The findings of the re-licensure survey, conducted 11/28/22 through 12/01/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

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

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

OAR 411-054-0055 (1) Medication and Treatment Administration Systems; and

OAR 411-057-0160 Behaviors.

The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the first revisit to the re-licensure survey of 12/01/22, conducted 06/06/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Division 004 for Home and Community Based Services.

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

During a tour of the environment on 11/28/22, there were no postings related to the administrator or designee in charge or the current facility staffing plan in an accessible or conspicuous location.

The findings were reviewed with Staff 2 (ED designee) on 11/29/22. He acknowledged the findings.

1. The required postings for for administrator or designee and staffing are posted.

2. Administrator or designee will do daily walkthroughs to ensure postings are current.

3. Daily for one month and then move to weekly audits, and when the ABST is updated.

4. Admnistrator and MC Program Director.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 3 of 4 sampled residents (#s 1, 2, and 4) whose records were reviewed. Findings include, but are not limited to:

During the survey, resident records were reviewed and were found to be missing, inaccurate, or incomplete in multiple areas, including signed physicians' orders, service plans, evaluations, monitoring, incident investigations, and outside provider notes.  

On 12/01/22, the need to ensure facility records were accurate and complete was shared with Staff 2 (ED designee) and Staff 3 (Consultant).  No additional information was provided.

Refer to C231, C252, C260, C270, C280, C290, and C303 related to resident records and documentation.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.

The resident's service plan, dated 04/27/22, progress notes from 08/31/22 through 11/28/22, interim service plans (ISPs), and incident reports were reviewed. The following incidents were identified:

* 09/23/22 - a fall resulting from another resident running over his/her foot with their wheelchair;

* 10/22/22 - resident reported pain in right heel; staff wrote in a progress note the pain seemed to be from a "gash" in the heel. In the progress note, staff stated "Resident enjoys spending time in the courtyard where there are many sharp rocks and other potentially hazardous materials on the ground that could cause injury"; and

* 11/26/22 - staff discovered a cut on the resident's left forearm "that was bleeding which appeared to be from dry skin [sic]."

There was no documented evidence these incidents were investigated to rule out abuse and/or neglect, reported to the local SPD office if needed, or reviewed by the administrator.

The need to promptly investigate all incidents of abuse or suspected abuse and report to the local SPD if needed was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No additional information was provided.

Based on interview and record review, it was determined the facility failed to investigate incidents of possible abuse or neglect to rule out abuse or neglect, and to report to the local SPD office if needed, for 2 of 2 sampled residents (#s 2 and 4) who were identified to have incidents of possible abuse or neglect, including falls and injuries. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility 12/2021 with diagnoses including Parkinson's disease and cognitive communication deficit.

A chart noted dated 10/22/22 stated: "FAMILY COMMUNICATION: resident's son called this med tech about 30 minutes ago to inquiring [sic] regarding alleged abuse and neglect that was witnessed by his sister and niece yesterday on evening shift. Family members state caregivers acted inappropriately by ignoring calls for help while they sat on their phones, dry BM [bowel movement] was in [his/her] chair and in [his/her] bed, an old sandwich was found under the bed, caregiver that changed [him/her] stated 'ew ...gross' when changing BM soiled brief."

There was no documented evidence the incident was reviewed by the administrator, investigated, or reported to SPD as necessary.

In an interview on 11/29/22, Staff 1 (Memory Care Program Designee/LPN) was unable to confirm that the incident had been investigated. Staff 2 (ED designee) was requested by surveyor on 12/01/22 to report the incident to the local SPD office. Confirmation the incident had been reported was provided to the survey team on 12/01/22.

The need to ensure incidents of possible abuse were reviewed by the administrator and immediately investigated to rule out abuse and/or neglect, and reported to the local SPD office when abuse and neglect could not be ruled out, was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

1. Residents 2, 4 will be assessed and service plan updated as determined. All residents will be assessed and their service plans updated. Resident rights training will be provided to all staff. All staff will be trained again on abuse and neglect reporting. Management staff will be trained on investigation, reporting, and documentation. All sharp rocks or other potentially hazardous materials on the ground that could cause have been removed. All staff training on abuse and neglect reporting and resident rights scheduled for December 29, 2022.

2. Review incident reports within 24 hours of incident occurance. Incidents and concerns will be reviewed in the clinical meeting. Regular maintenance walkthroughs of the courtyard.

