The findings of the initial licensure survey conducted 01/03/22 through 01/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 01/04/22, conducted 06/27/22 through 06/28/22, 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 and Division 57 for Memory Care Communities.

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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 01/04/22, conducted 09/07/22 through 09/08/22, 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 and Division 57 for Memory Care Communities.

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

The findings of the third visit to the re-licensure survey of 01/04/22, conducted 11/29/22, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control for 1 of 2 sampled residents (#2). Findings include, but are not limited to:

Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.

Resident 2 was admitted to the MCC in 12/2021.

Observations and interviews with staff during the survey revealed s/he was incontinent and relied on staff for incontinence care needs.

On 01/04/22 at 09:15 am, the surveyor obtained permission and observed a CG provide ADL care to Resident 2. During the observation, the CG assisted the resident onto the toilet. She failed to wear gloves when removing a soiled incontinent product and wiping urine from Resident 2's perineum. Additionally, no handwashing occurred. The CG touched the resident's clothing, clean incontinence brief, wheelchair handles, toothbrush and toothpaste, mouthwash, deodorant, face cream, a face mask and eye protection (CG was wearing during observation) and her own face with soiled hands. No hand hygiene was observed after she provided care to Resident 2.

After care was completed, the CG wheeled the resident to the dining room and poured the resident a glass of juice.

The above observation was discussed with Staff 1 (Administrator) on 01/04/22 at 2:00 pm. She acknowledged appropriate infection control practices were not implemented. No further information was provided.

1. Immediate counseling was provided to the caregiver. Infection Control Concepts module has been assigned to the caregiver to reinforce teachings.

2.  Staff to be retrained at the all staff meeting on community's Infection Control procedures. Staff to then be observed regularly to ensure existing Infection Control procedures are being practiced.  

3.  Infection Control practices will be audited weekly and as needed.

4.  Administrator, RCC, Nurse

Based on interview and record review, it was determined the facility failed to ensure all incidents involving residents were thoroughly investigated to determine if abuse/neglect or suspected abuse/neglect could be ruled out and/or report the incident to the local Senior and People with Disabilities Office (SPD) for 1 of 1 sampled resident (#5) who experienced unwitnessed falls and/or injuries of unknown cause. Findings include, but are limited to:

Resident 5 was admitted to the facility in December 2021, with diagnosis including dementia and hypertension.

The following information was documented in Resident 5's clinical records including the service plan dated 07/19/22, incident reports, progress and alert charting notes dated 08/12/22 - 09/05/22, preadmission evaluation dated 12/2/21 and hospital discharge records dated 08/12/22 and 09/03/22:

Resident 5 had cognitive impairments due to dementia and communication impairment related to hearing loss. The resident was alert, disoriented but was able to follow simple instructions. Staff were to provide reminders, cues, and ADL assistance as needed.

Review of the resident's clinical records identified Resident 5 experienced the following incidents:

* On 08/12/22, staff documented they found Resident 5 on the floor of  his/her bathroom with pants and brief around ankles and his/her head against the wall. The resident was sent to the hospital and returned to the facility with a diagnosis of urinary tract infection and a "chronic subdural hematoma." The facility incident report noted abuse was ruled out because "the resident was the only person in the apartment and was able to state what happened" however, the resident's description of the event was not documented in the record.

* On 8/16/22 staff documented bruising to right upper arm and on the right side of the resident's head. Staff documented the injuries were related to the fall on 08/12/22, but no further investigation was completed to reasonably rule out abuse for potential injuries of unknown cause.

* 08/20/12, staff documented Resident 5 was found on the floor of his/her room, half dressed in day clothes and night gown with his/her walker next to the chair and "it looked like [Resident 5] fell reaching for it." The resident stated s/he hit his/her head and was sent to the hospital and returned to the facility the next day with new orders for a blood pressure medication. The facility's investigation noted abuse was ruled out because "the resident was the only person in the room and denied anyone harming [him/her]." No further investigation was completed.

