The findings of the re-licensure survey conducted 12/13/21 through 12/17/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

A situation was identified where there was a failure of the facility to comply with the Department's rules that caused residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-057-0160 Behaviors.

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

The findings of the first re-visit to the re-licensure survey of 12/17/2021, conducted 04/26/22 through 04/27/22, 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to protect residents from abuse, failed to immediately notify the local SPD office of any incident of abuse or suspected abuse and failed to promptly investigate all reports of abuse or suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 4 of 5 sampled residents (#s 1, 2, 3, and 4) who experienced injuries of unknown cause, physical altercations, sexual touching and an unwitnessed falls with injury. The facility failed to promptly investigate and report when Resident 3 was involved in an incident of suspected sexual abuse with another resident on two occasions. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in March 2021 with a diagnosis including Alzheimer's dementia.

Resident 3's current service plan dated 08/26/21, stated Resident 3 had late stage dementia, was confused often, required cues, reminders and redirection from staff and was dependent on staff's assistance for most ADL care.

a. A temporary service plan dated 09/21/21, indicated staff observed an unsampled resident trying to touch Resident 3. The incident was not investigated until 09/27/21 and reported the unsampled resident had his/her hands on top of Resident 3's pants "trying to get under them". The report provided conflicting information and stated abuse had been ruled out because it was possible the unsampled resident was trying to hold Resident 3's hand and touched Resident 3's pants instead. Staff 18 (CG), who completed the temporary service plan on 09/21/21, was interviewed via phone on 12/15/21 and stated the unsampled resident had his/her hand on top of Resident 3's pants near the waist band and was trying to lift Resident 3's shirt.

An incident report dated 09/22/21, indicated staff observed the same unsampled resident "with [ his/her] hands down Residents 3's pants touching [Resident 3's] private parts."

The facility failed to promptly investigate the incident on 09/21/21. On 09/22/21 the unsampled resident involved in the incident the day prior was observed with his/her hands down Resident 3's pants. There was no documented evidence the incidents were reported to local SPD office.

b. Resident 3's service plan dated 08/26/21, stated Resident 3 required assistance of one staff member for ambulation. Review of Resident 3's incident reports indicated the resident was a high fall risk, and had experienced five unwitnessed falls between   07/16/21 and 10/20/21. Two of the falls resulted in injury.

In an incident report dated 09/05/21, staff documented Resident 3 was found on the ground in the facility's outdoor courtyard. Resident 3 was sent to the Emergency Room (ER) for evaluation and treatment of left side drooping and weakness. The resident returned from the ER with a diagnosis of a scalp contusion. The investigation completed on 09/05/21 sated staff were following the service plan and abuse was ruled out because the resident stated no one had hurt him/her. However, the resident's service plans indicated staff were to provide one person assist with ambulation and further stated the resident had late stage dementia and was often confused. There was no documented evidence the facility reported the unwitnessed fall with injury to the local SPD office.

An incident report dated 10/20/21, stated staff found Resident 3 down on the floor in the dining room. The resident was sent to the ER for evaluation and treatment of complaints of severe hip pain. The incident report did not indicate the facility had investigated the incident to rule out abuse or suspected abuse, and there was no documented evidence the facility reported the incident to the local SPD office.

c. An incident report dated 06/19/21, stated Resident 3 was involved in a physical altercation with another resident where the other resident put his/her hands on Resident 3's neck and pushed Resident 3 down. There was no documented evidence the facility reported the incident to the local SPD office.

An incident report dated 08/15/21, stated Resident 3 was involved in a physical altercation with another resident where the other resident hit Resident 3's face with an open hand. There was no documented evidence the facility reported the incident to the local SPD office

The need to ensure  incidents of abuse or suspected abuse were promptly investigated and reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings and reported all required incidents to the local SPD office, per the survey team's request. Confirmation of the reports were provided to the survey team prior to survey exit.

2. Resident 2 was admitted to the facility in October 2014 with a diagnosis including dementia.

Resident 2's service plan dated 10/05/21, stated the resident was "wheelchair bound"  and required full assistance from staff for all transfers and ADL's.

A progress note dated 10/12/21, stated staff discovered a bruise on Resident 2's upper left arm and a temporary service plan dated 10/13/21, stated staff discovered a bruise on Resident 2's right hip. There was no documented evidence the facility investigated the incidents to determine if abuse or suspected abuse could be ruled or reported the incidents to the local SPD office.

