The findings of the re-licensure survey conducted 09/06/22 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, 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

The findings of the re-visit to the re-licensure survey of 09/08/22, conducted 11/28/22 through 11/29/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

During the relicensure survey, conducted 09/06/22 through 09/08/22, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the severity and number of citations.

Refer to deficiencies in this report.

Refer to other citations.  

Based on observation and interview, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to:

1. On 09/07/22, Staff 10 (CG) was observed carrying linens in her arms without gloves against her body. When interviewed, Staff 10 revealed the linens were soiled. Staff 10's improper handling of soiled linens represented a risk for the spread of disease that could threaten the health of residents and staff.

2. A tour of the environment on 09/07/22 revealed five unlocked electrical boxes connected to the heating and air conditioning units located in the courtyard. The fence surrounding the electrical boxes and air conditioning units was not secure and residents could access the equipment. This represented a safety risk for the residents. Staff 1 (Owner/Administrator) was notified of the unlocked electrical boxes immediately and she installed locks on them later that day.

The need to ensure the facility exercised reasonable precautions against any condition that may threaten the health, safety or welfare of the residents was discussed with Staff 1 and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

1. All staff meeting completed on infection control, linen handling. All employees are completing Oregon Care Partners infection control traininig. Locks added to electrical boxes. Infection control specialist identified and completed training. New RN hired.

2. New system for new employee orientation and training. Administrator/maintenance director walkthroughs.

3. Daily, weekly.

4. Administrator and RN

Based on interview and record review, it was determined the facility failed to immediately report abuse or suspected abuse to the local APD office or the local AAA and failed to take measures necessary to protect residents and prevent the reoccurrence of abuse, for 1 of 1 sampled resident (#5) with documented physical altercations with another resident. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2022 with diagnoses including dementia associated with other underlying disease and severe major neurocognitive disorder due to traumatic brain injury with behavioral disturbance.

Review of the resident's record, including progress notes, incident reports, evaluations, service plan, alert charting record and transcripts from the Telegram messaging application (used by the facility to send messages to employees), identified the following deficiencies:

a. On 08/02/22 Resident 5 pushed another resident out of a chair and onto the floor. This represented an incident where the facility failed to protect a resident, is considered neglect/abuse and needed to be reported to the local APD office immediately.

* There was no documented evidence the facility reported the incident to the local APD office as required.

b. On 08/02/22 Resident 5 pushed the same resident down to the floor when the peer wandered into Resident 5's room. This represented an incident where the facility failed to protect a resident, is considered neglect/abuse and needed to be reported to the local APD office immediately.

* There was no documented evidence the facility reported the incident to the local APD office as required; and

* The facility placed the residents on "Alert Charting" but there was no documented evidence the facility developed specific interventions to protect the residents from further incidents of aggression and communicated the interventions to staff.

The need to immediately report incidents of abuse or suspected abuse to the local APD office and take measures necessary to protect residents and prevent the reoccurrence of abuse was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/07/22. The facility was instructed to self-report the two incidents noted above. Verification the facility reported the incidents was provided on 09/08/22.

1. Staff 2 self-reported the two incidents between the residents, faxed the report & provided surveyors with a copy. Interventions necessary to prevent reoccurance were put into place.

2. Consultant will provide manager and staff training on abuse and neglect reporting, investigation, and documentation. Implementation of new system for incident reporting and follow up process. Incident reports will be reviewed daily in the clinical meeting process and reviewed thoroughly daily and weekly by the administrator. Incident reports will be reviewed monthly during new QI meeting process.

3. Daily, weekly, monthly.

4. Administrator.

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

Observation of meal preparation on 09/06/22 revealed the following:

1. Staff 4 (Cook) cut open chicken to see if it was cooked thoroughly and said that was how he checked to see if meat was thoroughly cooked. When asked if he had a thermometer, he said "yes" and used a thermometer to ensure the chicken was above 165 degrees Fahrenheit. The chicken was not 165 degrees and he put the chicken back in the pan.

