have a manually-operated emergency call system in the unit bathrooms. Room 223 had a wireless emergency call device in the bathroom but the resident stated it did not work.

b. Public restrooms on the 1st and 2nd floors had wireless emergency call devices, not manually-operated devices as required in the rule.

3. The facility was toured on 12/05/22 at 11:00 am. A door alarm in one of the MCC units and several door alarms in the ALF did not operate when the door was opened.

The need to provide a call system that connected resident units to the care staff and a manually-operated emergency call system at each resident bathroom and public-use restroom was discussed with Staff 1 (Interim Administrator) on 12/07/22. She acknowledged the findings. The exit doors were toured with Staff 1 and Staff 23 (Maintenance) on 12/05/22. They acknowledged the door alarms needing batteries or repair/replacement.

Based on observation and interview, it was determined the facility failed to ensure a manually-operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exited the facility. This is a repeat citation. Findings include, but are not limited to:

1a. Random resident apartments were toured during the revisit survey. Resident rooms 205, 233, 311, 313 and 333 did not have a manually-operated emergency call system in the unit bathrooms.

b. Public restrooms on the 1st and 2nd floors had wireless emergency call devices. However, when the 2nd floor restroom device was activated, it did not notify the staff iPod devices.

In an interview on 05/24/23, Staff 9 (Facility Administrator) acknowledged the facility had recently upgraded its wifi system but the wireless wall-mounted devices no longer connected with staff iPods. She stated she would follow-up with the corporate IT department.

2. The facility was toured on 05/23/23 at 9:40 am. A door alarm in the north MCC unit and several door alarms in the ALF did not operate when the door was opened.

The need to ensure exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exited the facility was discussed with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23. They acknowledged the door alarms needing batteries or repair/replacement.

Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exited the facility. This is a repeat citation. Findings include, but are not limited to:

1a. Random resident units in the ALF were toured on 04/15/24 and 04/16/24. Resident rooms 206, 209, and 330 did not have a manually-operated emergency call system in the unit bathrooms.

b. Random resident units in the North and South MCC cottages were toured on 04/15/24 and 04/16/24. Resident rooms 120, 122, and 137 did not have a manually-operated emergency call system in the unit bathrooms.

c. Public restrooms on the 2nd and 3rd floors of the ALF had wireless emergency call devices. However, when the 2nd floor restroom device was activated, it did not notify the staff iPod devices.

During an interview on 04/16/24, Staff 23 (Maintenance) confirmed the wireless push-button call devices in resident bathrooms and in the public bathrooms were inoperable.

2. The facility was toured at 9:06 am on 04/15/24. A door alarm in the South MCC unit and several door alarms in the ALF did not operate when the doors were opened.

The need to ensure a manually operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable systems were provided for security purposes and to alert staff when residents exited the facility was discussed with Staff 9 (Director of Facility Operations) on 04/16/24. She acknowledged the findings.

Facility failed to ensure a manually operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable system were provided for

security purposes and to alert staff when residents exited the facility.

1.All rooms audited to ascertain functionality of manually operated call system. A call system that is secured to the bathroom wall will be installed in all resident rooms and public-use restrooms. Malfunctioning units will be repaired or replaced.

All exterior doors will have an audible alarm installed to alert staff when a resident exits.

2.Maintenance Director will monitor devices on an ongoing basis to ensure functionality. Staff will be trained to notify maintenance when a call device or door alarm is not functioning properly.

3.MC door alarms will be checked twice a shift for functionality. Administrator or designee will perform regular walking rounds with random tests to ensure resident and public use restroom call systems are functioning properly and exit door alarms are audible.

4.Administrator is responsible to see that the plan of correction meets acceptable standards.

?

Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers and failed to provide manually operated emergency call systems at each resident bathroom and public-use restrooms. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. This is a repeat citation. Findings include, but are not limited to:

During a re-licensure survey in 12/2022, facility staff were made aware that resident bathrooms in the MC and AL communities did not have manually operated emergency call systems. Subsequent re-visit surveys in 05/2023 and 04/2024 identified the same concerns and facility staff were made aware.

On 09/17/24 and 09/18/24 during a re-licensure re-visit, the memory care and assisted living communities were toured and interviews with facility staff and residents were conducted, the following was identified:

a. Multiple assisted living unit bathrooms were observed to lack a manually operated emergency call system. Interviews with multiple direct-care staff, identified these unit bathrooms previously had an emergency call system, but it was removed a "long time ago."