The need to ensure injuries of unknown cause were promptly investigated and reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings and reported all required incidents to the local SPD office, per the survey team's request. Confirmation of the reports were provided to the survey team prior to survey exit.

3. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack. Review of the resident's progress notes, incident reports and interim service plans identified the following deficiencies:

The facility failed to immediately report three incidents of abuse to the local SPD office, involving resident to resident altercations. These were listed as:

* 09/14/21- Resident 4 was involved in an unwitnessed altercation with another resident;

* 11/14/21- staff witnessed Resident 4 gripping another resident's arm, while scratching and trying to hit [him/her]; and

* 11/18/21- staff observed Resident 4 grab another resident's arm and "smack [him/her] across the face four times".

There was no documented evidence the facility reported these three incidents to the local SPD office.

On 12/15/21 the need to ensure incidents of abuse or suspected abuse were promptly reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. At survey's request, the facility reported the incidents to the local SPD office. Confirmation of the reports were provided to survey prior to exit.

4. Resident 1 was admitted to the facility in October 2021 with diagnoses including history of Cerebrovascular accident.

An incident report dated 10/26/21 stated Resident 1 was involved in a physical altercation with another resident where the other resident hit Resident 1 two to three times in the upper arm. There was no documented evidence the facility reported the incident to the local SPD office.

On 12/16/21, the need to ensure incidents of abuse or suspected abuse were promptly investigated and reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. The facility reported the incidents to the local SPD office per the survey team's request. Confirmation of the reports were provided to the survey team prior to survey exit.

All staff will complete Abuse Reporting and Investigation from Oregon Care Partners.

Abuse reporting and investigation will also be covered at the all staff meeting

Staff will be trained to notify ED/LN/RCC of suspected abuse/neglect immediately.

Incident reports will be reviewed by RCC/LN/ED within 24 hours of notification per state guidelines.  Incidents where abuse and neglect cannot be ruled out, i.e. unwitnessed falls with injury, injuries of unknown origin, res to res altercations, inappropriate contact, will be reported immediately to APS.

Consultant to monitor monthly during visits.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components and were updated with changes as appropriate within the first 30 days for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in October 2021.

Resident 1's move-in evaluation failed to address the following required components:

* List of current diagnoses;

* List of medications and PRN use;

* Visits to health practitioner(s), ER, hospital, and/or NF in the past year;

* Effective non-drug interventions (related to mental health issues);

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

* Ability to manage medications;

* Transportation;

* List of treatments; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, and room temperature.

There was no documented evidence the facility updated the resident move-in evaluation within the first 30 days.

On 12/16/21, the need to ensure new move-in evaluations included all required components and were updated within the first 30 days was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Res 1 will have 30 day evaluation completed.

New resident move in eval will be reviewed by ED prior to admission to ensure all components included.

ED will continue to review eval/service plan due dates weekly with RCC/LN to ensure they are completed timely.

Move-in eval tool will be reviewed to ensure all required components are included per OAR

Consultant to review monthly at visits.

3. Resident 3 was admitted to the facility in March 2021 with diagnoses including Alzheimer's dementia.

Resident 3's current service plan dated 08/26/21, was reviewed on 12/13/21. The service plan had not been updated quarterly and was not updated when the resident experienced a significant change in condition related to a severe weight lost on 07/30/21.

The need to ensure service plans were updated quarterly and/or updated when the resident had a significant change in condition was discussed with Staff 1 (ED) and Staff 2 (Regional  Director of Operations) on 12/16/21. They acknowledged the findings.

2. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA).

Review of Resident 4's service plan, dated 08/12/21, progress notes, incidents reports and staff interviews identified the following deficiencies:

a. The service plan was not reflective of the resident's current status or lacked direction to staff in the following areas:

* Challenging or volatile behavior patterns;

* Non-drug interventions; and

* Multiple resident to resident altercations.

b. The facility failed to update the service plan quarterly, as the rule required.

On 12/16/21 the need to ensure service plans were reflective of residents' current status, provided instructions to staff and were updated quarterly was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). 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, provided clear direction regarding the delivery of services, were reviewed and updated quarterly and/or when a resident experienced a significant change in conditionand, or were followed for 3 of 5 sampled residents (#s 1, 3, and 4). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in October 2021 with diagnoses including history of Cerebrovascular accident.