2. Staff 4 was wearing gloves while preparing deep fried chicken. He grabbed chicken, placed it in egg wash and breadcrumbs and then into the pan. Staff 4 did not remove the gloves and proceeded to touch multiple kitchen utensils. When reaching for other food, the surveyor stopped the cook and informed him of potential cross contamination and asked him to remove the gloves and wash his hands and all pots, pans and utensils he had soiled in the process.

The need to ensure the facility prepared food in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/06/22. They acknowledged the findings.

1. Staff 4 no longer works at the community. New dining staff hired and in training. New training content for dining staff will be developed.  

2. Consultant will assist development of training for dining staff. Daily and weekly walkthroughs of the kitchen by the administrator and dining manager..

3. Daily, weekly.

4. Administrator.    

Based on interview and record review, it was determined the facility failed to ensure initial evaluations included sufficient information on all required elements and were signed to indicate who was involved in the evaluation process, and that subsequent evaluations were separate and distinct from the initial evaluation, for 3 of 3 sampled residents (#s 2, 3 and 4) whose initial evaluations were reviewed. Findings include, but are not limited to:

1 a. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, diverticulitis and community-acquired pneumonia.

Resident 2's initial evaluation was not signed and lacked information for the following required elements:

* Routines: sleeping, bathing;

* Traditions;

* Mental health issues;

* How the person copes with change or challenging situations;

* Hearing and vision status;

* Toileting status;

* Dental status;

* Non-pharmacological interventions for pain;

* Fluid preferences;

* Indicators of nursing needs;

* Complex medication regimen;

* History of dehydration and weight loss/gain;

* Recent losses;

* Unsuccessful prior placements;

* Alcohol and drug use; and

* Environmental factors that impact the resident's behavior.

The need to ensure the resident's initial evaluation was signed and addressed all required elements was reviewed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the deficiencies.

b. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia, bipolar disorder - current episode depressed with severe psychotic features and colitis.

Resident 3's initial evaluation was not signed and lacked information for the following required elements:

* Routines: eating, bathing;

* Traditions;

* Mental health issues;

* Decision-making abilities;

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

* Hearing and vision status, and assistive devices;

* Ability to understand and be understood;

* Dental status, assistive devices for eating;

* Housework needs;

* Pharmacological and non-pharmacological interventions for pain;

* Fluid preferences;

* Complex medication regimen;

* History of dehydration and weight loss/gain;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident's behavior.

The need to ensure the resident's initial evaluation was signed and addressed all required elements was reviewed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the deficiencies.

2. Resident 2, 3 and 4's initial and 30-day evaluations were reviewed during the survey.

* The facility was not maintaining the initial evaluation as a separate document from subsequent evaluations as required.

The need to keep the initial evaluation separate from subsequent evaluations was reviewed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They stated they were not aware of the requirement and acknowledged the deficiency.

1. The evaluation tool will be updated to include all required information. Resident 2, 3, and 4s evaluations will be updated. All resident evaluations will be reviewed and updated.

2. The evaluation tool will be updated to include all required information. Consultant will provide resident evaluation checklist. Consultant will provide training on initial, 30-day, and quarterly evaluations. The initial evaluation will be kept separate in the resident record.

3. With each evaluation and monthly.

4. Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, updated following changes of condition and provided clear direction regarding the delivery of services, for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2, 3, 4 and 5's current service plans were reviewed, observations were made and interviews were conducted with facility staff and, if possible, the resident. The following deficiencies were identified:

1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, diverticulitis and community-acquired pneumonia.

Resident 2's service plan, dated 07/13/22, was not reflective or lacked clear instructions for staff in the following areas:

* Resident was receiving hospice services;

* Hospice provided showers;

* Oral care, given resident had no teeth and does not wear dentures;

* Whether resident was still an aspiration risk and needs supervision during meals;

* Current transfer and ambulation status and assistance needs;

* Recent fall history, fall risk and interventions;

* Pericare assistance needs;

* Frequency of safety checks during night shift; and

* Information and interventions regarding resident wandering into peers' rooms.

The need to ensure resident service plans were reviewed and updated in response to changes in status and care needs and included clear instructions for staff regarding how to provide care was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia, bipolar disorder - current episode depressed with severe psychotic features and colitis.