* 09/03/22, staff documented Resident 5 was found on the on the floor near the chair in his/her room. When staff asked the resident if s/he was hurt the resident "began talking but nothing made sense" and the resident was "laughing hysterically." The resident was sent to the hospital for evaluation due to increased confusion and memory loss, and returned to the facility the same day with a diagnosis of "dizziness." The facility's investigation noted abuse was ruled out "per resident and no one else was in the room."

There was no documented evidence the facility's investigations included whether or not the service plan was being followed at the time of the falls in order to rule out possible neglect of care. Additionally, the investigations provided conflicting information related to the resident's cognitive impairments and ability to provide an accurate descriptions of the incidents. There was no documented evidence the facility had reported the incidents to the local SPD office.

The need to ensure all incidents involving residents, were thoroughly investigated to determine if abuse/neglect or suspected abuse/neglect could be ruled out and/or report the incident to the local SPD office was discussed with Staff 1 (Administrator) on 09/08/22. The facility reported the required incidents to the local SPD office per the surveyor's request, confirmation of reports was provided prior to exit.

1. Investigations in question were reported to APS.

2. All staff to receive re-training on current Policy & Procedure on investigating and reporting abuse.

3. Will be evaluated daily between the Administrator, RCC and nurse.

4. Administrator, RCC, Nurse

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

During the survey the memory care community was home to eight residents, several of whom relied on staff for all activities. Random resident observations made on 01/03/22 and 01/04/22, review of the activity calendar, and interviews with staff and a family member revealed the following:

The January 2022 MCC Activity Program Calendar provided during the entrance conference indicated the following activities would occur on 01/03/22:

    * 8:00 am- Current Events

    * 10:00 am- Coffee Chat

    * 1:30 pm- Resident Choice

    * 3:00 pm- Monday Matinee

    * 6:00 pm- Sudoku

On 01/03/22 the only activity observed on the unit between 11:30 am and 5:00 pm was the Monday Matinee.

The activity calendar indicated the following activities would occur on 01/04/22:

    * 8:00 am- Current Events

    * 10:00 am- Chaircise

    * 1:30 pm- Crosswords

    * 3:00 pm- Card Sharks

    * 6:00 pm- Puzzles

On 01/04/22 none of the scheduled activities were observed between 8:00 am and 6:00 pm.

In interviews during the survey with staff and a family member, the following was stated/shared with the survey team:

    * "They don't have enough staff to do activities. They are lacking".                                   

    * "I haven't seen activities on the memory care side."

    * "We don't have enough caregivers assigned to get everything done".

    * "With our staffing levels, we really can't do proper activities."

During the survey, at the activity times listed, residents were observed in their rooms, wandering around the unit, or watching TV in the common area.

Failure to provide a daily activity program of social and recreational activities that were based on individual and group interests, physical, mental and psychosocial needs, and created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) on 01/04/22. She acknowledged the lack of activities in the MCC. No further information was provided.

1.  The Life Enrichment Coordinator has been counseled on ensuring the scheduled activities are being held

2. The Life Enrichment Coordinator will be the individual running the scheduled activities in order to ensure they are occurring.  

3.  The daily activity program will be evaluated on a weekly basis  

4.  Administrator, Life Enrichment Coordinator

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations were dated, indicated who was involved in the evaluation process, and addressed all required elements for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 moved into the MCC in 12/2021.

The new move-in evaluation was not dated, did not indicate who was involved in the evaluation process, and failed to address the following elements:

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

* History of treatment and effective non-drug interventions for mental health issues;

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

* Pain: pharmaceutical and non-pharmaceutical interventions; and

* Environmental factors that impact the resident's behavior including lighting and room temperature.

The need to ensure move-in evaluations were dated, indicated who was involved in the evaluation process, and addressed all required elements was discussed with Staff 2 (RCC) on 01/03/22 at 3:55 pm, and with Staff 1 (Administrator) on 01/03/22 at 4:45 pm. The findings were acknowledged.

1.  The evaluation has been updated to reflect the deficiencies noted in the SOD.  Existing Pre-Admission Evaluation requirements will be reviewed.

2.  Administrator, RCC, Nurse will collaborate to ensure the move in admission evaluation is complete and reflects an accurate discovery process of the  prospects condition and needs.