Resident 1's service plan, progress notes, incidents reports and staff interviews identified the service plan was not reflective of the resident's current status or lacked direction to staff in the following areas:

*Shaving assistance; and

*Transfer assistance.

On 12/16/21, the need to ensure service plan's were reflective of resident needs and were being followed was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

An audit of all service plans will be conducted, to include residents 1,3, and 4 by RCC/LN to ensure all components are included as well as updated timely.

ED will review weekly with RCC/LN to ensure completion as well as that all components are included

ED will review service plan due dates weekly with LN/RCC to ensure completion within 30 days for new residents, 90 days for existing residents, and with significant changes of condition.

LN/RCC will review 24 hour report/incident reports daily to monitor for significant changes in condition. Service plans will be updated to reflect the significant changes per state guidelines. ED will review updated service plans for completion.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated and referred to the RN for further assessment as indicated, necessary actions/interventions were determined, documented and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through resolution for 3 of 5 sampled residents (#s 2, 3, and 4) who had documented changes of condition. Resident 2 experienced pressure wounds which went untreated and worsened over time. Resident 3 experienced a severe weight loss, continued to lose weight over time, and displayed repetitive intrusive wandering behaviors which placed the resident at risk of injury. Resident 4 displayed repetitive episodes of physical aggression towards other residents, which placed the residents at risk of injury. Findings include but are not limited to:

1. Resident 2 was admitted to the facility in October 2014 with diagnoses including dementia.

Resident 2's service plan dated 10/05/21 stated the resident was "wheelchair bound"  and required full assistance from staff for all transfers and ADLs.

a. Progress notes (10/05/21 -12/13/21), MARs/TARs  (10/01/21 - 12/13/21) and temporary service plans were reviewed and indicated the following information related to a wound on Resident 2's coccyx area:

*10/12/21- A temporary service plan stated Resident 2 had a "small pressure sore on right buttocks/hip. Apply A&D ointment as needed." There was no documented evidence staff had administered the treatment per review of the October 2021 MAR/TAR and progress notes;

* 10/22/21- A progress note stated the facility received orders for "calmoseptine topical paste for residents pressure wound on buttocks." There was no documented evidence staff had administered the treatment, per review of the October and November 2021 MAR/TAR and progress notes;

* 11/27/21- A temporary service plan noted the resident now had an "open wound on his/her coccyx".

* 11/28/21- An RN progress note indicated the resident had an "open area" on his/her coccyx which measured 1cm x 1cm. The note stated the facility was to notify hospice and the resident was placed on alert for weekly skin checks.

* 12/2/21- Staff 3 completed an assessment and documented the coccyx wound measured 1.2 cm x 1 cm. Staff 3 contacted the resident's hospice provider and requested they provide an evaluation and wound care orders.

*12/3/21- A progress note stated Resident 2's hospice provider assessed the wound as a "stage III wound on coccyx" and initiated wound care orders.

The facility's failure to evaluate and monitor the wound on the resident's coccyx and failure to administer treatments as prescribed resulted in worsening of the wound.  

The resident's coccyx wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 on 12/16/21 indicated the wound had worsened and measured 3 cm x 2.5 cm. The survey team's RN stated the wound was at a minimum a stage III pressure wound.

b. Progress notes (10/05/21 -12/13/21), MARs/TARs  (10/01/21 - 12/13/21) and temporary service plans were reviewed and indicated the following information related to wounds on Resident 2's left hip, right hip and right heel:

* 10/28/21- A progress note indicated staff identified a skin abrasion on Resident 2's left hip;

* 11/05/21- Dressing changes for "left hip pressure sore" were initiated on the MAR;

* 11/12/21- A temporary service plan stated Resident 2 had "pressure sores" on the right and left hip and right heel;

* 11/28/21- An LN progress note stated the resident had a 4 cm x 3 cm blister on the right heel, there was no mention of the hip "pressure sores"; and

* A progress note and skin assessments, completed by Staff 3, dated 12/02/21 indicated the blister on the residents right heel remained intact, the wound on the resident's right hip had resolved but the wound on the left hip measured 4 cm x 2.4 cm, with the open area of the wound measuring 2 cm x 1.5 cm. Staff 3 contacted the resident's hospice provider and requested an evaluation and wound care orders. The facility continued to provide dressing changes as directed.