3. With each incident. Weekly property inspections for three months and then monthly.

4. Administrator or designee, RN, maintenance director, operations consulting team.  

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

During the survey, there was a lack of unscheduled and scheduled activities that occurred for residents who were unable to self-initiate activities or for the community at large.

No group activities were observed in Cottage 1 or Cottage 2 between 11/28/22 and 11/30/22.

Board games scheduled for 1:00 pm in Cottage 1 on 11/30/22 did not occur. Staff 9 (Resident Assistant) reported no activity staff was on the unit.

The need to ensure an activity program was implemented to meet the needs of the residents was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

1. A full time activity director will be hired. Activity calendar is in place and posted. Staff are being trained in how to engage in activities.

2. The new activity director will be trained in how to develop and deliver activities in memory care. Carestaff will be trained in how to engage in activities listed on the calendar and on each resident's individual activity plan. The RCC will monitor activity delivery.

3. Daily and weekly.

4. Administrator/designee, MC program director, activity director (when hired).

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 3 of 3 sampled residents (#s 1, 2, and 4) whose records were reviewed. Findings include, but are not limited to:

Records for Residents 1, 2, and 4 were reviewed, and there was no documented evidence  resident evaluations were updated quarterly.

1. Resident 1's clinical record contained an evaluation dated 03/17/22. The next quarterly evaluation would have been due on 06/17/22. There was no documented evidence an evaluation had been completed after 03/17/22.

2. Resident 2's clinical record contained an evaluation completed 02/01/22. The next quarterly evaluation would have been due on 05/01/22. There was no documented evidence an evaluation had been completed after 02/01/22.

3. Resident 4's clinical record contained an evaluation completed when the resident was admitted, dated 04/27/22. The next quarterly evaluation would have been due on 07/27/22. There was no documented evidence an evaluation had been completed after 04/27/22.

On 11/30/22, the need to ensure the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates, was discussed with Staff 1 (ED Designee), Staff 3 (Consultant), and Staff 4 (Consultant). No additional information was provided.

1. Resident 1, 2 and 4 evaluations have been updated. All residents evaluations will be reviewed and updated. The ABST will be updated as determined by the updated evaluations.

2. A new evaluation form will be implemented that includes all required elements. Once all evaluations are updated, an evalation schedule will be developed and implemented to correspond with the service plan.

3. Weekly and monthly.

4. Administrator, designee.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.

The resident's service plan, dated 04/27/22, and progress notes, dated 08/31/22 through 11/28/22, were reviewed and staff were interviewed. The service plan was not reflective of the resident's current status and care needs in the following areas:

* Toileting needs; and

* Behaviors.

There was no documented evidence the resident's service plan had been updated since 04/27/22.

The need to update service plans within 30 days of admission and quarterly thereafter, as well as the need for service plans to be reflective of the resident's current status and care needs and provide clear direction to staff on the provision of care, was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were followed, were reflective of resident needs, were readily available to staff, provided clear instructions to staff, and/or were updated quarterly for 2 of 2 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Review of Resident 2's service plan and interim service plans (ISPs), observations of the resident, and interviews with staff identified the following:

a. The most recent service plan was dated 02/01/22. There was no documented evidence the service plan was updated quarterly.

b. The service plan was not reflective and lacked clear direction to staff in the following areas:

* Feeding;

* Bathing; and

* Repositioning.

c. The most recent service plan was in a binder in the MT room, making it not readily available to staff.

d. The resident's service plan was not followed in the following areas:

* Every 2 hours toileting checks;

* Every 2 hours repositioning; and

* Every 2 hours hydration.

On 11/29/22 at 11:10 am, Staff 13 (Resident Assistant) reported she had last provided incontinence care, repositioning, and hydration for the resident at 8:00 am.

The need to ensure service plans were reflective of resident needs, included clear direction and were available to staff, were followed, and were updated quarterly was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 12/01/22. They acknowledged the findings.

1. Resident 2 and 4 service plans have been updated to reflect current needs. ABST will be updated. All resident sevice plans will be reviewed and updated. Service plans will be available to staff at all times. Staff will be trained on how to read and follow the service plan.

2. The evaluation data will be used to develop the service plan. A service plan schedule will be developed and implemented. Adherence to the service plan schedule will be reviewed weekly. New service plans will be reviewed by all staff.