3.  Evaluated prior to each admission date and during the first 30 days of residency.  Further review will be conducted on a quarterly basis.

4.  Administrator, RCC, Nurse  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 1 of 1 sampled resident (#3). This is a repeat citation. Findings include, but are not limited to:

Resident 3 was admitted to the facility on 06/26/22. The resident's move-in evaluation was undated and unsigned. Staff 1 (Administrator) and Staff 3 (Business Office Manager) stated the evaluation was completed on 06/24/22. The following elements were not addressed or had conflicting information in the move-in evaluation:

* Cultural preferences and traditions;

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

* Depression;

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

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Skin Condition;

* History of dehydration or unexplained weight loss;

* Recent losses;

* Unsuccessful prior placements;

* Alcohol and drug use not prescribed by a physician.

The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (Administrator) on 06/28/22. She acknowledged the findings.

1.  The evaluation has been updated to reflect the deficiencies noted in the SOD.

2.  Administrator, RCC will collaborate to ensure the Pre-Admission evaluation is thorough and contains all required elements and accuratley reflects the prospects condition and needs.

3.  Evaluated prior to each admission

4.  Administrator, RCC

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 1 of 2 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:

During the entrance conference acuity interview on 01/03/22, staff indicated Resident 2 needed assistance with ADLs, two staff were often needed for transfers, and had assistive transfer devices on both sides of the bed.

Observations, an interview with the resident's family, interviews with staff, and review of the clinical record revealed the service plan was not reflective or failed to provide clear direction to staff in the following areas:

* Use of Halo assistive bed devices;

* Eye glasses;

* Food provided by family;

* Two-person transfer assistance;

* Use of incontinence pad liners; and

* Sleep preferences.

The need to ensure the service plan was reflective of Resident 2's current needs and provided clear direction to staff was reviewed with Staff 1 (Administrator) on 01/04/22 at 2:00 pm. She acknowledged the findings.

1.  The Service Plan has been updated to address the deficiencies noted.

2.  A copy of the current Service Plan will be provided to all staff for feedback and comment on each resident for the residents 30 day and quarterly review to ensure the care needs are captured and reflected on the service plan.

3.  Evaluation of Service Plan to be on a monthly basis

4.  Admininstrator, RCC

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed, reflective of residents' needs, provided clear direction regarding the delivery of services and/or were followed by staff for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in June 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/26/22 and progress notes dated 06/26/22 to 06/28/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not followed in the following areas:

* Two person vs. One person transfers;

* Dressing, toileting and assistance with bathing;

* Full assistance vs. stand by assistance;

* Footrest use for transport;

* Skin injury;

* Ability to initiate and direct care;

* Nutritional shake between meals;

* Frequent full assist for meals, finger foods and lidded bottles with straws;

* Increased care needs when groggy/sleepy;

* Excessive itching and picking at skin; and

* Gaitbelt use.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were consistently followed was discussed with Staff 1 (Administrator) on 06/28/22.  She acknowledged the findings.

2. Resident 4 was admitted to the facility in November 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/28/22 and progress notes dated 04/01/22 to 06/28/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not followed in the following areas:

* Exit seeking;

* Agitation/aggression around finding dog, car, going to work;

* Toileting and incontinent care; and

* Compression stockings.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were consistently followed was discussed with Staff 1 (Administrator) on 06/28/22.   She acknowledged the findings.

1.  The service plans will be updated to address the deficiencies noted in the SOD.

2.  A copy of the current Service Plan will be provided to all staff for feedback and comment on each resident for the residents 30 day and quarterly review to ensure the care needs are captured and reflected on the service plan.

3.  Evaluation of Service Plan to be done prior to completion.

4.  Admininstrator, RCC

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with, or who provided services, for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

The current service plans for Residents 1 and 2 included no documented evidence they were developed by a service planning team. In both cases, the service planning team signature page was simply left blank.

On 01/04/22, the need to ensure service plans were developed by a service planning team and were documented was discussed with Staff 1 (Administrator) and Staff 2 (RCC). They acknowledged the findings.

1.  The existing service plan policy and procedure has been reviewed with the Administrator and RCC.  Resident #1 and #2 service plans to be reviewed by the legal representative, the Administrator and RCC and to be documented on the signature page.

