The findings of the change of ownership survey, conducted 05/07/24 through 05/09/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the Change of Ownership survey of 05/09/24, conducted 10/21/24 through 10/23/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the Change of Ownership survey of 05/09/24, conducted on 12/26/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

The facility was toured at 11:00 am on 05/07/24. The following were not in an accessible or conspicuous location:

* Facility license; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction.

During an interview at 11:21 am on 05/09/24, Witness 1 stated s/he had asked several staff for a copy of the last survey and they stated there was none available.

The need to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings.

1. All required postings have been placed, including the state survey and all required documents as well as the facility license.

2. Training will be provided so that staff are aware of where these items are to remain and that they are to be accessible.

3. Weekly review will occur.

4. The Executive Director will be responsible.

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

a. On 05/08/24 at 10:08 am, the facility's kitchen was observed to need cleaning in the following areas:

* Dirt and dust build-up on and surrounding baseboard next to the oven area;

* The reach in refrigerators and freezers had spillage, debris and crumbs on the bottom shelves;

* Stove oven had black matter on the bottom;

* The caulking around the kitchen sink had black stains;

* The interior of microwave had dried food splatter;

* Utensil tray, pans, and equipment in drawers and cabinets had loose dirt and were greasy to the touch; and

* Sticky residue on exterior drawers and cabinets.

b. On 05/08/24 at 10:08 am, the facility's kitchen was observed to need repair in the following areas:

* Exterior drawers and cabinets doors had chipped paint;

* The wood shelves in the dry food storage area had worn on the edge, exposing raw wood materials; and

* Both wood doors into/out of the kitchen had chipped paint.

c. On 05/08/24 at 10:08 am, the facility's kitchen was observed to need infection prevention in the following areas:

* There were no thermometers in or outside of the two free-standing refrigerators;

* There were no labels or dates on open food containers including ready to eat fruits and feta cheese in the refrigerator next to the hallway;

* There were no labels or dates on open cereal boxes in the dry food storage area;

* Staff 7 (Universal Worker) was observed preparing meals without her waist-length hair pulled back. The surveyor requested Staff 7 tie back her hair during the observation;

* There were tablets for sanitizing pots but there were no test strips to check proper level of sanitation; and

* Staff 3 (Universal Worker), Staff 6 (Universal Worker), and Staff 7, who prepared and served meals to the residents as part of their job duties, had no documented evidence of food handler cards.

The areas requiring cleaning, repair, and infection prevention were discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They both acknowledged the findings.

1. The following items have been addressed:

* Dirt and dust build-up on and surrounding baseboard next to the oven area has been cleaned

* The reach in refrigerators and freezers have been deep cleaned

* Stove oven will be deep cleaned

* The kitchen sink will be replaced and re-caulked

* The interior of microwave has been deep cleaned

* Utensil tray, pans, and equipment in drawers will be deep cleaned

* Sticky residue on exterior drawers and cabinets deep cleaned

* Exterior drawers and cabinets doors will be re-painted

* The wood shelves in the dry food storage area will be repaired, cleaned and re-painted

* Both wood doors into/out of the kitchen will be cleaned and re-painted.

* Thermometers are in the fridges and we have ordered 2 additional thermometers for back up

* All open food items will be labeled with the open date * All staff instructed to put hair up and/or wear proper hairnet prior to preparing or handling food

* Test strips ordered to check proper level of sanitation

* All staff that are handling resident food have their food handler cards and they are kept in the kitchen binder.

2. Kitchen Binder with task sheets for cleaning and auditing the above issues are now in place. All staff re-trained on proper food handling.

3. Monitoring will occur weekly.

4. The Assistant Executive Director and Executive Director will be responsible.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted into the facility in 06/2007 with diagnoses including traumatic brain injury with significant cognitive impairment.

The resident's current service plan dated 05/06/24 was reviewed, observations were made, and interviews with caregivers were conducted between 05/07/24 and 05/09/24.

Resident 1's service plan was not reflective, and did not provide clear direction to staff including how often services shall be provided in the following areas:

* Conflicting information in amount of assistance needed for restroom use, shower, and dressing;

* Assistance needed for personal hygiene and grooming;

* Incontinence care status including how often the service shall be provided;

* Activity status including how often the service shall be provided;

* Mobility status including use of devices; and

* Fall interventions.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. The findings were acknowledged.

2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia, macular degeneration (eye disease) and dysphagia (difficulty swallowing).