Multiple memory care unit bathrooms were identified to have a white circular push button mounted on the wall. Interviews with multiple direct-care staff identified the emergency call system was inoperable.

Public bathrooms located throughout the facility were identified to have a white circular push button mounted on the wall. Interviews with facility staff determined the emergency call system was inoperable.

On 09/18/24 at 9:47 am, Staff 23 (Maintenance) reported the emergency call system provided at each resident bathroom was removed several years ago in both the memory care and assisted living communities and was aware the public bathrooms did not have an operable emergency call system.

b. Several direct care staff interviewed on both the memory care and assisted living units stated assisted living residents were provided an emergency call pendant that would notify staff when used. However, each confirmed the memory care residents were not provided with pendants.

On 09/18/24 at 9:33 am, Staff 23 confirmed the memory care residents were not provided a pendant and did not have a call system that connected the resident or the resident unit to the facility staff.

On 09/18/24 at 10:26 am, Staff 2 (Corporate Director of Nursing/Administrator) and Staff 37 (Corporate Director of Wellness) confirmed they were aware the facility did not have an operable call system.  

The facilities failure to ensure residents had a working call system, left residents unable to call for assistance when needed and placed the residents health, safety, and welfare at risk.

On 09/18/24 at 11:29 the facility was asked to complete and provide an immediate plan of correction. The plan of correction was received and accepted at 3:34 pm. The facility plan of correction included hourly checks for all residents until full installation of a new system was completed by 09/30/24. The immediate risk was addressed, however the facility will need to evaluate the overall system(s) failures(s) associated with the licensing violation.

The need to have an operational call system that connected residents to the care staff center or staff pagers and to have a manual emergency call system in all resident bathrooms including public restrooms was discussed with Staff 2, Staff 23, Staff 37, Staff 38 (Resident Services Director), Staff 39 (Director of the Cottages), and Staff 40 (LPN) on 09/18/24. They acknowledged the findings.

Facility failed to ensure a manually operated emergency call system was provided at each resident bathroom and public-use restroom

1.All rooms audited to ascertain functionality of manually operated call system. A call system that is secured to the bathroom wall will be installed in all resident rooms and public-use restrooms. Malfunctioning units will be repaired or replaced.

2.Maintenance Director or designee will monitor devices on an ongoing basis to ensure functionality.

3.Administrator or designee will perform regular walking rounds with random tests to ensure resident and public use restroom call systems are functioning properly

4.Administrator is responsible to see that the plan of correction meets acceptable standards.

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 C240, C242, C295, C361, C372, C420, C422, C610, C613, C645 and C655.

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

Refer to C361, C372, C420, C422, C610, C613, C615, C645 and C655.

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

Refer to C 150, C 156, C 231, C 420, C 422, C 455, C 610, C 613, C 615, and C 655.

Refer to C150, C156,?C231, C420, C422, C455, C610, C613, C615, C655

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

Refer to C 150, C 156, C 455, C 610, and C 655.

Refer to C150, C156, C455, C610, C655

Based on interview and record review, it was determined the facility failed to provide required training for 2 of 2 sampled newly-hired non-direct care staff (#s 28 and 21), 3 of 3 sampled newly-hired direct care staff (#s 29, 30 and 8) and 3 of 3 sampled long-term direct care staff (#s 11, 31 and 22) whose training records were reviewed. Findings include, but are not limited to:

The building consisted of an Assisted Living Facility that included two endorsed MCC units that fell under the same license. In an interview on 12/06/22, Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) stated the facility provided training for staff as required under the MCC rules (OAR 411-057-0155) so that all staff had knowledge of dementia care, regardless of whether they worked in the MCC units or the ALF.

Staff training records were reviewed on 12/06/22. The following deficiencies were identified:

1. Staff 28 (Housekeeping) and Staff 21 (Dietary Cook) were hired on 06/01/22 and 10/04 22, respectively.

* There was no documented evidence Staff 28 and Staff 21 completed the required orientation and pre-service dementia training, were provided written job descriptions or that Staff 21 completed Oregon Food Handler's training prior to beginning their job duties.

2. Staff 29 (CG) was hired 08/16/22, Staff 30 (MT) was hired 09/16/22 and Staff 8 (CG) was hired 09/24/22.

* There was no documented evidence Staff 30 and Staff 8 completed orientation training prior to beginning their job duties and pre-service training prior to working independently, or were provided written job descriptions.