The facility failed to refer the resident to the RN for further assessment when the resident's left hip abrasion (identified on 10/28/21) had not resolved and two additional "pressure sores" were documented by staff on 11/12/21.  

There was no documented evidence the facility monitored the left hip "pressure sore" between 10/28/21 - 12/02/21, the right heel "pressure sore" between 11/12/21 -11/28/21, and the right hip "pressure sore" between 11/12/ 21 - 12/02/21.

The facility's failure to monitor the wound on Resident 2's left hip between 10/28/21 -12/02/21 resulted in worsening of the wound.

The left hip wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 indicated the wound on the left hip had worsened and measured 4 cm x 3 cm, with the open area of the wound measuring 3 cm x 2.5 cm.

The need to ensure residents who experienced changes of condition were referred to the RN for further evaluation, monitored at least weekly through condition resolution and necessary interventions were determined and documented was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

2.  Resident 3 was admitted to the facility in March 2021 with a diagnosis including Alzheimer's dementia.

a. Resident 3's weight records dated 06/30/21 through 12/13/21 indicated the following:

On 06/30/21 Resident 3's weight was documented as 170.2 pounds and on 07/30/21 Resident 3's weight was documented as 161.2 pounds. This indicated Resident 3 experienced a severe weight loss of  9 pounds or 5.28% of total body weight within 30 days. The resident continued to experience weight fluctuations over the next several months. On 12/15/21 the resident weighed 156.6 pounds which represented a  weight loss of 13 pounds, or 8% of total body weight over six months.

There was no documented evidence the facility identified, evaluated, determined interventions and monitored the resident's severe weight loss between 07/30/21 and 08/27/21, or referred the resident to the RN for assessment when the resident experienced a significant change of condition.

On 08/27/21, a temporary service plan instructed staff to provide Resident 3 with an adaptive lipped plate. There was no evidence the facility monitored the use of or effectiveness of the adaptive device in reducing further weight loss 08/27/21 - 12/13/21. No other weight loss interventions were noted in the residents chart.

The need to ensure resident changes of condition were identified and evaluated, interventions were determined, documented and monitored weekly and residents with significant changes of condition were referred to the facility RN for assessment was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

b. Resident 3's current service plan dated 08/26/21, stated the resident had late stage dementia, was confused often, had a history of falls and had a history of wandering.

The following interventions were included in the 08/26/21 service plan:

When the resident is observed wandering throughout facility:

* Staff were to offer food/drink;

* Staff to conduct safety checks each shift;

* Hold the resident's hand;

* Offer toileting;

* Put music on while encouraging the resident to sit in a chair, and

* Redirect the resident by walking him/her to dining or living room.

In an incident report dated 10/09/21, staff documented Resident 3 experienced an unwitnessed fall and was found sitting on the floor of another resident's room. No injury was noted. The temporary service plan did not include new interventions to address the resident's fall or intrusive wandering.

An incident report dated 11/15/21, stated Resident 3 experienced an unwitnessed fall and staff found the resident on the floor in an unoccupied room. The temporary service plan included interventions to lock the doors of unoccupied rooms. There was no documented evidence interventions to address the resident's behavior of wandering into other rooms were developed.

An incident report dated 11/25/21 stated staff found Resident 3 on the floor of another resident's room. No injury was noted. The temporary service plan did not include new interventions to address the resident's fall or intrusive wandering behaviors.

An incident report dated 12/01/21 stated staff responded to a scream coming from another resident's room. Staff found Resident 3 on the floor in the other residents room. The resident in that room stated "I pushed the intruder down". Resident 3 sustained "a small scratch on [his/her] vertebra and a scratch on [his/her] back going along the right side."

The facility failed to determine, document and monitor interventions for effectiveness when Resident 3 displayed repetitive intrusive wandering behaviors which placed Resident 3 at risk for injury. On 12/01/21 Resident 3 wandered into another residents room and was injured.

The facility's failure to determine, document and monitor interventions for effectiveness when Resident 3 experienced a change in behavior and unwitnessed falls was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

3. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA).