The resident's most recent service plan dated 05/06/24 and temporary service plans dated 02/07/24 to 05/07/24 were reviewed, observations of the resident were made, and interviews with staff were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas:

* Shower refusals including instructions to staff;

* Meal assistance including clothing guard and adaptive equipment;

* Food cut into small bites;

* Soft foods; and

* Utensils placed on his/her plate.

The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings, and no additional information was provided.

1. Both residents indicated will have a thorough review done to ensure accuracy of their service plans and care needs.

2. Employee Service Plan Review form will be handed out 1 week prior to each quarterly evaluation due date. ED will utilize this form to ensure accuracy of care needs.

3. The service plans will be reviewed upon admission, 30 days, quarterly and as needed.

4. The Executive Director and Nurse will be responsible.

Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition had actions or interventions determined and communicated to staff on each shift, and the conditions monitored with weekly progress noted until resolution for 2 of 2 sampled residents (#1 and 2) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted into the facility in 06/2007 with diagnoses including traumatic brain injury with significant cognitive impairment.

a. Review of the 02/07/24 through 05/07/24 progress notes, 05/06/24 service plan, weight records dated 08/2023 thru 05/03/24, and Temporary Service Plans (TSP's) revealed Resident 1 experienced the following short-term changes of condition:

* 02/25/24 - Missed medications (Celexa for depression and Lipitor for high cholesterol);

* 04/04/24 - Emergency room visit due to left lower leg pain and limping;

* 05/03/24 - Weight loss of 4.6 pounds or 3.37 % of his/her body weight between 04/15/24 and 05/03/24.

The facility lacked documented evidence actions or interventions were developed and communicated to staff on each shift, and changes of condition were monitored, with progress noted at least weekly through resolution.

The need to ensure each of Resident 1's short term changes of condition had interventions developed, communicated to staff on each shift, and the conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia.

The resident's 02/07/24 to 05/07/24 progress notes and temporary service plans (TSPs) and 04/01/24 to 05/07/24 MARs were reviewed, and interviews with staff were conducted. The following was identified:

There was no documented evidence the facility determined and documented actions or interventions, communicated to staff on each shift, and monitored with weekly progress noted to resolution for the following short-term changes of condition:

* Missed aspirin (for heart health) on five occasions between 04/01/24 to 04/05/24 due to not being in the facility;

* Missed Prevident (for dry mouth) on four occasions between 04/04/24 to 04/24/24 due to resident refusal; and

* Missed naproxen (for pain) on one occasion on 04/11/24 due to resident refusal.

During an interview at 1:30 pm on 05/09/24, Staff 2 (Regional Director of Operations) stated the facility had since January 2024 been training MTs on the use of TSPs and monitoring for medication changes.

The need to ensure actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and monitored at least weekly with progress noted to resolution was discussed with Staff 1 (Administrator) and Staff 2 on 05/09/24. They acknowledged the findings.

1. All Residents will be placed on alert charting for any changes in condition, medications or incidents. Monitoring will continue each shift until resolved and closed by the Executive Director or nurse. Any COC needed and observed will be reported and put on the nursing communication board in pcc and communicated with the nurse.

2. Executive Director and assistant Executive Director will both check alert charting for correct opening documentation on incidents and change of conditions and monitoring. The Executive Director and Nurse will close alerts when resolved.

3.The Executive Director and Assistant Executive Director will check at least 3 times a week that staff are completing alert charting each shift.

4.The Executive Director and Assistant Executive Director will be responsible to see that corrections are complete and monitored.

Based on observation, interview, and record review, it was determined the facility failed to monitor short-term changes of condition until resolution for 2 of 2 sampled residents (#s 6 and 7). This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the MCC in 06/2024 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/18/24, temporary service plans, incident investigations, physician communications, and progress notes from 07/01/24 through 10/21/24 was completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution in the following areas:

* Bruising;

* Medication changes;

* Injury when s/he hit head on grab bar;

* Altercations with other residents;

* ER visits;

* Injury to pinky finger;

* Move to another apartment; and

* Stomach pain.

Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition until resolution.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly until resolved was discussed with Staff 12 (ED) on 10/22/24. She stated she reviewed the resident's record and acknowledged the lack of monitoring until resolution for short term changes in condition.

