The findings of the re-licensure survey, conducted 04/29/24 through 05/03/24, 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 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

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

During the survey, conducted 04/29/24 through 05/03/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcome and satisfaction was discussed with Staff 1 (Memory Care Director) and Staff 2 (ED) on 05/03/24. No additional information was provided.

Refer to the deficiencies in the report.

2. The following general observations were made from 04/29/24 through 05/03/24:  

a. Meal services were observed from 04/29/24 through 05/02/24. For every meal observed, the residents were provided plastic flatware.

During an interview with Staff 9 (MT) on 05/01/24 at 4:55 pm, she reported the residents only received plastic flatware as the kitchen had concerns that the silverware was "getting lost" in the unit. Staff 9 also stated residents only got very small cups to drink from.

On 05/03/24 at 8:51 am, Staff 6 (Executive Chef) reported she had only been in the position for "about a month" and that she would order silver flatware as soon as possible. Staff 6 stated she would make sure the unit was provided with larger cups as well.

b. Caregivers were observed using terms of endearment instead of the residents' names in the following instances:

* 04/30/24 at 12:19 pm - When a CG was pouring a drink for an unsampled resident she stated, "it's sugar-free hun."

* 05/01/24 at 8:23 am - An unsampled resident was taking food off another resident's plate. The CG responded with, "that's not your plate, sunshine."

* 05/01/24 at 8:30 am - Resident 1 was given something to drink. The CG stated, "there you go hun."

* 05/01/24 at 8:49 am - An unsampled resident was redirected from another resident's room. The CG said, "[Resident's name], that's not your room hun, come here."

c. On 05/02/24 at 11:36 am, Staff 11 (MT) was observed in a common area where other residents were watching television. There were between 10 and 15 residents observed to be in the common area at the time. Staff 11 had a chair scale in the front of the room, to the right of the television. She was calling residents up to the scale, taking their weight, verbalizing the residents' weights while documenting the weights on a piece of paper. This was done in the presence of other residents.

d. On 05/01/24 at 8:59 am, an unsampled resident was observed to be sitting at a table in front of a plate of food. A CG approached the resident from behind, moved his/her chair out from the table without alerting the resident first, and when the resident was facing his/her walker proceeded to ask if the resident was done with his/her food.  

The need to ensure residents received services in a manner that protected dignity and respect, and were provided in a homelike environment was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.  

3. Resident 2 was admitted to facility in 08/2020 with diagnoses including Alzheimer's disease.

The resident's service plan, dated 03/11/24, and progress notes, dated 01/30/24 through 04/29/24, were reviewed. Resident 2 was observed and staff were interviewed. The following was noted:

a. The service plan indicated the resident was a vegetarian who ate eggs. On 05/01/24 the resident was observed in the dining room at 8:09 am with two pork sausage patties, scrambled eggs, hashbrowns, toast, and a blueberry muffin. At 9:28 am, staff confirmed Resident 2 ate all of the breakfast meal. Later, on the same day, at 12:04 pm, the resident was observed in the dining room for lunch. Resident 2 was served beets, fruit cocktail, and a grilled ham and cheese sandwich. By 12:37 pm, the resident had consumed all of the lunch meal.

During an interview on 05/01/24 at 1:00 pm, Staff 11 (MT) stated she was aware Resident 2 was a vegetarian, but that "[the resident] didn't know it was meat." Staff 11 also reported that the kitchen only sent "veggie burgers" for the resident and s/he got tired of eating the same thing.

On 05/03/24 at 8:51 am, Staff 6 (Executive Chef) confirmed there were two vegetarian options, either a "veggie burger" or a "veggie chicken patty." She stated she would order more vegetarian options for Resident 2.

b. On 03/09/24 at 8:59 pm, staff documented in a progress note, "Resident attempted to get out of chair two times but was told to remain seated and [s/he] stopped."

c. The following observations were made:  

On 04/30/24 at 4:35 pm, the resident was in a common area where the television was located with nine other residents. Staff 10 (MT/CG) said to Resident 2, "Do you have to go to the bathroom? We need to get a [urine analysis] on you." This was said loud enough for everyone in the area to hear. Staff 10 went on to repeat himself two more times. During the third time of asking the resident if s/he "was sure" s/he did not need to use the bathroom, he went behind the resident and starting pulling his/her wheelchair backwards without any warning. Resident 2 repeated, "I don't have to go." Staff 10 walked away.

On 05/01/24 at 9:17 am, the resident was observed to be eating breakfast with four staff members. Staff 11 got up from the table and started to comb Resident 2's hair with her fingers. During the interaction, Staff 11 called the resident "Pedro." The other staff members sitting at the table were laughing. When asked why she called him/her "Pedro," Staff 11 said because after the resident's most recent hair cut, she thought the resident "looked like a boy."