3. Weekly and monthly.

4. Administrator, designee.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.

A review of the resident's record revealed s/he experienced multiple short-term changes of condition between 08/31/22 and 11/28/22, including falls, injuries, medication changes, and behaviors.

There was no documented evidence the facility consistently determined what actions or interventions were needed, communicated the actions or interventions to staff on each shift, documented resident-specific staff instructions or interventions and made them part of the resident's record, or monitored changes with weekly progress noted through resolution.

The need to monitor short-term changes of condition through resolution was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No additional information was provided.

Based on interview and record review, it was determined the facility failed to identify and evaluate changes of condition, determine resident-specific actions or interventions needed, provide written communication of those interventions to staff on each shift, and/or monitor the conditions to resolution for 2 of 2 sampled residents (#s 2 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including Parkinson's disease and cognitive communication deficit.

A review of the resident's record revealed s/he experienced multiple short-term changes of condition between 08/28/22 and 11/28/22, including behaviors, skin issues, and medication changes.

There was no documented evidence the facility monitored these changes through resolution.

The need to monitor changes of condition through resolution was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

1. Resident 2 and 4 will be assessed by the RN including historical review to identify risks. Any changes of condition identified will be noted on a TSP and staff will be notified of interventions and monitoring.

2. The 24-hour book will be reviewed, redeveloped and implemented with staff training. Staff will be taught to read and follow a TSP and to notify the RN when required. Med techs will be taught how to document. Clinical meeting will occur multiple times per week and changes of condition and documentation will be reviewed. Licensed nurses will be trained in assessment, interventions, and follow up of change of condition and monitoring. All direct care staff will be trained on change of condition.

3. Daily and weekly.

4. Administrator, designee, licensed nurses.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.

The resident's 04/27/22 service plan, 08/31/22 through 11/28/22 progress notes, and ISPs were reviewed.

A progress note and interim service plan, both dated 11/18/22, revealed the resident had been admitted to hospice that day. There were no hospice visit notes located in the resident's chart, nor was there any documented coordination of care between the facility and hospice.

The need to coordinate care with outside providers and ensure service  providers left written information in the facility addressing services being provided to the resident and any clinical information necessary for staff to provide supplemental care was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure outside service providers left written information in the facility which addressed the on-site services being provided to the resident and failed to coordinate care with outside providers to ensure continuity of care for 3 of 3 sampled residents (#s 1, 2 and 4) who received services from an outside provider. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including dementia, diabetes, and edema. The resident was identified during the acuity interview on 11/28/22 as having skin issues related to leg cellulitis.

Resident skin notes were requested. One chart note was provided: 11/21/22 "SKIN NOTE: ...Left leg has weeping of clear fluid on lower leg. Home Health notified ..."

Staff 1 (MC Program Designee/LPN) stated in an interview on 11/29/22 that she did not have additional skin notes or home health notes.

No additional information was provided.

2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including Parkinson's disease and cognitive communication deficit. The resident was identified during the acuity interview on 11/28/22 as being on hospice.

* Staff 15 (MT) and Staff 1 reported in interviews on 11/28/22 and 11/29/22, respectively, that the process for communication with outside providers sometimes included providers faxing their notes after the visit.

* A chart note dated 11/26/22 stated: "OUTSIDE PROVIDER COMMUNICATION: ... HOSPICE NOTE RN: ...PLEASE DO NOT GIVE [HIM/HER] FOOD. IT IS OKAY TO GIVE GOOD AND FREQUENT ORAL CARE AND SIPS OF WATER ONLY IF S/HE IS AWAKE AND ABLE TO SAFELY SWALLOW."

An observation was made on 11/28/22 of a paper sign taped on the wall at the head of the bed in resident's room: "Please don't feed resident food. Sips of water OK only if awake. Provide constant oral care."

There was no documented evidence the resident's service plan had been updated with the recommendation from the hospice RN.

A request was made of Staff 1 on 11/30/22 for the hospice RN note from which the chart note on 11/26/22 was based. A hospice RN visit note dated 11/26/22 was provided on 12/01/22 with a fax transmittal date/time of 11/30/22 9:00 pm.

No written hospice notes for Resident 2 were provided during the survey.