2. Resident 7 was admitted to the MCC in 08/2024 with diagnoses which included dementia.

Observations and an interview with the resident, interviews with staff, and review of the resident's service plan dated 08/05/24, physician communications, temporary service plans, incident investigations, and progress notes from 07/01/24 through 10/21/24 was completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution in the following areas:

* Skin tear;

* Falls;

* Chest pain, shortness of breath and blurred vision; and

* High blood pressure.

Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition until resolution.

The need to ensure short-term changes of condition had documented resolution was discussed with Staff 12 (ED) on 10/22/24 at 1:45 pm. She acknowledged the findings.

1. All residents on alert where reviewed and updated as needed to reflect short term changes as they ended. All residents with short term changes will be added to our alert/communication board immediatly. They will not be removed until nurses assessment deems it appropriate for removal.

2. Executive Directior will be reviewing all short term conditions daily to ensure there is proper documentation and follow up.

3. Short term changes will be audited daily by Executive Director and weekly by Regional Director of Operations.

4. Exuctive Director, Registered Nurse, Regional Director of Oporations.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 4) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted into the facility in 06/2007 with diagnoses including traumatic brain injury with significant cognitive impairment.

During the entrance acuity interview on 05/07/24, the resident was identified to have a foot fracture and required staff assistance for transfers.

A review of the resident's clinical record, including chart notes dated 02/07/24 through 05/07/24, temporary service plans (TSPs) was completed, and interviews with staff were conducted during the survey and identified the following:

* 04/04/24 - Emergency room visit due to left lower leg pain and limping; and

* 04/10/24 - Alert for left foot fracture.

During an interview on 05/08/24 at approximately 12:43 pm, Staff 7 (Universal Worker) reported the resident had an overall decline in status after the foot fracture  in the following areas:

* The resident ambulated independently using a walker before the foot fracture, but now required a wheelchair and staff assistance for ambulation; and

* The resident was independent with incontinence care prior to the foot fracture but now required staff assistance.

The decline in functional status represented a significant change of condition and required an RN assessment. On 05/09/24, Staff 2 (Regional Director of Operations) confirmed no significant change of condition assessment had been completed by an RN, including findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessed all significant changes of condition, including findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 on 05/09/24. They acknowledged the findings.

2. Resident 4 was admitted into the facility in 05/2023 with diagnoses including Parkinson's disease.

A review of the resident's clinical record, including weight records, dated 08/21/23 through 05/03/24, was completed, and interviews with staff were conducted during the survey and identified the following:

* 09/01/23 - 151.0 pounds;

* 01/10/24 - 176.7 pounds; and

* 03/05/24 - 170.6 pounds.

From 09/2023 to 01/2024, Resident 4 had gained 25.7 pounds or 17.01 % of his/her body weight, which constituted a significant change of condition requiring an RN assessment.  

There was no documented evidence an RN conducted an assessment of the resident's significant weight gain which included findings, a description of resident status, and interventions made as a result of the assessment.

On 05/09/24, the need to ensure the facility RN completed an assessment for the significant change of condition was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

1. COC done for resident for resident #1 due to foot fx, RN will review weights and implement a COC for those requiring due to 5% change in 30 days, 7.5% change in 90 days and 10% change in 180 days.

2. Executive Director and assistant Executive Director will both check alert charting for correct opening documentation on incidents and change of conditions and monitoring. The Executive Director and Nurse will close alerts when resolved.

3.The Executive Director and Assistant Executive Director will check the dashboard for alerts daily, and alert charting 3 times weekly to monitor for change of conditions.

4.The Executive Director and Nurse will ensure that COC's are done in a timely manner.

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 (# 5) who received insulin injections by unlicensed facility staff. 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 unlicensed persons, teaching the task, and observing the staff demonstrate the task.

During the acuity interview on 05/07/24, Resident 5 was the only resident identified to receive insulin injections from staff.

Resident 5's MARs, dated 04/01/24 through 05/08/24, were reviewed and revealed insulin had been given by Staff 9 (Universal Worker) and Staff 10 (Universal Worker) on multiple occasions.

Delegation records for Resident 5 were reviewed on 05/09/24 and revealed the following:

* Staff 9 signed the MAR on 04/01/24, 04/02/24, and 04/06/24 which indicated she administered insulin injections to Resident 5. However, Staff 9's delegation record indicated Staff 9's initial delegation was completed on 04/16/24; and

* There was no documented evidence Staff 10 was delegated for the insulin administration including the staff's skills, abilities, and willingness for the delegation tasks.