Review of Resident 4's progress notes, interim service plans, incident reports and staff interviews indicated the resident had six physical altercations with other residents between 09/13/21 and 12/13/21. The incidents were listed as follows:

* 09/14/21- Resident 4 was in an unwitnessed altercation with another resident. An interim service plan stated staff should re-direct the two residents from each other;

* 09/26/21- Staff witnessed Resident 4 being struck in the face by another resident, who stated Resident 4 had "hit [him/her] first". An interim service plan stated Resident 4 was to be re-directed to the dining room, Montessori room when observed near the other resident;

* 09/28/21- Staff witnessed Resident 4 being "punched repeatedly in the head", by the same resident as the previous incident. An interim service plan instructed staff to "re-direct Resident to his room or other common area";

* 11/14/21- Resident 4 was seen by staff gripping another resident's forearm, while scratching and trying to hit the resident. An interim service plan stated "if these two residents are up on [night] shift and near each other, they will be supervised";

* 11/18/21- Staff witnessed Resident 4 grab another resident's arm and "smack [him/her] across the face four times". An interim service plan stated staff should observe for other residents in Resident 4's path, as s/he self-propels in wheel chair, directing Resident 4 around other residents when necessary; and

* 12/02/21- Staff observed Resident 4 holding onto another resident's blouse and wrist, and "tugging [him/her] back and forth". An interim service plan instructed staff to "intervene if the two residents are seen together, and are having any issues".

In each of these instances an interim service plan was developed and Resident 4 was put on "alert charting".  However, the service plans did not provide new interventions and the facility failed to monitor the  previous interventions for effectiveness.

On 12/07/21 the facility RN sent a fax to Resident 4's physician requesting a medication review, diagnostic lab work, and PT/OT evaluation. On 12/07/21 an order was obtained to increase Resident 4's Risperidone (an antipsychotic) to twice daily, for behaviors. The medication was started on 12/07/21 and there were no further incidents documented through survey entrance date of 12/13/21. However, the facility's failure to implement new interventions and monitor those for effectiveness contributed to a prolonged pattern of physical aggression, which put Resident 4 and other residents at risk for harm.

On 12/17/21 the need to develop new behavior interventions and monitor those for effectiveness was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

All staff to be trained on abuse reporting and investigation through Oregon Care Partners and all staff meeting.

Res 2,3,4 will have change of condition completed.

MA's will receive in-service on weight and skin policies. MA will complete incident report and notify LN/RCC/ED of any changes in behavior or skin integrity.

RCC/LN will implement appropriate interventions for behaviors and monitor effectiveness.

LN will complete weekly skin assessments and implement appropriate interventions, notify appropriate outside agencies i.e. HH, Hospice,PCP

RN/LN/RCC will review weights weekly.  Should a resident experience significant weight loss/gain-RN/ED will be notified immediately.  Interventions will be implemented and PCP notified. Interventions for residents experiencing significant weight loss/gain will be monitored for effectiveness weekly by RN/LN/RCC

Consultant to review COCs monthly at visits.

Based on observation, interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, to include findings, resident status and interventions, for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of condition. Resident 3 experienced severe and ongoing weight loss and Resident 2 experienced multiple pressure wounds that worsened over time. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in October 2014 with diagnoses including dementia.

Resident 2's service plan dated 10/05/21, sated the resident was "wheelchair bound" and required full assistance from staff for all transfers and ADLs.

a. On 11/27/21, a temporary service plan noted the resident had an "open wound on his/her coccyx".

* 11/28/21- An RN progress note indicated the resident had an "open area" on his/her coccyx which measured 1 cm x 1 cm. The note stated the facility was to notify hospice and the resident was placed on alert for weekly skin checks. There was no documented evidence the RN completed an assessment of the residents wound to include residents status, interventions made as a result of an assessment, or that the residents service plan had been updated. A thorough RN assessment was not completed until 12/02/21.

The resident's coccyx wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 on 12/16/21 indicated the wound had worsened and measured 3 cm x 2,5 cm. The survey team's RN stated the wound was at a minimum a stage III pressure wound.

On 12/16/21 Staff 1 (ED) stated the facility had recently undergone a change in the RN position and the facility was not able to locate or access previous RN assessments.

The facility's failure to ensure a timely and thorough RN assessment was completed resulted in worsening of the resident's coccyx wound.

Refer to C270 example 1a.

b. Progress notes (10/05/21-12/13/21), MARs/TARs  (10/01/21-12/13/21) and temporary service plans were reviewed and indicated the following information related to wounds on Resident 2's left hip, right hip and right heel:

* 10/28/21- A progress note indicated staff identified a skin abrasion on Resident 2's left hip;

* 11/12/21- A temporary service plan stated Resident 2 had "pressure sores" on the right and left hip and right heel;

There was no documented evidence the pressure sores were assessed by the facility's RN until 12/02/21.