On 05/01/24 at 12:04 pm, the resident was observed with a plastic container of beets and a plastic container of fruit cocktail. Resident 2 was using his/her hands to eat the beets as there was no flatware on the table for him/her to use. At 12:07 pm, the resident had finished all of the beets by eating them with his/her hands. A grilled ham and cheese sandwich was given to the resident. By 12:37 pm, Resident 2 had finished his/her fruit cocktail and sandwich. No flatware had been provided to the resident.

The need to ensure residents received services in a manner that protected dignity and respect, and was provided in a homelike environment, was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' rights to be treated with dignity and respect, to receive services in a manner that protected privacy and dignity, and to have a safe and homelike environment for 2 of 2 sampled residents (#s 1 and 2) and for unsampled residents who were observed to receive ADL and nursing care in common areas. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 09/2020 with diagnoses including dementia.

The resident's service plan, dated 04/23/24, was reviewed. Resident 1 was observed and staff were interviewed. The following was noted:

a. The service plan stated Resident 1 "is primarily non-verbal ..." and to facilitate effective communication "by maintaining eye contact, allowing the individual enough time to respond and talk, and paying attention to non-verbal cues when necessary."

During ADL observations on 04/30/24 at approximately 9:43 am, Staff 18 (CG), Staff 20 (CG) and Staff 21 (CG) provided assistance with toileting. Throughout the observation, all three staff were standing in the restroom talking and giggling with one another while Resident 1 was sitting on the toilet. Staff would address the resident by asking "are you done yet?" and "you done pooping, buddy?" Resident 1 stated "no" multiple times in response to staff questions. When staff attempted to transfer Resident 1 from the toilet to his/her wheelchair, s/he proceeded to defecate on the restroom floor. During that time, Staff 18, 20, and 21 all made comments to one another including "[s/he] is pooping still", "[s/he] has diarrhea", and "[s/he] pooped on the floor."

b. The following observations were made between 04/30/24 and 05/03/24:

* On 04/30/24 at 12:53 pm, a staff member was observed asking Resident 1, "Are you going to play with your food?"

* On 05/01/24 at 9:03 am, an unsampled resident was told by a CG, "[Resident 1] can't have coffee because [s/he] gets diarrhea."

* On 05/01/24 at 8:57 am - Resident 1 was told by a CG to, "stop throwing your cup, [mister/miss]."

* On 05/01/24 between 9:03 and 9:07 am, Resident 1 was observed attempting to take sips from a cup when a CG approached and asked, "Are you done?" Resident 1 shook his/her head no. The question was repeated, and the resident continued to shake his/her head no. The CG removed the resident's clothing protector and escorted the resident to the television room. No additional fluids were offered to the resident.

* On 05/01/24 at 12:44 pm during lunch service, Staff 18 (CG) was handing out cookies to residents. An unsampled resident asked Staff 18 to give Resident 1 a cookie. After multiple requests from the unsampled resident, Staff 18 stated "[S/he] is not allowed to have [a cookie]."

* On 05/02/24 at 10:04 am, Resident 1 was sitting with his/her spouse and two surveyors in the dining room during an interview. Staff 24 (CG) wheeled the resident to a separate dining room table, lifted the resident's sweatshirt from the waist, and pulled his/her right arm out of the sleeve of the sweatshirt. A bandage was removed from the resident's arm and wound care was provided in the common area. This procedure was repeated for the resident's left arm.

The need to ensure residents received services in a manner that protected dignity and respect was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.  

2. Resident 2 was admitted to the facility in 08/2020 with diagnoses including Alzheimer's disease.   

The resident's progress notes, dated 01/30/24 through 04/29/24, and incident reports were reviewed. The following was noted:

* On 02/21/24, Staff "found resident on the floor sitting up". When Resident 2 was asked what happened, the resident stated s/he did not know. Staff found the resident "sitting on [his/her] bottom again" on 02/22/24, this time stating that s/he was tired and wanted to go to bed. On 02/23/24, staff documented, "resident has serious bruising on [his/her] buttocks from [his/her] fall."

On 03/11/24, Staff 3 (RN) conducted the investigation for the 02/21/24 unwitnessed fall. She investigated the 02/22/24 unwitnessed fall on 03/13/24. Staff 3 documented both falls as non-injury.

* Staff found Resident 2 "laying on [his/her] side on the floor in front of [his/her] wheelchair" on 04/18/24. They reported the resident had a skin tear on his/her "left forearm." Staff documented asking Resident 2 what happened and the resident stated, "I don't know."