2.  The Service Planning team to follow existing facility policy and procedure on service planning.  

3.  Service plan signatures will be reviewed upon completion of the initial, the 30 day, and the quarterly service plans.  

4.  Administrator, Office Manager, RCC

Based on interview and record review, it was determined the facility failed to monitor short-term changes of condition until resolution for 1 of 2 sampled residents (#2). Findings include, but are not limited to:

Resident 2 was admitted to the MCC on 12/07/21 with diagnoses which included dementia.

Resident 2's progress notes, a hospital discharge summary, alert charting notes, and 24-hour communication notes reviewed from 12/07/21 through 01/04/22, indicated the following:

* The facility initiated short-term change monitoring on 12/07/21 when the resident moved in. No further information, including documented monitoring until resolution, was noted.

* On 12/22/21, s/he was seen in the hospital and was diagnosed with a yeast infection and UTI (urinary tract infection). Although the facility initiated and monitored the yeast infection, there was no documented monitoring of the UTI.

Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 2 (RCC) on 01/03/22 at 4:10 pm, and with Staff 1 (Administrator) on 01/04/22 at 2:00 pm. The findings were acknowledged. No further information was provided.

1.  Retraining of medication aides on the process of alert charting when a change of condition occurs.

2.  Residents to be placed on alert charting when a Change of Condition occurs. The resident to remain on alert until condition has resolved to ensure thorough monitoring.

3.  Monitored daily by Medication Aide and RCC. Admin/Nurse to review weekly.

4.  Admin/RCC/Nurse

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, and the condition was monitored at least weekly to resolution for 2 of 2 sampled residents (#s 3 and 4) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in June 2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/26/22, physician communications and progress notes from 06/26/22 through 06/28/22 was completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Bruising to the left leg;

* Scrapes and scabbed areas on the face; and

* New admission to the memory care.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) on 06/28/22. She acknowledged the findings.

2. Resident 4 was admitted to the facility in November 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/28/22, physician communications and progress notes from 04/01/22 through 06/28/22 was completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Yeast rashes;

* Medication changes and missed medications;

* Head injury and bruising;

* Behaviors, agitation and aggression towards staff;

* Bruising to the left leg; and

* Skin injury to the right arm.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) on 06/28/22. She acknowledged the findings.

1.  Retraining of all staff on reporting change of condition to RCC and RN.

2.  All staff to be retrained on Stop and Watch procedure.  This will allow swift determination of change of condition and implementation of interventions in order to monitor residents health, safety and welfare.

3.  Monitored daily by Medication Aide and RCC.

4.  Admin/RCC/Nurse

Based on interview and record review, it was determined the facility failed to ensure residents who experienced short term changes of condition were evaluated, resident-specific actions/interventions were developed, and the resident's condition, including effectiveness of interventions, were monitored at least weekly to resolution for 1 of 1 sampled resident (# 5) who experienced changes of condition. Resident 5 experienced repeated unwitnessed falls in which s/he hit his/her head or displayed increased confusion and memory loss. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in December 2021, with diagnosis including dementia and hypertension.

Resident 5's clinical records were reviewed, including a service plan dated 07/19/22, incident reports, progress and alert charting notes dated 08/12/22 - 09/05/22, preadmission evaluation dated 12/2/21, and hospital discharge records dated 08/12/22 and 09/03/22.

The service plan indicated Resident 5 was independent with transfers and ambulating with the use of a walker. The resident was generally independent with toileting, used a "toilet frame" and required "occasional assistance with toileting to clean up incontinent accidents." Staff were instructed to provide reminders, supervision and assist with ADLs as needed.

The following changes of condition were identified:

* 08/12/22, staff documented Resident 5 was found on the floor of  his/her bathroom with pants and brief around ankles and his/her head against the wall. The resident was sent to the hospital and returned to the facility with a diagnosis of urinary tract infection and a "chronic subdural hematoma." The service plan was updated the same day, and instructed staff to toilet the resident every 2-3 hours and remind resident to lock brakes on walker.