The left hip wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 indicated the wound on the left hip had worsened and measured 4 cm x 3 cm, with the open area of the wound measuring 3 cm x 2.5 cm.

On 12/16/21 Staff 1 (ED) stated the facility had recently undergone a change in the RN position and the facility was not able to locate or access previous RN assessments.

The facility's failure to ensure a timely RN assessment was completed on 11/12/21 when staff reported the resident's left hip abrasion (identified on 10/28/21) had not resolved and two additional "pressure sores" were identified by staff, resulted in the resident's left hip wound worsening.

Refer to C270 example 1b.

The need to ensure a significant change of condition assessment was completed by the RN, to include findings, resident status and interventions, in a timely manner was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in March 2021 with a diagnoses including Alzheimer's dementia.

Resident 3's weight records dated 06/30/21-12/13/21 indicated the following:

On 06/30/21 Resident 3's weight was documented as 170.2 pounds and on 07/30/21 Resident 3's weight was documented as 161.2 pounds. Resident 3 experienced a severe weight loss of  9 pounds or 5.28% of total body weight over 30 days, which indicated a significant change in the residents condition.

There was no documented evidence the weight loss was assessed by an RN and the resident continued to experience weight fluctuations over the next several months. On 12/15/21 the resident weighed 156.6 pounds which represents a 13 pound or 8% loss of total body weight from 06/30/21-12/15/21.

The need to ensure an RN assessment was completed when resident's experienced significant changes in condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

Refer to C270

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include, but are not limited to:

Resident 1's clinical records and MARs/TARs were reviewed during the survey and identified multiple medication and treatment refusals between 12/01/21 and 12/13/21.

There was no documented evidence the facility notified the physician when the resident refused consent to orders.

On 12/16/21 the failure to notify physicians of the documented medication and treatments refusals was reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Res 1's med refusals have been reported to MD.  Med refusal protocol will be reviewed and revised.

All MA's will receive training on procedure for resident refusal of medications.

MA's will notify MD of any missed medication via fax per facility protocol.

RCC/LN will review MARs weekly to ensure PCP's are notified any medication refusals. Med refusals will also be monitored by reviewing med omissions during 24 hour chart review.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly-hired direct care staff (#s 7 and 8) had documented evidence of completion of First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed during survey. The facility did not have documentation that Staff 7 (CG) and Staff 8 (MA), hired 08/06/21 and 10/01/21 respectively, completed the required First Aid and abdominal thrust training within 30 days of hire.

The need to ensure newly-hired direct care staff completed First Aid and abdominal thrust training with in 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

Care staff 7 and 8 have obtained first aid/abdominal thrust.

BOM will conduct audit of employee files.

BOM will ensure any existing direct care staff employed longer than 30 days has current First Aid/Abdominal Thrust.

BOM will review new employee files weekly after orientation to ensure completion.

Should a direct care staff fail to complete the first aid/abdominal thrust training within 30 days of hire, they will be removed from the schedule until complete.

BOM will review findings with RCC/LN/ED weekly to ensure compliance.

RDO to audit monthly during visits.

Based on interview and record review it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months from fire drills and failed to ensure fire drills included all required documentation components. Findings include, but are not limited to:

Fire and life safety records for June 2021 through November 2021 were reviewed on 12/15/21 and showed the facility failed to conduct fire and life safety trainings on alternate months and failed to consistantly document the following required fire drill components:

*Escape route used;

*Problems encountered;

*Evacuation time-period needed;

*Staff members on duty and participating; and

*Number of occupants evacuated.

In an interview with Staff 1 (ED) on 12/16/21, they reported there was no documented staff training records related to fire and life safety from June 2021 through December 2021.

On 12/16/21, the need to ensure fire and life safety training was provided to staff on alternate months of fire drills and fire drills had documented evidence of all required components was discussed with Staff 1 and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Maintenance Director (MD) will conduct fire and life safety training on alternate months of fire drills at the monthly all staff meetings.

A sign in sheet will be kept to track attendance of employees attending.

ED will review All Staff Inservices monthly with MD to ensure compliance.