There was no documented evidence the facility promptly investigated the suspected fall that resulted in a skin tear, or reported the injury of unknown cause to the local SPD office. The facility failed to promptly investigate the resident's injuries of unknown cause to rule out abuse. The facility was instructed to report the injury of unknown cause dated 04/18/24 to the local SPD office on 04/30/24. Proof of reporting was received on 04/30/24 at 4:08 pm.

The need to ensure injuries of unknown cause were promptly investigated to rule out abuse and to report the injuries of unknown cause to the local SPD office when abuse or suspected abuse could not be ruled out was discussed with Staff 1 (Memory Care Director), Staff 2 (ED) and Staff 3 on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to investigate injuries of unknown cause promptly to rule out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office for 2 of 2 sampled residents (#s 1 and 2) who were reviewed for injuries of unknown cause. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2020 with diagnoses including dementia.

Progress notes, dated 01/30/24 through 04/29/24, and incident reports were reviewed and revealed Resident 1 had "two newly discovered" skin tears, one on each arm, which were documented by Staff 12 (MT) on 04/15/24. An incident report was initiated by Staff 12 on 04/15/24; however, the injuries of unknown cause were not investigated to rule out abuse or suspected abuse by Staff 1 (Memory Care Director) until 04/30/24.

The facility failed to promptly investigate the resident's injuries of unknown cause to rule out abuse. The facility was instructed to report the injury of unknown cause to the local SPD office on 05/02/24 at 10:48 am. Proof of reporting was received by the facility.

The need to ensure injuries of unknown cause were investigated promptly rule out abuse and to report the injuries of unknown cause to the local SPD office when abuse or suspected abuse could not be ruled out was discussed with Staff 1 (Memory Care Director), Staff 2 (ED) and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 moved into the facility in 02/2024 with diagnoses including dementia and depression.

A review of Resident 3's move-in evaluations, dated 02/12/24 and 02/14/24, identified the facility failed to address the following required elements:

* Customary routines including eating and bathing;

* Interests, hobbies, social, and leisure activities;

* Mental health issues including non-pharmaceutical interventions;

* Personality including how the person copes with change or challenging situations;

* Dental status;

* Pain management and non-pharmaceutical interventions;

* Nutrition habits and fluid preferences; and

* Unsuccessful prior placements.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

2. Resident 2 was admitted to facility in 08/2020 with diagnoses including Alzheimer's disease and arthritis.   

The resident's service plan, dated 03/11/24, and progress notes, dated 01/30/24 through 04/29/24, were reviewed. Observations of Resident 2 were made, and interviews with staff were conducted. The service plan was not reflective of the resident's needs and preferences, or did not provide clear instruction to staff in the following areas:

* Use of "pool noodles" while s/he was in bed;

* Attending breakfast;

* Unable to move about freely without hands-on help;

* Frequency of safety checks for each shift;

* Scheduled and PRN shower assistance needed;

* Leaving the resident's unit door open;

* Occasional one to three person transfer assistance;

* Ability to assist with dressing;

* No longer able to choose clothing;

* Interventions for when the resident was resisting to have his/her teeth brushed;

* Who needed to be contacted when nail care was needed;

* Environmental factors that impacted the resident's behavior including loud noises and being cold;

* Usual sleeping schedule;

* Napping frequency;

* How the resident communicated pain;

* How the resident non-verbally communicated needing assistance after a bowel movement;

* Ability to verbally express needs and wants; and

* Interventions for fragile skin.

The following areas were reflected on the service plan but were not consistently implemented:

* Non-skid socks or shoes to be worn when out of bed; and

* Dietary preference of being a vegetarian.

The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction to staff regarding the delivery of services, or 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 to the facility in 09/2020 with diagnoses including Alzheimer's disease, esophagus stricture and stenosis.

The resident's current service plan, dated 04/23/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences or did not provide clear instruction to staff in the following areas:

* Eating/dining preferences including meal times and beverage preferences;

* Diet and nutrition including current diet texture, liquid consistency, assistive devices needed, and what meal options to offer;

* Outside providers relating to which services were provided and how often;

* Transfers including what assistive devices were used;

* Grooming including the use of eyewear and assistance provided;

* Toileting including number of staff needed, frequency, and bowel monitoring;

* Ability to communicate including how staff could effectively communicate with the resident; and

* Emergency evacuation assistance needed including the number of staff and assistive devices needed for physical assistance.

Sleep schedule preferences were reflective on the service plan, but were not consistently implemented.