* 08/20/22, staff documented Resident 5 was found on the floor of his/her room, half dressed in day clothes and night gown, walker was near chair, and "it looked like [Resident 5] fell reaching for it". The resident "mentioned twice that [s/he hit his/her] head". The resident was sent to the hospital and returned to the facility the next day with new orders for a blood pressure medication. The service plan was updated on 08/22/22 and instructed staff to provide assistance with transfers and dressing.

There was no documented evidence the previous fall interventions, developed on 8/12/22, had been monitored for effectiveness, or that the service planned interventions had been monitored to ensure staff were implementing the interventions.

* 09/01/22, a progress note stated Resident 5 complained of dizziness "three times," was "struggling with transfers," had "wobbly legs," needed more help toileting and was sleeping more than usual.

There was no documented evidence the resident was evaluated to determine necessary interventions, and no evidence the resident's change in condition was monitored to resolution.

* 09/03/22, staff found Resident 5 on the floor near the chair in his/her room. When staff asked the resident if s/he was hurt, the resident "began talking but nothing made sense" and the resident was "laughing hysterically." The resident was sent to the hospital for evaluation due to increased confusion and memory loss. The resident returned to the facility with a diagnosis of "dizziness." On 09/07/22, the residents service plan was updated to instruct staff to "use wheelchair or walker in room."

There was no documented evidence the service plan had been updated prior to 09/07/22, and no evidence the facility monitored the resident's dizziness between 09/03/22 and 09/07/22. There was also no evidence previous fall interventions had been monitored for effectiveness.

During an interview on 09/07/22, Staff 4 (CG) stated Resident 5 was able to communicate with "yes" or "no" answers using written communication on a dry erase board. The resident was usually able to make needs known but may not initiate making needs known so staff were to provide reminders and cues for ADLs. The resident was independent with transfers and ambulation with walker and was stand by assist with toileting, dress and bathing. The resident had recently experienced frequent falls and fall interventions included staff to keep the resident's room free of clutter, ensure his/her shoes were on and his/her walker was within reach.

During an interview on 09/08/22 Staff 5 (CG) stated he was notified fall prevention interventions were updated prior to the start of his shift that day, and staff were to provide hourly safety checks. Staff 5 stated he was not aware of any other fall prevention interventions.

Resident 5 experienced falls and was sent to the hospital related to hitting his/her head or displaying increased confusion on 08/12/22, 08/22/22 and 09/03/22. The facilities failure to monitor previous fall interventions, monitor the effectiveness of current interventions at the time of the falls, develop new fall interventions if previous fall interventions were ineffective, or evaluate and monitor the resident for episodes of dizziness and decreased physical ability,  placed the resident at risk of further injury.

The need to ensure residents who experienced short term changes of condition were evaluated, resident-specific actions/interventions were developed, and the condition including effectiveness of interventions were monitored at least weekly to resolution was discussed with Staff 1 (Administrator) on 09/07/22. She acknowledged the findings and Resident 5's service plan related to fall risk was updated with new interventions.

1. Interventions were implemented on the resident service plan.

2. All staff enrolled in the Change of Condition training offered by Oregon Care Partners.  Additional training with Medication Aides to review existing Alert Charting policy and procedure on changes of condition and monitoring to resolution.

3. Admin, RCC to review alert charting daily.

4. Administrator, RCC and nurse

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

Resident 2 was admitted in 12/07/21 with diagnoses which included irritable bowel syndrome.

Resident 2 had an order for dicyclomine 10 mg one capsule four times a day (with meals and at bedtime) for irritable bowel syndrome.

According to the 12/2021 MAR, reviewed from 12/07/21- 12/31/21, staff administered the medication three times a day, not four times a day as ordered, from 12/07/21 through 12/24/21 (18 days).

In an interview with Staff 1 (Administrator) on 01/04/22 at 3:10 pm, she stated she had not been informed of the medication error and was unsure why it occurred.

At 4:00 pm the same day, Staff 1 stated she investigated the error. She explained that the pharmacy had incorrectly transcribed the administration times onto the MAR. However, a facility MT had reviewed both the MAR and order and approved it. Additionally, several facility MTs had administered the medication during that time frame and had not reported the problem. She stated additional training would be provided to medication staff and a medication error report would be generated.