The need to ensure outside providers left written information for each of their visits and the facility reviewed the information and updated the resident's service plan or orders accordingly was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

1. Resident 1, 2 and 4 will be assessed to ensure updated status information is provided to outside service providers.

2. A new process in place for where outside services can obtain the outside service form and what to do with it when it is complete. There is a new outside provider binder with sign in sheet and blank forms. The completed form will go to the med tech and will be processed similar to a new order, using the 24-hour book system. Med techs and licensed nurses will be trained on how to review, process, and document outside provider communication. Outside provider communication and follow up documentation will be reviewed in clinical meeting. TSP will be implemented and service plan updated as needed.

3. Daily and weekly.

4. Administrator, designee, and licensed nurses.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related to not having physician orders and lack of competency training for employees who administered medications. The findings constituted an immediate plan of correction for the health and safety of residents. Findings include, but are not limited to:

During the re-licensure survey, conducted 11/28/22 through 12/01/22, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas:

* C303: Systems: Medication and Treatment Orders; and

* Z155: Staff Training Requirements.

On 11/30/22 at 11:15 am, the survey team requested an immediate plan of correction to address the issues identified. At 2:00 pm, a plan was received and accepted by the survey team. The immediate jeopardy situation was abated at that point in time.

1. Pharmacy contacted for every order including VA residents. Training for all med techs on December 7-8, 2022. Self-med evaluation audit complete for all residents. Full controlled substance to MAR audit will be done.

2. System review and correction to prevent future concerns with Consonus Pharmacy on December 27-28, 2022 (3-way audit). Exception and variances reports are reviewed multiple times per week. Order recaps will be reviewed and sent for signature. Training for all med techs on medication system needs. Clinical meetings held multiple times per week to review medication exceptions and variances. A competency checklist will be implemented and all med tech skill compentency will reviewed and training will be developed to address competency needs. New med techs will be trained and competency before being independently assigned medication related job duties.

RN will assess competence for all med techs related to RN delegation and complete documentation.

3. Daily, monthly and quarterly.

4. Administrator, designee, RN.

Based on interview and record review, it was determined the facility failed to ensure signed physician orders for all medications and treatments the facility was responsible for administering were documented in the resident's facility record for 2 of 2 sampled residents (#s 2 and 4) whose records were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.

A review of the resident's 11/01/22 through 11/28/22 MAR and the resident's clinical record revealed the facility did not have signed physician orders for any medications or treatments on the MAR.

The need to have signed physician orders for all medications and treatments administered by the facility was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No additional information was provided.

2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including Parkinson's disease and cognitive communication disorder.

The resident's 11/01/22 through 11/28/22 MAR and clinical record were reviewed. The following deficiencies were identified:

a. The following medications were being administered without a signed written physician's order in the resident's record:

* Haloperidol 2 mg/ml every 6 hours;

* Lorazepam 0.5 mg tab 4 times daily;

* Methadone 5 mg tab 0.5 tab (2.5 mg) every 12 hours;

* Quetiapine 200 mg tab 0.5 tab (100 mg) every night;

* Nicotine 21 mg/24 hr patch apply 1 patch to back daily;

* Senna 8.6 mg tab 1 tablet every morning; and

* Senna 8.6 mg tab 2 tablets (17.2 mg) every evening.

b. The facility ceased administering the following medications without a signed physician's order to discontinue the medications in the resident's record:

* Acetaminophen 500 mg caplets 1 tablet 4 times daily;

* Furosemide 40 mg tab 1.5 tablet 2 times daily;

* Melatonin 10 mg capsule every evening;

* Metoprolol 25 mg tab every day;

* Omeprazole 20 mg capsule every day;

* Polyethylene glycol powder 17 grams in 4-6 oz of water/liquid daily;

* Potassium CHL 20 MEQ tablet twice daily;

* Quetiapine 200 mg tab 0.5 tab (100 mg) every night;

* Senna 8.6 mg tab 1 tablet every morning;

* Senna 8.6 mg tab 2 tablets (17.2 mg) every evening; and

* Trazodone 50 mg tab every night.

The need to have signed physician orders in the resident's record for all medications and treatments the facility was responsible to administer, and signed orders to discontinue medications, was reviewed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

1. Resident 2 and 4 treatment orders are in place.

2. All resident orders have been reviewed by the pharmacy and sent to prescribers for review and signature. An audit will be done by Consonus Pharmacy on December 27-28, 2022 to reconcile orders. A new system will be implemented to review orders and send to prescribers at quarterly service plan updates.