The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the resident was evaluated each time a change of condition occurred, actions or interventions were determined and documented, the actions or interventions were communicated to staff on each shift, and the condition was monitored with weekly progress noted until resolution for 1 of 2 sampled residents (# 2) who were reviewed for changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to facility in 08/2020 with diagnoses including Alzheimer's disease and diabetes.    

The resident's service plan, dated 03/11/24, Interim Service Plans, dated 02/21/24 through 04/18/24, progress notes, dated 01/30/24 through 04/29/24, and MARs dated 01/2024 through 04/29/24, were reviewed. Resident 2 was observed and staff were interviewed.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:

* 01/31/24 - Low CBGs;

* 02/21/24 - Two falls;

* 02/22/24 - Fall;

* 02/23/24 - Bruising on bottom;

* 02/27/24 - Fall;

* 02/29/24 - Changed rooms;

* 03/01/24 - High CBGs;

* 03/08/24 - High CBGs;

* 03/14/24 - Change in insulin;

* 03/27/24 - Skin tear to right arm;

* 04/12/24 - Increased confusion and a fall;

* 04/14/24 - Rash in peri area;

* 04/18/24 - Fall and skin tear to left arm;

* 04/20/24 - Vomited;

* 04/23/24 - Vomited; and

* 04/24/24 - Fever and diarrhea.

On 02/29/24, Staff 3 (RN) documented an interdisciplinary high risk resident meeting in which safety checks were added to Resident 2's MAR relating to the falls. Upon review of the MARs, there was no documented evidence the intervention of safety checks was added.  

The need to ensure the resident was evaluated for changes of condition, resident-specific actions or interventions were determined, documented, and communicated to staff on each shift, and the condition was monitored with weekly progress noted through resolution was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings. No additional information was received.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed timely by an RN with findings, resident status, and interventions documented for 1 of 1 sampled resident (# 1) reviewed for significant changes of condition related to weight loss. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2020 with diagnoses including dementia.

During the acuity interview on 04/29/24, Resident 1 was identified to have a recent history of weight loss.

Resident 1's weight records were reviewed and revealed the following:

* 08/2023 - 147.2 pounds;

* 11/2023 - 144.8 pounds;

* 02/2024 - 132.4 pounds;

* 04/2024 - 137.1 pounds; and

* 04/30/24 - 139.4 pounds (requested during survey).  

On 05/02/24, Staff 1 (Memory Care Director) and Staff 3 (RN) were interviewed about the process of collecting weights due to the lack of date in facility documentation. Both Staff 1 and Staff 3 confirmed the facility's system included obtaining weights for all residents in the memory care from the first to the fifth of each month. The recorded weights were then provided to Staff 3 who reviewed the weights for significant changes.

Resident 1's weight loss was initially triggered in 02/2024. From 08/2023 to 02/2024, Resident 1 had a weight loss of 14.8 pounds or 10.05% of his/her body weight in six months. Additionally, from 11/2023 to 02/2024 the resident had a weight loss of 12.4 pounds or 8.56% of his/her body weight in three months. The weight loss indicated a significant change of condition and required an RN assessment.

An RN assessment for the significant change of condition was requested on 04/30/24. Staff 3 stated her assessment was in the facility's progress notes and provided an "Interdisciplinary High Risk" meeting note dated 02/29/24.

Although the note included documentation of an intervention for Resident 1's weight loss, it lacked documentation of the resident's status and findings of the RN assessment. On 05/02-24 at 12:13 pm, Staff 3 confirmed lack of documentation of an RN assessment.

The need to ensure all significant changes of condition were assessed timely by an RN with findings, resident status and interventions documented was discussed with Staff 1, Staff 2 (ED) and Staff 3 on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (# 2) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to:

Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant to OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client.

During the acuity interview on 04/29/24, Resident 2 was identified to be administered an insulin injection once daily by a facility UAP.

Resident 2's MARs, dated from 01/01/24 through 04/29/24, revealed insulin injections had been given by Staff 7 (Assisted Living MT), Staff 8 (Assisted Living MT), Staff 10 (MT), Staff 11 (MT), Staff 14 (Assisted Living MT), Staff 15 (Assisted Living MT), and Staff 18 (MT/CG).

Review of the nursing delegation binder found no documented evidence the nursing delegation was completed for Staff 7, Staff 8, Staff 10, Staff 11, Staff 14, Staff 15, and Staff 18.

During an interview on 04/30/24, Staff 3 (RN) confirmed Staff 7, 8, 10, 11, 14, 15, and 18 were not delegated to prepare and administer insulin injections for Resident 2.

On 04/30/24, Staff 1 (Memory Care Director) confirmed that most care giving staff on the unit were cross-trained as MTs.