The need to ensure medications were administered as prescribed was reviewed with Staff 1 and Staff 2 (RCC) during the exit interview on 01/04/22. They acknowledged the findings. No further information was provided.

1. The resident's medication administation record was correct at survey to reflect the current Physician's order.

2.  Medication Aides have been counseled and will be retrained on the facility procedure for reviewing new orders to ensure transcription is correct.  If an error has been found in the pharmacy's transcription, the Medication Aide is to contact the pharmacy immediately and then notify the RCC/Nurse.

3.  Medication orders will be reviewed daily by Medication Aides and weekly by RCC/Nurse to ensure new orders are reflected on the Medication Administation Record.

4.  Administrator, RCC, Nurse

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 2 sampled residents (#2). Findings include, but are not limited to:

Resident 2 was admitted to the MCC on 12/07/21.

Residents 2's MARs were reviewed from 12/07/21 through 01/03/22 and the following was noted:

* S/he had an order for clotrimazole cream to be applied to "affected areas 2 times daily as needed." The MAR lacked resident-specific instructions for the application of the cream and reason for use; and

* Reasons for use was not indicated for all medications.

In an interview on 01/03/22 at 4:10 pm, Staff 2 (RCC) reviewed the resident's MAR. She confirmed several medications were lacking reasons for use and the PRN clotrimazole cream lacked specific administration instructions for staff.

The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Administrator) on 01/04/22 at 2:00 pm. She acknowledged the findings. No further information was provided.

1.  The resident Medication Administration record was reviewed.  The reason for use and specific administration instructions have been added.

2. RCC trained on new order procedure to ensure the reason for use and any specific instructions are added the Medication Administration Record as needed to ensure non licensed medication aides can safely and accurately administer medications.

3.  The RCC will audit with each new medication order received.  The Nurse will audit monthly and as needed.

4.  RCC/Nurse

Based on interview and record review, it was determined the facility failed to ensure the Administrator completed 20 hours of documented continuing education credits annually, pursuant to OAR 853-050-0005, as approved by the Health Licensing Office.  Findings include, but are not limited to:

On 01/03/22 training records for Staff 1 (Administrator) were requested and reviewed. The records documented a total of seven hours of continuing education credits, which did not meet the requirement.

On 01/04/22 the need for the facility Administrator to complete 20 hours of documented continuing education credits annually was discussed with Staff 1 (Administrator). She acknowledged the findings.

1.  The Administrator has been counseled on requirement of Continuing Education hours and is in process of becoming current.

2.  Continuing Education certificates to be printed after each course and scanned into employee file for ease of access.  

3.  Continuing Education will be audited monthly   

4.  Administrator, Office Manager

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:

The facility was home to eight memory care residents at the time of the initial licensure survey.

During the acuity interview on 01/03/22, and observations on 01/03/22 and 01/04/22, the facility was noted to have residents with high ADL care needs including one who occasionally required two staff for transfer/mobility assistance, and one resident who needed PRN meal assistance to eat.

a. In interviews during the survey with staff and a family member, the following was stated/shared with the survey team:

* "I wish they had two staff in the memory care at all times. My mom often gets left waiting."

* "They don't have enough staff to do activities. They are lacking ...I haven't seen activities on the memory care side."

* "[Resident] is a two-person transfer if [s/he's] had [his/her] evening medications."

* The facility scheduled one CG in the MCC for the day, evening and night shifts. If assistance was needed, the MCC staff had to request help from the ALF staff.

* The MA assigned to work in the ALF also passed medications to the MCC residents on the same shift. At the time of survey, there was no waiver allowing sharing direct care staff between licensures.

* "We need at least two CGs in the memory care at all times."

* "With only one person, I cannot get everything done that needs to get done."

* "I feel concerned for residents' safety when I have to be in a resident's room for up to ½ hour and no one is on the floor."

* "The residents all need care."

* "I can't take a break unless someone from the ALF side comes and gives me a break."

* "We need two staff. I can't sit with [Resident] and help [him/her] eat when I have to get meals served and help everyone else."