Resident 3's service plan, dated 07/28/22, was not reflective or lacked clear instructions for staff in the following areas:

* Ability to stand at the sink while brushing teeth;

* Ability to drink from a glass and use of a straw;

* Transfer and ambulation status and assistance needed;

* Frequency of toileting assistance;

* Frequency of safety checks during night shift; and

* Interventions to address punching things/self-injurious behavior when frustrated.

The need to ensure resident service plans were reviewed and updated in response to changes in status and care needs and included clear instructions for staff regarding how to provide care was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 05/2022 with diagnoses including dementia associated with other underlying disease and severe major neurocognitive disorder due to traumatic brain injury with behavioral disturbance.

Resident 5's service plan, dated 09/06/22, was not reflective or lacked clear instructions for staff in the following areas:

* Grooming/personal hygiene abilities, and specific instructions as to assistance needed and frequency;

* Information regarding resident wearing the same clothes day after day and instructions for staff to address this behavior;

* Bowel status;

* Housekeeping needs regarding toilet area/bathroom; and

* Specific information about conflicts with a peer, triggers for escalating behavior and interventions for staff to implement.

The need to ensure resident service plans were reviewed and updated in response to changes in status and care needs and included clear instructions for staff regarding how to provide care was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 07/2022 with a diagnosis of dementia and was a fall risk.

Review of Resident 4's most recent service plan, dated 06/23/22, and progress notes dated 07/13/22 through 09/06/22 revealed the following:

On 08/17/22, Resident 4 had a fall, was sent to the emergency room, was diagnosed with a right wrist fracture and was ordered to wear a soft cast. During the survey, Resident 4 was observed wearing a wrist brace. Interviews with staff indicated the resident could no longer assist with transfers, groom themselves, brush their own teeth and experienced increased agitation due to pain.

The facility did not update Resident 4's service plan or create a temporary service plan outlining his/her increased care needs or increased agitation due to pain.

The need to ensure the service plan was reflective, updated after a significant change of condition and provided clear instruction to staff was discussed with Staff 1 (Owner/Administrator) and Staff 2 on 09/08/22. They acknowledged the findings.

1. The service plan tool will be updated to include all required information. Resident 2, 3, 4, and 5's service plans will be updated. All resident service plans will be reviewed and updated.

2. The service plan tool will be updated to include all required information. Consultant will provide training on initial, 30-day, quarterly service plans, and updating the service plan with change of condition.

3. With each service plan review and monthly during the QI meeting.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were consistently developed by a Service Planning Team and that involved family and case managers were notified in advance of the service-planning meeting, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

A resident's service plan must be developed by a Service Planning Team consisting of the resident, the resident's legal representative (if applicable), any person of the resident's choice, the facility administrator and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.

Resident 1, 2 and 3's current service plans were reviewed. The service plans lacked documentation that the resident or the resident's legal representative was involved in the development of the service plan, that the family was involved in the service-planning process and that the resident's case manager was notified in advance of the service-planning meeting.

The need to ensure resident service plans were developed by a Service Planning Team and that family members and case managers were included in the process was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the facility needed to improve its service-planning process.

1. A new process was developed to involve the team in service planning. The resident, resident's representative, and case manager (as appropriate) will be invited. The service planning team will include managers, direct care/kitchen/activity staff.

2. A new service planning team process is in place. A service planning schedule has been developed and a tracking tool put into place. Families have been invited to go over the service when they visit.

3. With each service plan and monthly.

4. Administrator.  

3. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, diverticulitis and community-acquired pneumonia.

Resident 2's record was reviewed, including progress notes since admission, evaluations, service plans and incident reports. The following deficiencies were identified:

* The resident had falls on 07/09/22 and 08/26/22. Though the facility placed the resident on "Alert Charting" following each incident, there was no documented evidence the facility determined, documented and communicated to staff what action or intervention was needed for the resident, or reviewed the service plan to determine if instructions regarding ambulation and fall interventions were adequate or whether additional interventions needed to be implemented.