On 04/30/24 at 3:03 pm, Staff 2 (ED) provided a written plan for nursing delegation which included delegating Staff 1. Additionally, the documentation confirmed that only UAPs who were delegated to administer insulin to Resident 2 would be doing so.

Staff 3 confirmed that when scheduling for the evening shift staff on the memory care unit, there would be at least one staff member delegated to administer insulin to the resident.  

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1, Staff 2, and Staff 3 on 04/30/24. They acknowledged the findings.

2. Observations of snack and meal service were completed between 04/29/24 and 05/01/24 and revealed the following:

* On 04/29/24 at 2:32 pm, Staff 19 (CG) was observed using bare hands to give an afternoon snack to two unsampled residents. No hand hygiene was observed.

* Multiple care staff served food and provided occasional direct feeding assistance to residents without donning a protective barrier over potentially contaminated clothing.

* Multiple care staff were observed serving meals and beverages, retrieving items from drawers or cupboards in the MCC's kitchenette, leaving then returning to the locked unit, eating or drinking their own meals, providing in-room ADL assistance, assisting with feeding, touching residents, or coughing and touching their faces without performing hand hygiene prior to or between tasks.

In an interview with Staff 18 (CG) on 04/30/24 at 1:12 pm, she stated the facility expected caregivers to perform hand hygiene when they assisted residents, but it wasn't always completed because care staff were pulled in many directions.

The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Memory Care Director), Staff 2 (ED) and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (# 1) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2020 with diagnoses including Alzheimer's disease.

The resident's service plan, dated 04/23/24, was reviewed. Resident 1 was observed and staff were interviewed. The resident was dependent on staff for toileting assistance. The following was noted:

On 04/30/24 at 9:43 am, Staff 18 (CG), Staff 20 (CG) and Staff 21 (CG) were observed assisting Resident 1 with toileting. During the observation, the staff transferred the resident back to his/her wheelchair before the resident was ready. This resulted in bowel matter needing to be cleaned from the bathroom floor.

Both Staff 18 and Staff 21 did not change gloves or perform hand hygiene in-between cleaning the restroom floor and assisting Resident 1 with toileting, transferring to the wheelchair, and dressing.

In an interview with Staff 18 on 04/30/24, she stated they usually carried hand sanitizer with them, but had been busy today.

The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2020 with diagnoses including Alzheimer's disease and diabetes.

The resident's MARs, dated 01/01/24 through 04/29/24, progress notes, dated 01/30/24 through 04/29/24, and physician's orders were reviewed.

a. The following medications and treatments were not administered due to the staff not being able to "locate" the medication or "waiting on pharmacy" to deliver the medication:

* Trimeth-polymyxin (for corneal abrasion) on 01/28/24, 02/19/24, 03/12/24 through 03/14/24, and 04/19/24;

* Donepezil (for dementia) on 02/16/24, 02/17/24, and 02/23/24;

* Sertraline (for depression) on 02/17/24;

* Ropinirole (for leg cramps) on 02/18/24 through 02/20/2024; and

* Atorvastatin (for high cholesterol) on 03/05/24 and 03/06/24.

b. There was a blank on the MAR entry for 8:00 pm on 01/26/24 relating to Lantus (for diabetes).

On 04/30/24, Staff 3 (RN) was asked if the insulin was administered on 01/26/24. No additional information was received.  

c. There was an order dated 03/19/24 for trimeth-polymyxin which directed staff to administer "[two] drops" "into left eye every [four] hours/days." There was no documented evidence the order was clarified for staff to administer the medication every four hours or every four days.

d. On 03/30/24, staff documented in a progress note the treatment provided to the resident's skin tear: "have removed the wrap and cleansed cut put A&D ointment and a regular bandaid." Resident 2 did not have a physician's order for "A&D ointment." In addition, the physician orders directed staff to "rinse area with sterile normal saline", "pat dry", "apply skin prep to surrounding tissue. Let dry. Apply steri-strips and cover with non-adherent dressing."

e. On 04/14/24, staff identified a "rash in [Resident 2's] peri area" There was no documented evidence staff treated the rash per physician's orders.   

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 on 05/03/24. They acknowledged the findings.

Based on interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible for administering for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2020 with diagnoses including Alzheimer's disease and esophagus stricture and stenosis.

The resident's MAR, dated 04/01/24 through 04/29/24, and physician orders dated 04/23/24 were reviewed. The following was identified:

The physician orders noted to administer "Loperamide 2 mg tablet ...after first episode of loose stool ..."

On 04/30/24 at 9:43 am, Staff 18 (CG), Staff 20 (CG) and Staff 21 (CG) provided Resident 1 assistance with toileting. In an interview with Staff 18 and Staff 20, they stated Resident 1 had "loose stool" and "diarrhea."