3. Monthly and quarterly.

4. Administrator, designee, RN.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

During an interview on 11/29/22 with Staff 2 (ED Designee) and Staff 3 and 4 (Consultants) the following was revealed:

1. During a review of sampled residents' service plans, it was determined the ABST failed to accurately include activities of daily living, other tasks related to care due to service plans lacking updated and accurate information on resident care needs.

2. The facility did not have a system for conducting updates of the ABST tool for each resident as required, including:

(a) Before a resident move-in, with amendments as appropriate within the first 30 days to address a resident's needs;

(b) Whenever there was a significant change of condition; and

(c) No less than quarterly, preferably at the same time the resident's service plan was updated.

3. The facility was using an ABST tool which generated daily staff hours but was not consistently staffing to the levels identified. The ABST staff level noted two caregivers and two medication aides on day shift and swing shift and one caregiver and one medication aide on the overnight shift.  Review of the 11/01/22 through 11/28/22 staffing schedule revealed 69 times the facility was not staffing according to the levels identified by the ABST tool.

The ABST tool was reviewed and discussed with Staff 2, Staff 3, and Staff 4 on 11/29/22 at 3:15 pm.  Staff acknowledged the findings.

1. The ABST is being updated as evaluations and service plans are updated, and with any change of condition.

2. Same as above. Staffing will be scheduled based on ABST information.

3. With any change of condition and quarterly.

4. Administrator, designee.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly-hired direct care staff (#s 20 and 22) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 11/29/22 and identified the following:

Staff 20 Resident Assistant (RA), hired on 09/15/22, and Staff 22 (MT), hired 11/04/22, lacked documentation of demonstrated competency in First Aid/abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 2 (ED designee) and Staff 3 (Consultant) on 11/29/22. They acknowledged the findings.

1. All staff with missing documentation for abdominal thrust will be trained and redemonstration observed by RN.

2. All staff training records will be reviewed for completeness and staff will be assigned training. Training packets will include all required assigned training on Relias for preservice and 30 day training. All staff will complete CPR training in January 2023 to include abdominal thrust. A training checklist will be developed to go into each employee file.

3. Monthly.

4. Administrator, designee.

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

Review of fire drill and fire and life safety records from 05/30/22 through 08/20/22 identified the following:

* The facility failed to provide fire and life safety instruction to staff on alternate months;

* Escape route used;

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

* Evacuation time needed;

* Number of occupants evacuated; and

* Alternate routes used during fire drills were not documented.

In an interview with Staff 13 (Resident Assistant) and Staff 14 (MT) on 11/30/22, they were unable to identify the designated points of safety within or outside the building.

The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 2 (ED Designee) and Staff 3 (Consultant). They acknowledged the findings.

1. Consultant will provide facility with new fire drill form to include all required elements. Fire drill is planned for December 2022.

2. Training will be provided to maintenance director on how to run and document a fire drill. A schedule of fire drills and alternating fire and life safety topics will be developed.

3. Monthly.

4. Administrator, designee, maintenance director.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:

Fire drill records, from 04/30/22 through 10/03/22, were reviewed on 11/29/22.

On 11/30/22 at 09:15 am, Staff 2 (ED designee) stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 2 on 11/30/22. He acknowledged the findings.

1. Consultant will provide a form for resident fire and life safety instruction to be part of the admission packet. All residents will be provided fire and life safety information and documentation completed.

2. Fire and life training instructions will be included in the admission packet. Staff engaged in the admission process will be trained on how to provide instruction. Completed admission packets will be audited after each move in. A checklist will be developed to go with every resident move in for process elements.

3. At each admission and annually.

4. Administrator, designee.

Based on observation and interview, the facility failed to ensure toxic materials were properly labeled and stored. Findings include, but are not limited to:

A tour of the facility was completed on 11/29/22. The laundry room in Cottage 1 was unlocked and contained toxic materials.

In an interview with Staff 2 (ED designee) on 11/29/22 at 01:45 pm, he stated the closets should be locked.

The need to ensure the facility properly labeled and stored toxic materials was discussed with Staff 2. He acknowledged the findings.

1. All toxic materials are securely stored. Staff have been trained that laundry closets must be locked.

2. Staff will be trained on hire regarding chemical storage and securing laundry areas. Daily administrative walkthroughs to ensure laundry areas are secured.