* CGs provided ADL care, meal service and clean-up, activities, housekeeping as needed, laundry as needed, and cleaned kitchenettes. "We don't have enough caregivers assigned to each shift to get everything done."

b. The facility MCC staffing plan, staff schedule, and number of staff observed during the survey revealed the following discrepancies:

- The MCC staffing plan identified "1 Direct Care Staff, 1 Medication Aide, 1 Universal Worker and 1 Activity Worker" for the day (6:00 am - 2:00 pm) and evening shifts (2:00 pm - 10:00 pm), and "1 Direct Care Staff, 1 Medication Aide" for the night shift (10:00 pm - 6:00 am);

- Review of the January 2022 staff schedule revealed the facility had scheduled one staff person (a CG) for each shift in the MCC; and  

- Observations during the survey revealed one CG worked during the day shifts and one CG worked the evening shifts. Staff from the ALF would come and assist when the MCC CG requested it. Additionally, the ALF MA passed medications in the MCC, but did not remain in the unit the entire shift.

On 01/04/22 at 2:00 pm, the lack of sufficient care staff on each shift, discrepancies between the staffing plan/staff schedule/observed number care staff, and sharing direct care staff on the same shift between licensures without approval from the State Office of Licensing was discussed with Staff 1 (Administrator). She was unaware that the facility needed to obtain an waiver/approval to share direct care staff on the same shift between licensures. She acknowledged the need for additional CGs in the MCC and stated she was in the process of hiring more staff.

1.  Resident service plans will be reviewed to ensure accurate care is accounted for and will then base staffing needs off of resident acuity.

2.  Service plans updated as required. Acuity/staffing data will be reviewed monthly for accurate staffing.

3.  Monthly and as needed  

4.  Administrator, RCC

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 direct care staff (#s 7 and 13) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 01/04/22 and revealed Staff 7 (MA) and Staff 13 (CG), hired on 06/09/21 and 10/11/21, respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 3 (Community Relations Manager) on 01/04/22 at 11:00 am. She acknowledged the findings.

1.  Staff #7 and #13 have been assigned First Aid and abdominal thrust to be completed within one week.

2.  New employee files will remain in open status until all required trainings, including First Aid and abdomnial thrust, are complete within 30 days of hire.

3.  Training records will be reviewed before 30 days of hire.

4.  Administrator, Office Manager

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, in accordance with the Oregon Fire Code. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed on 01/03/22. The following deficiencies were identified:

There was no documented evidence the facility was providing fire and life safety instruction to all staff on alternating months.

On 01/04/22 the need to provide fire and life safety instruction to staff on alternating months was discussed with Staff 1 (Administrator) and Staff 2 (RCC). They acknowledged the findings.

1. Educate safety committee and facility staff in monthly staff meetings and orientation of new employees as to proper fire drill protocols to include potential problems and barriers to overcome, relative escape routes to use based on fire locations, evacuation time tracking, and occupant evacuee participation;

2. In each monthly staff meeting (as well as direct feedback to staff upon conclusion of each fire drill), review the most recent fire drills discussing timely responses by staff, problems and barriers observed, escape route utilization; time management to successful evacuation and occupant participation;

3. In each unannounced fire drill on rotating shifts, the maintence director will monitor the drill at the site of designated fire to evaluate and then document findings of drill;

4. The safety Committee will review the evaluation for improvements; the Administrator shall ensure effectivness of drills.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C252, C260 and C270.

1)  All management team assess and will work together to comply with all OAR's

2) Management team will plan accordingly and discuss reglarly in meetings

3) Management team will manage this in quarterly QUAPI meetings as a group

4) Administrator, RN and RCC will manage this

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

Refer to C 270.

1)  All management team assess and will work together to comply with all OAR's

2) Management team will plan accordingly and discuss reglarly in meetings.

3) Management team will manage this in quarterly QUAPI meetings as a group

4) Administrator, RN and RCC will manage this

Based on observation and interview, it was determined the facility failed to have exit door alarms or other acceptable systems in place, to alert staff when a resident exited the building. Findings include, but are not limited to:

On 01/03/22 a tour of the building and grounds was conducted. The exit door leading to the enclosed outdoor courtyard had no alarm or system to alert staff when a resident exited.