On 05/01/24 at 1:35 pm, Staff 16 (CG), Staff 18, and Staff 20 provided Resident 1 assistance with toileting. In an interview with Staff 18 and Staff 20, they described the consistency of the residents bowel movement to be "loose to medium loose."

There was no documented evidence the facility followed the physician's order to administer the loperamide on 04/30/24 after the resident's episode of loose stool.

On 05/02/24 at 3:10 pm, Staff 12 (MT) stated it was the caregivers responsibility to report if a resident had loose stool or was constipated. She confirmed there was no documented evidence Resident 1 had loose stool on 04/30/24 and 05/01/24.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

1. Resident 1 was admitted to the facility in 09/2020 with diagnoses including Alzheimer's disease.

Resident 1's MAR, dated 04/01/24 through 04/29/24, and most recent physician orders, dated 04/23/24, were reviewed. The following was identified:

Physician orders stated to discontinue the following medications that were still active on the MAR:

* Arnicare gel; and

* Mylanta 200-200-20mg/5 ml.

In an interview with Staff 1 (Memory Care Director) on 05/02/24, she confirmed the medications had not been removed from the MAR.

The need to ensure MARs were accurate was discussed with Staff 1, Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, and had documentation of the initials of the person administering the medication for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2020 with diagnoses including Alzheimer's disease and diabetes.     

Resident 2's MARs, dated 01/01/24 through 04/29/24, and progress notes dated 01/30/24 through 04/29/24 were reviewed and revealed the following:

a. The resident was out of the facility from 01/25/24 through 01/26/24, but staff initialed all medications as if they had been administered during that time frame.

b. On 01/28/24, staff documented they were "unable to locate" trimeth-polymyxin drops (for corneal abrasion). The same staff member who documented they were unable to locate the medication at 5:00 pm, also documented that they administered the medication at 2:00 pm.

c. Staff 10 (MT) was identified as not being delegated to administer Resident 2's scheduled insulin. Documentation showed he would request a delegated MT from the assisted living community to administer the insulin when he was on shift. However, Staff 10 initialed the MAR as administering the insulin 11 times from 02/05/24 through 04/13/24.

d. From 03/12/24 at 11:00 am through 03/14/24 at 2:00 pm, staff documented they were waiting for the pharmacy to deliver the resident's trimeth-polymyxin drops. Staff also documented administering the eye drops on 03/12/24 at 2:00 pm and at 8:00 pm, on 03/13/24 at 8:00 am, and on 03/14/24 at 8:00 am.

e. On 04/24/24, staff documented in the progress notes that PRN lopermide (for diarrhea) was administered, but there was no corresponding documentation on the MAR.  

The need to ensure MARs were accurate, and had the correct documentation of the initials from the person administering the medication was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as ineffective prior to PRN psychotropic medications being administered for 1 of 2 sampled residents (# 4) who were prescribed as needed psychotropic medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 07/2021 with diagnoses including dementia and anxiety.

The resident's 04/01/24 through 04/28/24 MAR, prescriber orders, and medical records were reviewed, and staff were interviewed.

Resident 4 had a physician order to receive lorazepam 0.5 mg tab - one tablet by mouth twice daily as needed for anxiety. The resident received the PRN medication five times between 04/08/24 and 04/17/24. Four out of the five lorazepam administrations lacked documented evidence that non-pharmacological interventions were attempted and were ineffective prior to receiving the PRN medication.

On 04/30/24 at 9:26 am, Staff 11 (MT) was requested to check the computer medication system for direction relating to non-drug interventions to try with Resident 4 prior to administering the PRN psychotropic. Staff 11 confirmed there were no interventions documented in the electronic MAR.

The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was discussed with Staff 1 (Memory Care Director), Staff 2 (ED) and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT for 1 of 1 sampled resident (# 1) who had side rails. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2020 with diagnoses including Alzheimer's disease, and stricture and stenosis of esophagus.

Resident 1 was observed to have a hospital bed with full side rails. The full side rails were in the lowered position when not in use and were observed in the upright position when the resident was in bed.

There was no documented evidence the side rails were assessed by an RN, PT, or OT.

On 05/03/24, Staff 3 (RN) confirmed there was no documented evidence that the side rail assessment for Resident 1 was completed by an RN, PT, or OT.

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a written, defined system to determine appropriate numbers of general staffing based on resident acuity and service needs for 1 of 1 sampled resident (# 2) who required scheduled insulin administration. Findings include, but are not limited to:

The facility was an endorsed memory care community to 21 residents at the time of the re-licensure survey. During the acuity interview on 04/29/24, the facility was identified to have a resident who required an 8:00 pm, scheduled insulin injection.