The need to ensure unlicensed staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings.

1. All required staff have been delegated in accordance with OSBN Division 47.

2. Executive Director will inform nurse of any upcoming staff needing to be delegated. Updated schedule will be sent out weekly to the nurse and home office nurse to ensure oversight.

3. The Executive Director will inform the nurse weekly on whether we have any upcoming delegation needs.

4. The Executive Director and Nurse

2. Resident 1 was admitted into the facility in 06/2007 with diagnoses including traumatic brain injury with significant cognitive impairment.

During interviews and observations from 05/07/24 through 05/09/24, Resident 1 was noted to require one to two person assistance in transfer status from bed to wheelchair and relied on staff for incontinence care needs.

On 05/07/24 at 1:25 pm, the surveyor obtained permission from the resident and observed Staff 6 (Universal Worker) provide incontinence care. During the observation, Staff 6 donned gloves without performing hand hygiene. Staff 6 removed the resident's soiled shirt and placed it on the carpet floor. Staff 6 failed to doff the soiled gloves, perform hand hygiene, and don clean gloves before touching the resident's body and clean incontinence products. Staff 6 then proceeded to remove the soiled brief, cleanse the resident's perineum area and pulled up the new incontinent brief and clean pants while wearing soiled gloves.

The above observation was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged appropriate infection control practices were not implemented.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 2 sampled residents (#s 1 and 2) who received ADL care. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia and was identified in the acuity interview as needing assistance with toileting and incontinence care from staff.

Staff 7 (Universal Worker) was observed providing toileting and incontinence care to the resident at 2:06 pm on 05/07/24. Staff 7 had been providing meal service to multiple residents. She donned gloves without first performing hand hygiene. She escorted Resident 2 via wheelchair to his/her room. She assisted the resident with pulling down pants and removing a urine-soaked brief. She placed the brief directly on the floor of the bathroom. Staff 7 then provided pericare without first doffing soiled gloves, performing hand hygiene, and donning clean gloves. She applied a clean brief with the same soiled gloves and assisted the resident with pulling his/her pants up. Staff 7 wet a washcloth and assisted the resident with wiping his/her hands, still wearing the same soiled gloves. She then assisted the resident into bed wearing the same soiled gloves. Staff 7 picked up the soiled brief and took it to the laundry room where she deposited it in the garbage and removed the gloves. Without performing hand hygiene, she went to the kitchen and opened a drawer, then moved to the med cart, and finally opened the front door of the facility.

The need to ensure the facility maintained infection prevention and control protocols was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

1. All staff are being re-trained on proper infection control, including having to re-take the pre-service infection control class.

2. Assistant Executive Director and Executive Director will spot check to ensure that proper infection control procedures are being followed.

3. At minimum of 6 days per week, daily, and at all-staff meetings monthly.

4. The Assistant Executive Director and Executive Director

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system. Findings include, but are not limited to:

During the change of ownership licensure survey conducted 05/07/24 through 05/09/24, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 282: RN Delegation and Teaching;

C 303: Systems: Medication and Treatment Orders;

C 315: Systems: Treatment Administration;

C 325: Systems: Self administration of medications; and

Z 155: Staff Training Requirements.

The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings.

1. Refer to: C 282: RN Delegation and Teaching; C 303: Systems: Medication and Treatment Orders; C 315: Systems: Treatment Administration; C 325: Systems: Self administration of medications; and Z 155: Staff Training Requirements.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 2 sampled residents (# 2) who had medications administered by the facility. Findings include, but are not limited to:

Resident 2 was admitted to the facility with diagnoses including dementia. The resident's 04/01/24 to 05/07/24 MARs, 10/2023 physician orders, and 04/01/24 to 05/07/24 "Bowel Documentation" logs were reviewed, and the following was identified:

The resident had an order for polyethylene glycol (for constipation), to be administered as needed after two days without a bowel movement. Day shift staff documented no bowel movement on 04/13/24, and a large bowel movement on 04/14/24 on the "Bowel Documentation" log. On 04/15/24, staff administered the polyethylene glycol.

During an interview at 3:08 pm on 05/08/24, Staff 2 (Regional Director of Operations) acknowledged the medication was given in error. No further information was provided.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

1. Only one bowel care record will be kept, staff have been trained to keep track of bowel movements via PCC so that the system will alert them if no BM in 2 days and proper follow up can occur.