* The resident was pushed to the floor by a peer on 08/02/22 and 08/18/22. Though the facility placed the resident on "Alert Charting" following each incident, the only information communicated to staff following the first incident was that the residents had an "issue" and staff should keep them separated; the interventions were not made a part of the resident's record. In response to the second incident, there was no documented evidence the facility determined, documented and communicated to staff what action or intervention was needed for the resident, or reviewed the service plan to determine if instructions regarding conflicts with this peer were adequate or whether additional interventions needed to be implemented.

The need to develop and implement a system for responding to changes of condition that included determining and documenting what action/intervention was needed in a way that could be included in the resident's record, updating the resident's service plan as needed, communicating new information and interventions to staff and reviewing the service-planned interventions for effectiveness was reviewed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged their current process for responding to changes of condition was deficient.

4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia, bipolar disorder - current episode depressed with severe psychotic features and colitis.

Resident 3's record was reviewed, including progress notes since admission, evaluations, service plans and incident reports. The following deficiencies were identified:

* The resident was found on the floor in his/her room on 07/12/22 and 07/19/22 after apparently trying to self-transfer. Though the facility placed the resident on "Alert Charting" following each incident, there was no documented evidence the facility determined, documented and communicated to staff what action or intervention was needed for the resident, or reviewed the service plan to determine if instructions regarding transfer ability and fall interventions were adequate or whether additional interventions needed to be implemented. The facility documented monitoring of the resident for one day following each fall and did not indicate whether the condition was resolved.

* The resident sustained an abrasion to the left forehead from the 07/19/22 fall. The facility failed to determine, document and communicate to staff what action or intervention was needed for the resident and there was no documented evidence the facility monitored and documented on the status of the abrasion at least weekly until resolved.

* On 07/22/22, Staff 2 (LPN) documented in a progress note that she evaluated bruising on Resident 3's right hand which the resident stated was the result of hitting the wall or other solid objects when angry. The facility failed to determine, document and communicate to staff what action or intervention was needed for the resident and there was no documented evidence the facility monitored and documented on the status of the bruise or the resident's mood at least weekly until resolved.

The need to develop and implement a system for responding to changes of condition that included determining and documenting what action/intervention was needed in a way that could be included in the resident's record, updating the resident's service plan as needed, communicating new information and interventions to staff and, reviewing the service-planned interventions for effectiveness and monitoring and documenting on the status of the condition at least weekly until resolved was reviewed with Staff 1 (Owner/Administrator) and Staff 2 on 09/08/22. They acknowledged the findings.  

Based on interview and record review, it was determined the facility failed to identify and document significant changes of condition, refer to the facility RN and update the service plan as needed, and determine and document what actions or interventions were needed for a resident following a change of condition, communicate the interventions to staff and monitor and document on the condition at least weekly until resolved, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted into the facility in 03/2022 with diagnoses including dementia and diabetes.

Resident 1's record was reviewed, including progress notes from 06/30/22 through 09/06/22, evaluations, MARs and service plans. The following deficiencies were identified:

A dietary assessment conducted on 03/24/22 documented Resident 1's weight upon move as 248 pounds. On 04/28/22, Resident 1's weight was documented as 220 pounds. This represented a loss of 11.2% body weight in 34 days, and constituted a severe weight loss and significant change of condition. There was no documented evidence the facility notified the RN of the significant change of condition, no interventions were created to prevent future weight loss and the resident was not monitored at least weekly after the change of condition.

Resident 1's documented weight on 08/01/22 was 198 pounds. This represented a loss of 10% body weight in three months, and constituted a severe weight loss and significant change of condition. There was no documented evidence the facility notified the RN of the significant change of condition, no interventions were created to prevent future weight loss and the resident was not monitored at least weekly after the change of condition.

On 09/08/22, the surveyor asked Staff 2 (LPN) to obtain a current weight on Resident 1; the weight was 202 pounds. Staff 2 shared that Resident 1 had been admitted with edema and had undergone diuresis to remove the excess fluid. In an interview on 09/08/22, Resident 1 told the surveyor s/he was okay with losing weight.

The need to ensure the facility identified and notified the RN when a significant change of condition occurred, put interventions into place to prevent weight loss,  updated the service plan as needed and documented on the progress of the condition at least weekly until resolution was discussed with Staff 1 (Owner/Administrator) and Staff 2. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 07/2022 with diagnoses including dementia and was a fall risk.