3. Daily.

4. Administrator, designee.

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

Observations of the facility on 11/29/22 revealed the following areas were in need of cleaning or repair:

A. Cottage One:

* The interiors of the refrigerator and microwave had food spills and debris;

* There were food splatters on wall under kitchenette counter;

* The transition strip between the dining room and living room was loose and a possible tripping hazard; and

* The linoleum in laundry room was cracked, peeling, and was an uncleanable surface.

B. Cottage Two:

* The interiors of the refrigerator and microwave had food spills and debris; and

* Exit door to patio was scraped and missing paint.

The areas in need of cleaning and repair were discussed with Staff 2 (ED Designee) on 11/29/22. He acknowledged the findings.

1. Microwave and refrigerator were cleaned. Wall under kitchen counter cleaned. The transition strip has been ordered and will be replaced. The linoleum in the laundry room has been ordered and will be replaced. The exit door to the patio will be repaired and repainted.

2. A cleaning checklist will be developed and implemented for the kitchenette. Staff will be trained on how to clean the kitchenette. Maintenance will do regular walk throughs to identify any environmental concerns.

3. Weekly.

4. Administrator, designee, maintenance director.

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

During the re-licensure survey, conducted 11/28/22 through 12/01/22, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations issued during survey.

1. A situation was identified which constituted an immediate threat to residents' health and safety in the following area:

OAR 411-054-0055 (1)(a) Medication and Treatment Administration Systems.

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

2. A situation was identified which constituted an immediate threat to residents' health and safety in the following area:

OAR 411-057-0160(e) Behavior.

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

3. Refer to deficiencies in the report.

Refer to C300 and C165.

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 155, C 231, C 242, C 361, C372, C 420, C 422, C 510, and C 513.

Refer to C152, C155, C231, C242, C361, C372, C420, C422, C510, and C513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 20, 21, and 22) completed pre-service orientation topics, 2 of 2 newly-hired direct care staff (#s 20 and 22) failed to complete 6 hours of pre-service dementia care training, and 2 of 2 newly-hired staff failed to complete all required training and demonstration of competency (#s 20 and 22). Residents' care needs were put at risk related to lack of training. Findings include, but are not limited to:

Training records were reviewed with Staff 2 (ED Designee) and Staff 3 (Consultant) on 11/29/22. The following were identified:

a. Staff 20 (CG) was hired 09/15/22, Staff 21 (Activities) hired 11/18/22, and Staff 22 (MT) hired 11/04/22. There was no documented evidence the following orientation topics were completed:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

b. There was no documented evidence Staff 20 and 22 had completed pre-service dementia care training.

c. There was no documented evidence Staff 20 and Staff 22 completed the required training in:

* 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;

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

* General food safety, serving and sanitation;

* Other duties as applicable (Med pass, treatments); and

* First Aid/Abdominal Thrust.

Staff 20 was working independently as a caregiver without documented evidence of training in required areas, and Staff 22 was working as a medication aide and caregiver without documented evidence of required training, including competency demonstration.

On 11/29/22 at 11:35 am, in an interview with Staff 2 and Staff 24 (Business Office Manager) they stated they were unable to locate any staff training records or verify the staff completed, demonstrated, or documented evidence of their 30 day competencies.

At approximately 2:28 pm the survey team requested an immediate plan of correction to include:

* An audit of MT employee files to determine extent of training deficiency; and

* A timeframe and schedule for the completion of training and demonstrated competency in all required areas by MTs.

A plan was submitted and accepted prior to survey leaving the building on 11/29/22.

The plan verified Staff 23 (RN interim) completed the medication pass with the swing shift MT and night shift MT on the afternoon and evening of 11/29/22.

The need to ensure the facility had a system which included documented methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 2, Staff 3, and Staff 23 on 11/29/22. They acknowledged  the findings.

1. The training plan is being reviewed and updated to adhere to regulatory requirements. Staff training files are being audited for preservice training and competency completion. Consultant will provide a list of training from Relias that meets requirements. Staff will be assigned training to complete.

2. All staff training records will be reviewed for completeness and staff will be assigned training. Training packets will include all required assigned training on Relias for preservice. A training checklist will be developed to go into each employee file.