RDO to review Fire and Life Safety records quarterly.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code. Findings include, but are not limited to:

Fire and life safety records for June 2021 through November 2021 were reviewed and lacked the following components:

*Alternating evacuation routes during fire drills; and

*Documentation resident evacuation levels were determined and met.

On 12/16/21, the need to ensure fire and life safety training included all required components was discussed with  Staff 1(ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

MD will conduct fire drills in accordance with state guidelines on alternating months of fire and life safety training.

MD will complete the fire drill in its entirety utilizing the records on TELs system.

ED will review fire drills monthly with MD to ensure they encompass all components to include alternating evacuation routes and ensure resident evacuation levels are determined and met.

RDO to review fire drill records quarterly.

Based on observation and interview, it was determined the facility failed to ensure the door that exited to an interior courtyard was equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

Observations during the survey revealed exit doors, including doors to the enclosed courtyards, had no alarm or other acceptable system to alert staff when residents entered or exited.

On 12/14/21, the failure to ensure doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) and Staff 11 (Maintenance Director). They acknowledged the findings.

RDO and ED will contact customer support to ensure that chimes are working on all exterior doors leading to interior courtyards.

During times of inclement weather outlined in community policy, doors will be kept locked to ensure the safety of residents.

MD will inspect door alarms leading to interior courtyards monthly via TELs and alert ED of any malfunctions.

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

Refer to  C 231, C 372, C 420, C 422 and C 555.

Refer to C 231, C 372, C 420, C 422 and C 555

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired direct care staff (#s 7, 8, 10 and 14) completed all required competency training within 30 days of hire and 2 of 3 sampled veteran staff (#s 16 and 17) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

1. Training records for Staff 7 (CG) hired 08/06/21, Staff 8 (MA) hired 10/01/21, Staff 10 (CG) hired 09/14/21 and Staff 14 (CG) hired 06/30/21, were reviewed during survey. The following deficiencies were identified:

a. There was no documented evidence Staff 7, 8 and 14 had had completed competency training, in all required topics, within 30 days of hire.

b. There was no documented evidence Staff 10 had completed competency training within 30 days of hire on the following topics:

   * Changes associated with normal aging;

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

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

c. There was no documented evidence Staff 8 (MA) completed competency training within 30 days of hire related to demonstrating ability to perform safe medication and treatment administration unsupervised.

* On 12/15/21, Staff 2 (Regional Director of Operations) stated the facility had recently undergone a change in management and believed Staff 8 had completed the required training but the records had not been maintained by the previous management. Per the survey team's request, the facility removed Staff 8 from his/her medication administration duties and provided the staff member with the appropriate training prior to returning Staff 8 to medication administration duties.

2. Training records for Staff 16 (CG) hired on 08/20/19 and Staff 17 (CG) hired on 05/23/19, were reviewed during survey. The following deficiencies were identified:

There was no documented evidence Staff 16 (CG) and Staff 17 (CG) had completed six hours of annual dementia related training. Additionally, there was no documented evidence Staff 16 completed the required 10 hours of annual training related to provision of care.

The need to ensure newly-hired direct care staff completed competencies in all required topics within 30 days of hire, and veteran staff completed 16 hours of in-service training annually, including 6 hours of dementia care training, was reviewed with Staff 1 (ED) and Staff 2 on 12/16/21. They acknowledged the findings.

BOM will conduct audit of all direct care staff files.

Any staff missing their 30 day competencies will be required to complete with a trainer/RCC/LN.

BOM will notify RCC/LN of any direct care staff that have not completed the required CEU's.

Direct care staff will be assigned the appropriate CEU's and are expected to complete the required amount.

BOM will audit employees files monthly and review with ED any outstanding matters.

All direct care staff will receive Montessori (dementia specific) training.

BOM will continue to review staff training records weekly and review with RCC/ED any outstanding items.  Direct care staff that fail to meet these requirements will be removed from the schedule until their completion.

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, and C 305

Refer to C 252, C 260, C 270, C 280, and C 305

3. Resident 3 was admitted to the memory care community in March 2014 with diagnoses including Alzheimer's dementia.

Review of Resident 3's service plan dated 08/26/2021 and an undated activity evaluation indicated the following:

Resident 3's activity evaluation and activity service plan failed to address the following required elements:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations; and

* Adaptations necessary for the resident to participate.

On 12/16/21 the lack of an individualized activity plan that was reflective of the resident's current status, addressed all required components and was available during the resident's waking hours was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA).