Resident 4's record was reviewed, including progress notes since admission, evaluations, service plans and incident reports. The following deficiencies were identified:

On 08/17/22, Resident 4 had a fall, was sent to the emergency room and was diagnosed with a right wrist fracture. The fracture represented a significant change of condition for which an RN was required to be notified. There was no documented evidence the facility notified the RN of the significant change of condition and the resident was not monitored at least weekly until resolution after the change of condition.

The need to ensure the facility notified the RN when a significant change of condition occurred, updated the service plan as needed and documented on the progress of the condition at least weekly until resolution was discussed with Staff 1 (Owner/Administrator) and Staff 2. They acknowledged the findings and Staff 2 stated she was unclear as to what constituted a significant change of condition and when the RN needed to be notified.

1. The RN completed a significant change of condition for Resident 1, 4 and updated the service plan. Consultant will provide training to staff on change of condition and monitoring. A full time RN was hired and has started.

2. A whiteboard will be used to track change of condition and monitoring. Consultant will provide training on clinical meeting process to identify and respond to change of condition. The community is using a TSP/24 hour book system to provide information on change of condition and alert charting. Staff review every shift and sign the TSP at least once. The community will move from a paper charting system to QuickMAR. Consultant will do staff training on how to write TSPs and provide resources. A health services meeting will be scheduled several times per week to include RN.

3. Daily review in the clinical meeting and weekly.

4. Administrator, RN.  

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN for 2 of 2 sampled residents (#s 1 and 4) reviewed for significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted into the facility in 03/2022 with diagnoses including dementia and diabetes.

The record indicated Resident 1 experienced significant changes of condition related to severe weight losses triggered on 04/28/22 and 08/01/22.

There was no documented evidence the facility RN completed assessments for each of the weight losses.

The need to ensure significant changes of condition were assessed by an RN was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

Refer to C 270 example 1.

2. Resident 4 was admitted to the facility in 07/2022 with diagnoses including dementia and was a fall risk.

The record indicated Resident 4 sustained a wrist fracture as the result of a fall on 08/17/22.

There was no documented evidence the facility RN completed an assessment for the wrist fracture.

The need to ensure significant changes of condition were assessed by an RN was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

Refer to C 270 example 2.

1. The RN completed a significant change of condition for Resident 1, 4 and updated the service plan. Consultant will provide training to staff on significant change of condition and when to notify the RN. The consultant will provide training to the RN and managers on significant change of condition assessment requirements.

2. A whiteboard will be used to track change of condition and monitoring.  The community will move from a paper charting system to QuickMAR. A health services meeting will be scheduled several times per week to include RN. Staff will be trained on how to document alert charting. Change of Condition will be monitored daily in the clinicical meeting process and weights will be be reviewed regularly for change of condition for significant weight change.

3. Daily, weekly, monthly.

4. Administrator, RN.  

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 Administrative Rules, for 1 of 1 sampled resident (#1) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.

Resident 1 was admitted to the facility in 03/2022 with diagnoses including insulin-dependent diabetes. The MAR indicated unlicensed care staff were administering Resident 1's insulin.

* There was no documented evidence the previous RN transferred delegation to the current RN;

* There was no documented evidence the current RN completed an assessment of Resident 1's diabetic status to determine if his/her condition was stable and predictable; and

* There was no documentation of the frequency the resident should be reassessed, including rationale.

The need to ensure delegation, transfer and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

1. The RN completed the RN delegation assessment, documented the frequency of reassessment and rationale.

2. The consultant will train managers, RN, and staff on RN delegation requirements. All documentation for RN delegation will be reviewed by consultant and training/forms provided as needed.