3. Monthly.

4. Administrator, designee.  

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 252, C 260, C 270, C 290, C 300, and C 303.

Refer to C252, C260, C270, C300, and C303.     

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 1 of 1 sampled resident (#4) and others in the community. Resident 4 became combative when staff attempted to provide incontinence care and, as a result, was not toileted for greater than eight hours. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.

The resident's service plan, dated 04/27/22, 08/31/22 through 11/28/22 progress notes, and interim service plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified:

* The resident's 04/27/22 initial service plan indicated s/he was independent with toileting and had no behaviors.

* Staff documented in progress notes on 13 occasions between 08/31/22 and 11/21/22 when the resident had behaviors related to the provision of incontinence care.

* Interviews with staff on 11/29/22 and 11/30/22 revealed the resident frequently became agitated and combative when staff tried to change his/her brief. Staff indicated they made several attempts to provide incontinence care, and if the resident didn't allow them to provide care they would leave him/her alone and inform the next shift.

In an interview on 11/29/22 at 1:19 pm on, Staff 17 (Agency Staff) reported the resident had been in the recliner in the common area since she arrived at 6:30 am. She stated she was able to change the resident's brief at 8:45 am and his/her bottom was "very, very red." She stated no one had been able to change the resident since 8:45 am.

Observations between 10:32 am and 2:37 pm on 11/29/22 revealed no staff attempted to provide incontinence care to the resident. At 2:37 pm care staff were requested to change the resident's brief, as it had been nearly six hours since s/he was last changed. The caregiver stated the MT would have to give the resident a shot of morphine before she attempted to change his/her brief. The caregiver indicated it would take "about 30 minutes" for the morphine to take effect.

At 3:05 pm this surveyor returned to the MCC unit, where staff stated the resident "just received" the morphine shot and it hadn't "kicked in" yet.

At 3:37 pm the caregiver began asking the resident if s/he would go with her to change his/her brief. The resident refused several times. At 3:43 pm, the caregiver stated, "We'll give it a couple more tries and if he won't I'm not going to keep trying."

Staff 11 (MT) was not sure if the resident had a behavior plan instructing staff what to do when s/he refused care.

There was no documented evidence of a behavior plan in the resident's service plan. The facility failed to develop a behavior plan to address the resident's combative and aggressive behaviors to ensure the safety of the resident and staff during ADL care. The resident was observed to have skin breakdown on his/her buttocks.

At 4:40 pm, the RN surveyor went to the MCC unit to check if the resident had received incontinence care. Three staff were able to change the resident's brief at approximately 5:30 pm. The RN surveyor reported the resident's left gluteal area was red, and there was an approximately two-inch raw, red area on the resident's coccyx which had not yet opened.

At 4:30 pm, an immediate jeopardy situation was determined. Staff 2 (ED Designee), Staff 3 (Consultant), and Staff 4 (Consultant) were requested to develop a behavior plan for the resident.

At approximately 7:10 pm the facility provided a behavior plan for Resident 4 and the situation was abated.

The need to ensure behavior plans are developed for residents with behaviors which negatively impacted themselves and other residents in the community was discussed with Staff 2, Staff 3, and Staff 4 on 11/30/22. They acknowledged the findings.

1. Resident 4's evaluation and service plan has been updated. Consultant gero psych specialist was onsite to complete assessment with follow up written report. Consultant gero psych specialist also assessed two other residents with follow up written report.

2. All residents will be reviewed for need for behavioral assessment. Staff will be trained by consultant in recognizing and responding to behaviors as communication, responding to ADL needs, and change of condition. TSPs will be used to document changes. Documentation and concerns will be reviewed in clinical meeting. Behavioral plans will be developed for all residents with behavioral needs.

3. Daily, weekly, monthly.

4. Adminstrator, designee, licensed nurse.  

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:

A tour of the facility courtyard on 11/29/22 showed the following:

Multiple metal patio chairs were easily moveable and not of sufficient weight or design to prevent potential elopement.

The need for furniture that was sufficient weight and not easily moveable to prevent potential elopement discussed with Staff 2 (ED Designee) on 11/29/22. He acknowledged the findings.

1. The metal patio chairs were removed and weighted furniture or furniture that can be secured will be ordered.

2. Regular walkthroughs of courtyard area to ensure compliance.

3. Weekly.

4. Administrator, designee, maintanence director.