Review of Resident 4's service plan, dated 08/12/2021 indicated the following:

a. The resident's service plan lacked an individualized plan for meaningful activities that promoted the physical and emotional well-being of the resident, were person-directed and available during the resident's waking hours.

b. Resident 4's activity evaluation failed to address following required elements:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities for behavior interventions.

On 12/16/21 the lack of an individualized activity plan that was reflective of the resident's current status, addressed all required components and was available during the resident's waking hours was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the memory care community in October 2021 with diagnoses including history of CVA (cerebrovascular accident).

Review of Resident 1's service plan offered some information about the resident's interests, the facility had not fully evaluated the resident's:

*Current abilities and skills;

*Physical abilities and limitations;

*Adaptations necessary for the resident to participate; and

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

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

On 12/16/21, the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Activities Associate and Marketing Director will audit "My Life Stories" for all residents and ensure any missing are completed.

"My Life Stories" will be given to RCC/LN to incorporate into service plans.

RCC/LN will include this in their service plan audit.

Service plans will be reviewed with ED to ensure compliance.

Refer to C260

2. Resident 3 was admitted to the facility in March 2014. Resident 3's current service plan dated 08/26/21, stated Resident 3 had late stage dementia, was confused often, had a history of falls and had a history of wandering.

Review of Resident 3's service plan dated 08/26/21 and temporary service plans indicated Resident 3's behaviors of intrusive wandering were not evaluated and included on the service plan.

Refer to C 270 example 1 b.

The need to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service plan was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the memory care community, update the resident's service plan, or initiate outside consultation or acute care when indicated, for 2 of 3 sampled residents (#s 3 and 4) whose service plans were reviewed. Resident 3 displayed repetitive intrusive wandering behaviors which placed the resident at risk of injury. Resident 4 displayed repetitive episodes of physical aggression towards other residents, which placed the resident and others at risk of injury. Findings include, but are not limited to:

1. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA).

Review of Resident 4's progress notes, interim service plans, and incident reports identified three resident to resident altercations where Resident 4 was the aggressor, and one episode where the aggressor was undetermined. These incidents were listed as follows:

* 09/14/21- resident 4 was involved in an unwitnessed altercation with another resident;

* 11/14/21- staff witnessed Resident 4 gripping another resident's arm, while scratching and trying to hit [him/her];

* 11/18/21- staff observed Resident 4 grab another resident's arm and "smack [him/her] across the face four times"; and

* 12/02/21- Staff observed Resident 4 holding onto another resident's blouse and wrist, and "tugging [him/her] back and forth".

In an interview on 12/14/21, Staff 9 (MA) stated Resident 4 had "been involved in several resident to resident altercations, and had even assaulted staff members on a few occasions." When asked about safety measures to manage those behaviors, Staff 9 said "we just keep a close eye on [him/her], and try to redirect [him/her] if a conflict arises".

Resident 4 was observed on multiple days and in various settings during the survey. The resident was seen self-propelling in his/her wheel chair in the hall, eating or reading in the dining room, or watching TV. At none of these times was Resident 4 observed displaying any aggressive, disruptive or threatening behaviors.

The facility's failure to evaluate the negative behaviors, and to implement changes to Resident 4's service plan put the resident and others at risk of harm.

On 12/14/21 at approximately 3:00 pm, survey requested an immediate plan of correction to address the resident's behaviors. The plan was received and accepted at 4:41 pm, and the situation was abated.

On 12/16/21 the need for evaluation and service planning for behavioral symptoms which negatively impact the resident and others was discussed with Staff 1 and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Refer to C270

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:

The MCC was toured on 12/14/21. Resident rooms 32, 37, and 43 lacked any individualized identification to assist residents in recognizing their room.

The need to ensure each resident room was identified for the resident was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Activities Associate and Marketing Director will conduct a visual audit of resident doors and shadow boxes to ensure room are individually identified.

Activities Associate and Marketing Director will work with families to individualize any doors/rooms that do not meet this criteria.

Activities and Marketing will notify ED when occupied doors/rooms are individually identifiable. ED will conduct visual audit to ensure completion.

Activity associate will consult with families of new residents to ensure rooms/doors are individually identifiable prior to move in. Should family not be available/unable to assist, Activity Associate will utilize My Life Story to create identifiable doors.

ED will review with AA weekly for completion.

RDO will monitor monthly during visits.