3. Monthly.

4. Administrator, RN.

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site services with outside service providers, for 2 of 4 sampled residents (#s 3 and 4) who received services from outside providers. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia, bipolar disorder and colitis.

a. The record indicated Resident 3 had a history of verbal aggression toward staff and often ambulated independently without a walker, putting him/her at risk for falls and injuries. A behavior consultant developed a Behavior Plan for Resident 3 dated 07/14/22. The following recommendations, included in the Behavior Plan, were not implemented by the facility:

* Visual aids to help provide structure and routine, and help decrease confusion and paranoia:

    - Weekly or monthly calendar that includes meal times and appointments; and

    - Call button reminders to prompt resident to press the call button before s/he begins transferring or ambulating.

b. The record indicated Resident 3 received Home Health services which included physical therapy and social work visits. There was no documented evidence the following recommendations, included in the Home Health visit notes, were implemented by the facility and communicated to staff at the time they were written:

* 07/15/22: Gait belt and assist with all transfers and walking; walk when up for it with supervision/assist and belt with walker;

* 07/26/22: Recommend walking with front-wheeled walker, not 4-wheeled walker, and wheelchair behind to meals as tolerated; and

* 08/02/22: See discharge instructions left in resident room; do exercises daily, walk to dining room daily.

The need to ensure the facility had a system for reviewing outside provider orders and recommendations, informing staff of new interventions and updating the service plan as necessary was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the recommendations had not been reviewed, communicated to staff and implemented.

2. Resident 4 was admitted to the facility in 07/2022 with diagnoses including dementia and was a fall risk.

The record indicated Resident 4 had a fall in the facility, was sent to the emergency room and was diagnosed with a wrist fracture. The resident returned to the facility with a soft cast but, according to staff, kept removing it.

The resident was seen for a follow-up appointment by an orthopedic provider and was given a wrist brace to wear instead. However, at the time of the survey, the facility had not obtained a copy of the visit summary and had no written instructions for care of the fracture and use of the wrist brace.

The need to ensure the facility obtained documented care instructions from outside providers was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

1. Resident 3 behavioral plan was reviewed and administrator will contact behavioral health specialist to provide updated recommendations. Resident 3 is no longer ambulatory so physical therapy recommendations from July/August 2022 are no longer appropriate. A new PT/OT evaluation was requested and the recommendations will be followed.

2. The outside services form will be placed in a binder for review in the clinical meeting. The administrator and nurse will review third party notes and records from both on-site and off-site providers during the clinical meeting. TSPs will be developed for any change/recommendation. Care coordination progress notes will be entered in QuickMAR.

3. Weekly.

4. Administrator, RN.

Based on observation and interview, it was determined the facility failed to ensure it had a trained Infection Control Specialist and it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

1. In an interview on 09/08/22, Staff 1 (Owner/Administrator) and Staff 2 (LPN) reported Staff 2 was the facility's designated Infection Control Specialist. They acknowledged Staff 2 had not completed the required specialized, Department-approved training in infection control prevention and control protocols.

2. Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility (including an Memory Care Community) are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose and mouth.

The need to ensure the designated Infection Control Specialist completed all required training, and that staff consistently wore a face mask, was reviewed with Staff 1 and Staff 2 on 09/08/22. They acknowledged training had not been completed as required and staff needed to wear masks properly at all times.

1. An infection control specialist has been identified and training completed. Staff have been trained regarding mask requirements. A sign was posted on the door that masks are required.

2. Daily walkthroughs by administrator and nursing to monitor compliance with mask wearing and appropriate handling of linens.

3. Daily, weekly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place and failed to ensure adequate professional oversight of the medication and treatment administration system, for 1 of 1 sampled resident (#1) Findings include, but are not limited to:

Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia.

Review of Resident 1's most recent signed physician's orders, dated 07/24/22, and 08/01/22 through 09/06/22 MARs revealed the following:

Resident 1 had orders for the following scheduled medications, prescribed to treat constipation and glaucoma:

* Polyethylene glycol powder for constipation;

* Fish oil to lower triglycerides;

* Latanoprost .005% for glaucoma; and

* Magnesium oxide 420 mg for constipation.

Review of Resident 1's MARS from 07/24/22 through 09/06/22 indicated these medications had not been administered per physician's orders.

In an interview on 09/07/22, Staff 1 (Owner/Administrator) stated these medications were discontinued in June and so she believed they were added to the 07/24/22 order summary in error and did not need to be followed. However, there was no documented evidence the facility received clarification of the discrepancies with the orders.