Resident 2's 01/01/24 through 04/29/24 MARs, delegation records, and progress notes dated 01/30/24 through 04/29/24, were reviewed. Assisted living staff had initialed that they administered the resident's insulin on the MARs reviewed. There were some corresponding progress notes identifying the memory care MTs requested the assisted living MTs to administer Resident 2's insulin at 8:00 pm.

In total, there was documented evidence of 16 occasions from 01/01/24 through 04/29/24 when the memory care MTs were not delegated to administer insulin and MTs came from the assisted living license to administer insulin.

Staff 1 (Memory Care Director) confirmed on 04/30/24 that the MTs who had not been delegated on the memory care license were instructed to have a delegated assisted living MT come to administer Resident 2's insulin.

On 04/30/24 at 3:03 pm, Staff 2 (ED) provided a written plan that outlined how the memory care staff would be able to administer the resident's 8:00 pm insulin without having to share staff with the assisted living license.  

The need to ensure a written, defined system to determine appropriate numbers of general staffing based on resident acuity and service needs was discussed with Staff 1, Staff 2, and Staff 3 (RN) on 04/30/24. They acknowledged the findings.

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

The facility staffing tool was reviewed with Staff 1 (Memory Care Director) on 04/30/24 at 10:44 am.

Review of the facility ABST identified four out of twenty-one residents were not entered into the tool.  

The need to ensure all residents were entered into the ABST was discussed with Staff 1, Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

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

During a review of staff training records from 04/29/24 through 05/03/24, Staff 4 (Business Office Manager) was unable to provide documented evidence that the sampled staff had completed pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned before working independently with residents. In addition, there was no documented evidence the sampled long term staff had completed annual training including.

On 04/29/24 at 3:45 pm, Staff 4 reported the facility had switched staff training companies and that most of the previous training staff completed was not accessible to her.

The requirement to maintain written documentation of training completed by each employee was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Refer to Z 155.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 9, 13, and 22) were trained in the use of First Aid and abdominal thrust within 30-days of hire. Findings include, but are not limited to:

Staff training records were reviewed from 04/29/24 through 05/03/24. The following was revealed:

There was no documented evidence Staff 9 (MT), Staff 13 (MT), and Staff 22 (CG), hired 03/01/24, 11/03/23, and 09/21/23, respectively, completed training in First Aid and abdominal thrust.

The need for staff to complete all required training within the specified time frame was discussed with Staff 4 (Business Office Manager) on 05/02/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

On 05/02/24, fire and life safety records, dated 11/2023 through 04/2024, were reviewed with Staff 5 (Environmental Services Director).

a. The fire drill records lacked documentation of the following components:

* Escape route used;

* Evacuation time-period needed; and

* Number of occupants evacuated.

There was no evidence alternative routes were used during fire drills.

b. On 05/02/24 at 10:21 am, Staff 5 confirmed he was unaware fire and life safety instruction to staff was required on alternate months from the fire drills. Therefore, there was no documentation staff fire and life safety instruction was conducted during the time period reviewed.

The need to ensure fire drills included documentation of all required components and staff were instructed on fire and life safety responsibilities on alternate months was discussed with Staff 1 (Memory Care Director), Staff 2 (ED) and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were stored in locked storage and were properly labeled. Findings include, but are not limited to:

The memory care community was toured on 04/29/24 at 2:19 pm. The following toxic materials were observed to be unsecured:

* Wound cleanser, alcohol pads, and Oxivir sanitizing solution were stored in unlocked cupboards in the "Spa/Bather" room. Over multiple observations, the room was observed to be unlocked and accessible to residents;

* Two large containers of laundry detergent were stored in an unlocked cupboard in the laundry room. Over multiple observations, this room was observed to be unlocked and accessible to residents; and

* Oxivir sanitizing spray and Clorox bleach wipes were observed to be stored in an unlocked cupboard of the resident-accessible kitchenette.

On 04/29/24 at 4:02 pm, the facility was directed to ensure the identified unsecured toxic materials were stored in a secured location.

On 04/30/24 at 9:12 am, two bottles of Oxivir sanitizing spray and one unlabeled spray bottle were left unattended on the stove in the kitchenette.

The need to ensure all poisons, chemicals, and other toxic materials were stored in locked storage and properly labeled was discussed with Staff 2 (ED) on 05/01/24 and again with Staff 1 (Memory Care Director), Staff 2 and Staff 3 (RN) on 05/03/24. They acknowledged the findings.