2. Implemented new system to remove paper BM tracking.

3. Med tech will check each shift and document all bowel movements for the shift. Assistant and Executive Director will monitor each day that they are there to check the dashboard alerts.

4. Med tech, Assistant Executive Director and Executive Director will be responsible

2. Resident 1 was admitted the facility in 06/2007 with diagnoses including traumatic brain injury with significant cognitive impairment.

The resident's 04/01/24 to 05/07/24 MARs and progress notes were reviewed and showed staff documented the resident refused the following medications and treatments:

* Act 0.02% mouthwash for oral hygiene on 11 occasions;

* Aspirin for heart health on four occasions;

* Atorvastatin for cholesterol management on four occasions;

* Aveeno lotion for dry skin on four occasions;

* Citalopram for depression on four occasions;

* Polyethylene power for constipation on four occasions;

* Senna/Docusate for constipation on four occasions;

* Sodium Fluoride gel for dental hygiene on four occasions;

* Vitamin C for dietary supplement on four occasions;

* Monthly vital sign check on one occasion; and

* Ursodiol for biliary cirrhosis on four occasions.

There was no documented evidence staff notified the prescriber of the above refusals.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings, and no further information was provided.

Based on interview and record review, it was determined the facility failed to ensure the physician or other legally recognized prescriber was notified when a resident refused to consent to a medication or treatment order for 2 of 2 sampled residents (#s 1 and 2) who had medications and treatments administered by the facility. Findings include, but are not limited to:

1. Resident 2 was admitted the facility in 10/2023 with diagnoses including dementia. The resident's 04/01/24 to 05/07/24 MARs and progress notes were reviewed, and the following was identified:

Staff documented the resident refused the following medications and treatments:

* Prevident (for dry mouth), on four occasions between 04/04/24 and 04/24/24; and

* Naproxen (for pain), on one occasion on 04/11/24.

There was no documented evidence staff notified the prescriber of the above refusals.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings, and no further information was provided.

1. All residents PCP's will be contacted to find out how often they want to be notified of refusals. All staff re-trained to notify PCP of all missed medications.

2. Through staff training and ensuring that each physician preferences for notification are properly documented.

3. Physician orders will be reviewed upon move in and quarterly and refused meds report will be pulled weekly, missed meds will be reviewed 3 times weekly.

4. Assistant Executive Director and Executive Director

Based on interview and record review, it was determined the facility failed to ensure treatment records were accurate, including resident-specific parameters for PRN treatments for 1 of 2 sampled residents (# 1) whose treatment records were reviewed. Findings include, but are not limited to:

Resident 1 moved into the facility in 06/2007 with diagnoses including traumatic brain injury with significant cognitive impairment.

Resident 1's 03/01/24 through 04/30/24 treatment record was reviewed, and the following PRN treatment lacked clear parameters for administration:

* Baza protect cream for incontinence; and

* Calmoseptine for incontinence.

The need to ensure treatment records included resident specific parameters and instructions for PRN treatment was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings.

1. All orders will be reviewed for necessary parameters for any PRN treatments that are given for the same reason.

2. All incoming orders are reviewed three times:

a. By the pharmacy

b. By the Executive Director

c. By the Nurse - Any medications or treatments requiring parameters will only be confirmed by the nurse to ensure proper parameters are entered.

3. Daily monitoring of new orders and quarterly monitoring of 90 day physician orders.

4. The Executive Director and Nurse

Based on observation, interview and record review, it was determined the facility failed to obtain a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 4) who self-administered medications. Findings include, but are not limited to:

Resident 4 was admitted into the facility in 05/2023 with diagnoses including Parkinson's disease.

During the acuity interview on 05/07/24, the resident was identified to manage self administration of his/her medications.

On 05/08/24 at approximately 9:18 am, three pill boxes were observed in Resident 4's room in the secured storage area. Resident 4 reported s/he took his/her medications four times daily.

A review of the clinical record revealed there were no physician orders for self administration of the medications.

On 05/08/24 at 2:01 pm, Staff 2 (Regional Director of Operations) confirmed there was no signed physician order for the self administration of all medications.

The failure to obtain physician's orders for Resident 4 to self-administer medications was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

1. Physician order has been obtained for resident to self administer her medications and she has been assessed by the nurse.

2. The facility nurse will do initial/30 day/90 day/change of condition assessment on residents ability to safely administer medications.