In an interview on 01/03/22 Staff 5 (Maintenance Director) acknowledged that the door had no alarm, and stated the alarm company would be contacted to adjust the system appropriately.

In interviews on 01/04/22 Staff 1 (Administrator) and Staff 5 acknowledged the deficiency with the door, and stated the exit door would remain locked for safety, until the alarm system was adjusted to meet the rule.

1.  Caring Places Management to install an alarm that will sound when the exit door to the outdoor couryard is opened.   

2.  Caring Places Management to install alarm that will sound when exit door leading to the outdoor couryard is opened.

3.  Once alarm is installed, the alarm to be monitored weekly and as needed.  

4.  Administrator, Maintenance supervisor

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

Refer to C160, C242, C355, C360, C372, C420 and C555.

Refer to C160, C242, C355, C360, C372, C420 and C555

Based on observation, interview and record review, it was determined the facility failed to provide non-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 231.

1)  Management team will review and work to comply with all OAR's

2) Management will collectively review, discuss and monitor regularly to prevent any descrepencies going forward.

3) Management team will meet regularly at stand up and quarterly to ensure quality control.

4) Administrator, RCC and RN will monitor.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled newly hired staff (#s 10, 11 and 13) completed all required pre-service training, and 4 of 4 newly hired staff (#s 7, 10, 11 and 13) completed competency training within 30 days of hire or prior to independently providing personal care to residents. Findings include, but are not limited to:

Staff training records were reviewed with Staff 3 (Community Relations Manager) on 01/04/22 at 11:00 am. The following deficiencies were identified:

1. Staff 10 (CG) was hired 12/08/21.

a. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties:

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

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

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

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

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)

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

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

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

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

b. There was no documented evidence Staff 10 demonstrated competency in assigned job duties within 30 days of hire and prior to working independently in the following areas:

* Providing assistance with ADLs.

2. Staff 11 (CG) was hired 12/08/21.

a. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties:

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

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

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

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

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)

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

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

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

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

b. There was no documented evidence Staff 11 demonstrated competency in their job duties within 30 days of hire and prior to working independently in the following areas:

* Providing assistance with ADLs.

3. Staff 13 (CG) was hired 10/11/21.

a. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures;

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

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

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

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

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

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)

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

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

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

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

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

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

4. Staff 7 (MA) was hired 06/09/21. Training records revealed no documented competency in medication administration. The surveyor informed Staff 1 (Administrator) and Staff 3 at 11:30 am the same day that Staff 7 could not administer medications until documented training was completed. They both acknowledged and stated they would ensure documented medication training was completed for Staff 7 before she administered medications.

The facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 1 (Administered) and Staff 2 (RCC) during the exit conference on 01/04/22. They acknowledged the findings.

1. Staff #10 and #11 to complete pre-service dementia training prior to next shift. Staff #7, #10, #11 and #13 will have the 30 day skills competency demonstration completed on their next scheduled shift.

2. The new hire file will remain open until all necessary training has been completed.  The new hire will not be placed on the staff schedule until the pre-service dementia training has been completed per company policy.

3. Completion of pre-service dementia will be audited prior to new hire being placed on the floor. The 30-day skills competency will be verified prior to 30 day of hire per company policy.

4. Administrator and Office Manager

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

Refer to C252, C260, C262, C270, C303 and C310.

Refer to C252, C260, C262, C270, C303 and C310

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 C252, C260 and C270.

1)  Management team will review and work to comply with all OAR's

2) Management will collectively review, discuss and monitor regularly to prevent any descrepencies going forward.

3) Management team will meet regularly at stand up and quarterly to ensure quality control.

4) Administrator, RCC and RN will monitor.

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

Refer to C 270.

1)  Management team will review and work to comply with all OAR's

2) Management will collectively review, discuss and monitor regularly to prevent any descrepencies going forward.

3) Management team will meet regularly at stand up and quarterly to ensure quality control.

4) Administrator, RCC and RN will monitor.