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

The interior of the MCC was toured on 04/29/24. The following areas were observed to need cleaning and/or repair:

* Benches throughout the MCC were stained and had worn fabric;

* Multiple dining room chairs had food debris, spills, dust and dirt on the vinyl and wood surfaces;

* Multiple dining room chairs had torn seams which resulted in loose piping cords and unattached dust cover fabric below the seat cushion;

* Armchair near the medication room had torn seams with foam padding exposed;

* Baseboard was removed near resident Rooms 7 and 21;

* Drywall was gouged with metal corner guard exposed near the kitchenette refrigerator and near resident Room 22; and

* Plastic frame for the ombudsman poster was chipped which created a sharp edge.

The environment was toured with Staff 1 (Memory Care Director) on 05/03/24 at 9:09 am. She acknowledged the areas that needed to be cleaned and repaired.

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

During a walk-through of the facility on 04/29/24 at 2:42 pm, doors to the interior MCC courtyard were found to lack a working audible alarm or other system to alert staff when a resident exited the building. This lack of alarm or system was confirmed by an interview with Staff 12 (MT) on 04/29/24 at 3:51 pm.

The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited the building was discussed with Staff 1 (Memory Care Director) on 05/03/24 at 9:09 am. She acknowledged the findings.

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

H 1510: Individual Rights Settings: Privacy, Dignity OAR 411-004-0020(1)

(1) Residential and non-residential Home and Community Based Settings must have all of the following qualities:

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

Refer to C 200.

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

H 1511: Individual Rights Settings: Freedom from Restraints OAR 411-004-0020(1)(d)

(1) Residential and non-residential Home and Community Based Settings (HCBS) must have all of the following qualities:

(d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

Refer to C 340.

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

H 1518: Individual Door Locks: Key Access OAR 411-004-0020(2)(e)

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

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

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 156, C 200, C 231, C 295, C 360, C 361, C 365, C 372, C 420, C 510, C 513, and C 555.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 9, 13, and 22) had documentation of completed orientation, 3 of 3 sampled newly-hired direct care staff (#s 9, 13, and 22) completed pre-service dementia training prior to performing any job duties, 4 of 4 direct care staff (#s 9, 13, 17, and 22) demonstrated competency in all required areas within 30-days of hire, 1 of 1 long-term direct care staff  (#17) had documentation of completing 16 hours of annual in-service training which included six hours of dementia care training, and 2 of 2 long-term staff (#s 17 and 23) completed the required infectious disease training annually. Findings include, but are not limited to:

The facility's training records were reviewed from 04/29/24 through 05/03/24 and the following was identified:

a. There was no documented evidence Staff 9 (MT), Staff 13 (MT), or Staff 22 (MT/CG), hired 03/01/24, 11/03/23, and 09/21/23, respectively, completed the following pre-service orientation topics prior to beginning their job duties:

* Infectious disease prevention training.

Additionally, there was no documented evidence Staff 13, had a written job description or Staff 22, completed the following pre-service orientation topics prior to beginning their job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements; and

* Fire safety and emergency procedures.

b. There was no documented evidence Staff 9, 13, and 22 completed pre-service dementia training prior to beginning their job duties.

c. There was no documented evidence Staff 9, 13, and 22, demonstrated competency in all required areas within the first 30-days of hire.

d. There was no documented evidence Staff 17 (CG), hired 10/31/22, completed 16 hours of annual in-service training, including at least six hours of dementia care topics.

e. There was no documented evidence Staff 17 and Staff 23 (Housekeeper), hired 07/16/18, had completed the required annual infectious disease prevention training.

The need to ensure newly-hired direct care staff completed all pre-service orientation and training topics prior to beginning any job duties and demonstrated competencies in the required areas within 30-days of hire, long-term staff had documentation of required annual in-service training, and that the required infectious disease training was completed annually, was discussed with Staff 4 (Business Office Manager) on 05/02/24 at 11:37 am. She acknowledged the findings.

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: C 252, C 260, C 270, C 280, C 282, C 303, C 310, C 330, and C 340.

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations were completed and activity plans were developed for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Observations were made, interviews were conducted, and service plans were reviewed for Residents 1 and 2 from 04/29/24 through 05/03/24. Residents 1 and 2's evaluations revealed the facility had not evaluated the residents' activity needs in one or more of 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

* Activities which could be used as behavioral interventions, if necessary.

In an interview with Staff 1 (Memory Care Director) on 05/02/24, she confirmed the facility did not have documented evidence that individualized activity plans were developed for each resident based on their activity evaluation.  

The need to ensure residents were evaluated for activities and an activity plan was developed based on the activity evaluation was discussed with Staff 1, Staff 2 (ED), and Staff 3 (RN) on 05/03/24. They acknowledged the findings.