3. initially, 30-days, quarterly and as needed

4. The Executive Director and Nurse

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (# 3) demonstrated satisfactory performance in first aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Training records for Staff 3 (Universal Worker), hired 03/15/24, were requested at 9:15 am on 05/08/24. During an interview at 2:00 pm on 05/08/24, Staff 2 (Regional Director of Operations) stated she was unable to locate Staff 3's training files.

The need to ensure documented evidence that staff demonstrated satisfactory performance in first aid and abdominal thrust training was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

1. All staff will have all required trainings done and scanned into their personel file within Paycom.

2. Executive Director will upload all trainings to Paycom, and forward to our Chief People's Officer for her to log on the training spreadsheet. Staff will not be permitted to work if their training is not turned in.

3. The training log will be reviewed weekly.

4. The Assistant Executive Director and Executive Director

Based on interview and record review, it was determined the facility failed to ensure direct care staff demonstrated competency in assigned job duties within 30 days of hire for 2 of 2 newly hired staff (#s 13 and 14) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed with Staff 12 (ED) on 10/23/24. The following was identified:

Staff 13 (MT/CG) hired 07/22/24, and Staff 14 (MT/CG) hired 09/10/24, did not have documented evidence of completing First Aid and abdominal thrust training within the first 30 days of hire.

The need to ensure staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 12 (ED) on 10/23/24 at 10:35 am. She acknowledged the findings.

1. All staff that did not have their required training documents have completed them and have submitted a copy.

2.Upon hire staff will have all required training prior to training on the floor.

3. Executive Director has immplimented a training spreedsheet that will be audited by her weekly to ensure all staff have required prehired training as well as post hire training. Regional Director of Operations will audit monthly.

4. Executive Director and Regional Director of Oporations.

Based on interview and record review, it was determined the facility failed to ensure staff received fire and life safety training on alternate months from fire drills. Findings include, but are not limited to:

Six months of fire and life safety records were requested at 10:45 am on 05/07/24. During an interview at 10:30 am on 05/08/24, Staff 2 (Regional Director of Operations) stated fire and life safety training to staff had not been conducted in the facility; therefore, there was no documentation to review.

The need to ensure staff received fire and life safety training on alternate months from fire drills was discussed with Staff 1 (Administrator) and Staff 2 on 05/09/24. They acknowledged the findings.

1. Fire Drill will be done this month and Fire Safety Training will be done at the all-staff meeting.

2. All Fire Drill documentation will be uploaded to the internal website for home office review. Weekly stand ups to confirm that the Fire Life Safety/Fire Drills are performed per regulations.

3. Weekly review by home office

4. Executive Director and Maintenance Man

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

The facility was toured at 11:18 am on 05/07/24 and the following was observed to need cleaning or repair:

* Baseboards and door frames throughout the facility were scuffed with black marks, had chipped paint, or had gouges;

* The windows in the common areas and resident rooms were dusty, grimy, and had brown splashes on them;

* The walls throughout the facility, especially in the living room, had a buildup of dust;

* The floor vent covers in resident rooms and common areas were dented and had a buildup of dust and dirt;

* There was a defunct call system on the wall in Room 6 that had a 3-inch hole in it;

* The wall to the left and right of the living room fireplace had black scuffs and chipped paint; and

* The brown microfiber recliner, couch, and loveseat in the living room had dark stains on the headrests, arms, seats, and outer sides.

The facility was toured with Staff 5 (Maintenance) at 1:30 pm on 05/08/24. He acknowledged the areas needing cleaning and/or repair.

The need to ensure the interior of the facility was maintained clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings.

1. Baseboards and door frames throughout the facility will be deep cleaned, repaired and/or painted if necessary;

* The windows in the common areas and resident rooms will be deep cleaned;

* The walls throughout the facility, especially in the living room, will be deep cleaned;

* The floor vent covers in resident rooms and common areas will be replaced;

* There was a defunct call system on the wall in room 6 has been removed and repaired;  

* The wall to the left and right of the living room fireplace will be cleaned; and

* The brown microfiber recliner, couch will be cleaned.

2. We will provide a routine maintenance log to be completed as scheduled

3. Upon scheduled maintenance days, and weekly.

4. The Maintenance Director and Executive Director

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

The interior and exterior of the facility was toured at 11:17 am on 05/07/24 and the following was identified:

The exit door to the courtyard lacked an alarm to alert staff when residents exited. During an interview at 1:30 pm on 05/08/24, Staff 5 (Maintenance) stated he was unaware an alarm was required on the exit door to the courtyard.