* Staff 29 lacked documentation of having completed the following orientation and pre-service training:

    * Infectious Disease Prevention training;

    * Environmental factors that are important to a resident's well-being;

    * Family support and the role the family may have in the care of the resident;

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

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

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

* Staff 29, 30 and 8 lacked documentation of demonstrated competency in any duty they are assigned.

3. Staff 11 (MT) was hired 02/25/08, Staff 31 (CG) was hired 08/17/17 and Staff 22 (MT) was hired 06/18/15. Annual training records were reviewed for the last twelve month period from each staff person's anniversary date of hire.

* Staff 11 and Staff 31 lacked documented evidence they completed a minimum of 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting including six hours of annual in-service training on dementia care.

* Staff 11, 31 and 22 lacked documented evidence they completed annual in-service training on infectious disease prevention by July 1, 2022.

The need to ensure all staff completed all required training as specified in the rules was reviewed with Staff 1 and Staff 2 on 12/07/22. They acknowledged the findings. The surveyor provided them a copy of OAR 411-057-0155.

Based on interview and record review, it was determined the facility failed to provide required orientation training for 2 of 2 sampled newly-hired Staff (#s 33 and 34), pre-service training for 1 of 1 sampled newly-hired direct care Staff (#33) and have documentation of demonstrated competency in all required job duties for 1 of 1 sampled newly-hired direct care Staff (#33) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:

The building consisted of an Assisted Living Facility that included two endorsed MCC units that fell under the same license. In an interview on 05/24/23, Staff 9 (Facility Administrator) stated the facility provided training for staff as required under the MCC rules (OAR 411-057-0155) so that all staff had knowledge of dementia care, regardless of whether they worked in the MCC units or the ALF.

Staff training records were reviewed on 05/24/23. The following deficiencies were identified:

1a. Staff 33 (MT) was hired 01/24/23. There was no documented evidence s/he completed orientation training on the topic of resident rights and values of Community-Based Care or received a copy of their job description prior to performing any job duties. The other required orientation topics (abuse reporting requirements, infectious disease prevention and fire safety and emergency procedures) were not completed prior to performing job duties as required.

b. Staff 34 (Dining Server) was hired 02/01/23. There was no documented evidence s/he completed orientation training on the topic of infectious disease prevention or received a copy of their job description prior to performing any job duties.

2. There was no documented evidence Staff 33 completed training in the following pre-service topics prior to providing care and services to residents independently:

* Environmental factors that are important to a resident's well-being;

* Family support and the role the family may have in the care of the resident;

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

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

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

3. There was no documented evidence Staff 33 demonstrated knowledge and performance in all required areas, including medication administration, within the first 30 days of hire.

The need to ensure newly-hired staff completed all required orientation, pre-service and competency training within the required timeframe's was reviewed with Staff 9 (Facility Administrator) on 05/24/23. She acknowledged the facility still needed to review and improve its training process to ensure compliance.

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, C262, C270, C282, C290, C303, C340 and C310.

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

Refer to C260, C270, C280, C282, C310 and C330.

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

Refer to C 260, C 270, C 282, and C 330.

Refer to C260, C270, C282, C330

Based on interview and record review, it was determined the facility failed to ensure individualized activity plans were developed for each resident, based on their activity evaluations, for 2 of  2 sampled memory care residents (#s 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the MCC in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression, and Resident 6 was admitted to the MCC in 04/2020 with diagnoses including vascular dementia, emphysema and hypertension.

Residents 5 and 6's service plans offered some information about the residents' historical and current interests. However, the facility had not fully evaluated the residents in the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There were no specific activity plans developed from the evaluations which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

On 12/07/22 the need to ensure the facility developed individualized activity plans for each resident in the MCC was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages) who acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure individualized activity plans were developed for each resident, based on their activity evaluations, for 1 of 1 sampled memory care resident (#5) whose service plan was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the MCC in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.

Residents 5's record offered information about the residents' historical interests. However, the facility had not fully evaluated the resident in the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There were no specific activity plans developed from the evaluation which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

On 05/23/23 the need to ensure the facility developed individualized activity plans for each resident in the MCC was discussed with Staff 9 (Facility Administrator) and Staff 35 (RN) who acknowledged the findings.