The need to ensure an exit door alarm or other acceptable system for security purposes and to alert staff when residents exited the building was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/09/24. They acknowledged the findings.

1. The battery has been replaced to the backdoor alarm so it is fully functional.

2. This will be added to the routine maintenance to test and review.

3. The alarm will be tested weekly and staff notified to add to maintenance log if it stops working.

4. The Maintenance Director and Executive Director

Concerns were identified and technical assistance was provided for the following:

H 1510: OAR411-004-0020 (1)(c): Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Concerns were identified and technical assistance was provided for the following:

H 1517: OAR411-004-0020 (2)(d) Individual Privacy: Own Unit

(2)(d) Provider owned, controlled, or operated residential settings must have all of the following qualities: Each individual has privacy in his or her own unit.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:

The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision and overall conduct of the staff.

During the change of ownership licensing survey, conducted 05/07/24 through 05/09/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and scope of citations issued during the survey.

Refer to deficiencies in the report.

Refer to above POC for each section

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 152, C 372, C 420, C 513, and C 555.

Refer to C 152, C 372, C 420, C 513, and C 555

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

Refer to C 372.

Refer to C 372.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 3 and 5) completed all preservice orientation training and 1 of 1 newly hired staff (#3) demonstrated satisfactory performance in any duty they were assigned within the first 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 2 (Regional Director of Operations) at 2:00 pm on 05/08/24. The following was identified:

a. There was no documented evidence Staff 3 (Universal Worker), hired 03/15/24, and Staff 5 (Maintenance), hired 04/10/24, completed required preservice orientation training prior to beginning job duties in one or more of the following:

* Infectious disease prevention;

* Preservice dementia care; and

* Home and Community-Based Services.

b. There was no documented evidence Staff 3 demonstrated satisfactory performance in assigned job duties within 30 days of hire in the following areas:

* Role of service plans;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identifying, documentation, and reporting changes of condition;

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

* General food safety, serving, and sanitation; and

* Medication and treatment administration.

At 2:00 pm on 05/08/24, survey requested Staff 3 complete medication and treatment administration demonstration prior to administering medications and treatments, and confirmation was received prior to survey exit.

The need to ensure staff complete all preservice orientation training prior to beginning job duties and staff demonstrate competency in any duty they are assigned within the first 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 on 05/09/24. They acknowledged the findings.

1. All staff will have all required pre-service MCC trainings done as well as annual training and scanned into their personel file within Paycom.

2. Executive Director will upload all trainings to Paycom, and forward to our Chief People's Officer for her to log on the training spreadsheet. Staff will not be permitted to work if their training is not turned in.

3. The training log will be reviewed weekly.

4. The Assistant Executive Director and Executive Director

Based on interview and record review, it was determined the facility failed to ensure 1 of 4 sampled newly hired staff (#12) completed all required pre-service training prior to performing any job duties, and 2 of 3 newly hired direct care staff (#s 13 and 15) completed competency training within 30 days of hire and/or before independently providing personal care or other services to residents. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed with Staff 12 (ED) on 10/23/24. The following were identified:

a. Staff 12 (ED) was hired 07/29/24.

There was no documented evidence Staff 12 had completed pre-service orientation and the required dementia training prior to performing any job duties, including:

* Resident rights;

* Fire safety and emergency procedures;

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

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

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

b. Staff 13 (MT/CG) was hired 07/22/24.

There was no documented evidence Staff 13 demonstrated competency in job duties within 30 days of hire and/or prior to working independently in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

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

c. Staff 15 (CG) was hired 09/13/24 and began working on the floor on 10/02/24. According to Staff 12 (ED), Staff 15 was independently providing care to residents as of the revisit survey.

There was no documented evidence Staff 15 demonstrated competency in job duties prior to working independently in the following areas:

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

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

The facility's failure to ensure staff completed all required training in a timely manner and/or prior to working independently was discussed with Staff 12 (ED) on 10/23/24 at 10:35 am. She acknowledged the findings. No further information was provided.

Refer to C 372.

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

Refer to C 260, C 270, C 280, C 282, C 295, C 300, C 303, C 305, C 315, and C 325.

Refer to C 260, C270, C 280, C 282, C 295, C 300, C 303, C 305, C 315, and C 325

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

Refer to C 270.

Refer to C 270.