The need to ensure the facility provided a safe medication administration system and adequate professional oversight of the medication and treatment administration system was discussed with Staff 1 and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

1. Resident 1 physician orders have been reviewed and signed by the physician to ensure accurate MAR.

2. All resident orders are being sent for quarterly review. Consultant is providing training on ensuring MAR accuracy and orders are reviewed and clarified in a timely manner. The community is moving from paper to electronic MAR documentation (QuickMAR). Med-tech training to ensure med-techs understand the order processing and medication review. Orders will be reviewed multiple times per week in the clinical meeting and quarterly with order review.

3. Weekly.

4. Administrator

Based in interview and record review, it was determined the facility failed to carry out treatment orders as prescribed, for 2 of 2 sampled residents (#s 1 and 3) who had orders to obtain regular weights. Findings include, but are not limited to:

Resident 1 and 3's signed physician orders and 08/01/22 through 09/06/22 MARs were reviewed during the survey. The following deficiencies were identified:

1. Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia and edema.

The resident had signed physician orders for the facility to obtain the resident's weight every week.

Review of the MAR indicated the last documented weight obtained was on 08/01/22.

The need to follow physician orders as prescribed was reviewed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/07/22. They acknowledged the facility had not obtained Resident 1's weights as ordered.

2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia, bipolar disorder-current episode depressed and colitis.

The resident had signed physician orders for the facility to obtain the resident's weight every month.

Review of the record indicated the facility failed to obtain Resident 3's weights in 08/2022 and 09/2022. In an interview on 09/07/22, Staff 2 (LPN) stated Resident 3 was not able to stand to be weighed and the facility did not have a scale that could be used by residents in wheel chairs.

The need to follow physician orders as prescribed was reviewed with Staff 1 (Owner/Administrator) and Staff 2 on 09/08/22. They acknowledged the facility had not obtained Resident 3's weights as ordered.

1. Resident 1 weights were added to the MAR to comply with order for weekly weights. Residnt 3 weight was added to the MAR to comply with order to weigh monthly.  A wheelchair scale has been purchased.

2. Residents with routine weights have been added to the whiteboard to ensure appropriate monitoring of weights. Weights will be reviewed in clinical meeting. Weights will be recorded in the electronic MAR.

3. Weekly, monthly.

4. Administrator, RN.

Based on interview and record review, it was determined the facility failed to consistently notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (#4) with documented refusals of ordered medications or treatments. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 07/2022 with diagnoses including dementia and was a fall risk.

Resident 4's 09/01/22 through 09/06/22 MAR was reviewed and revealed the following:

* Resident 4 had no documented evidence the facility administered Nystatin cream on night shift. In an interview with Staff 7 (MT) on 09/07/22, revealed Resident 4 refused medications after s/he goes to bed. In an interview on 09/07/22, Staff 2 (LPN) stated she did not know the provider needed to be notified when residents refused medications.

The need to ensure the physician was notified when a resident refused consent to an order was discussed with Staff 1 (Owner/Administrator) and Staff 2 on 09/08/22. They acknowledged the physicians were not being notified as required.

1. Resident 4 medication refusals had been comunicated to PCP.

2. A MAR audit will be completed weekly to review medication refusals and ensure physician's are notified of medication refusals. Implementation of shift reports will be reviewed to ensure that refusals are communicated to PCP. Consultant will conduct staff training on medicaiton refusals. Medication refusals will be reviewed during clinical meetings multiple times per week and during the monthly QI meeting.

3. Daily, weekly, monthly.

4. Administrator, RN.

3. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, diverticulitis and community-acquired pneumonia.

The resident was admitted to hospice services in 06/2022 with an order for lorazepam 0.5 mg tablet - 1 tablet every 2 hours PRN for mild agitation, anxiety, mild nausea or shortness of breath. The order directed the facility to "Please call [hospice agency] before administering."

The 08/2022 and 09/2022 MARs lacked the instructions for staff to notify the hospice agency before administering the PRN lorazepam.

The need to ensure MARs were complete and accurate was reviewed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the order had not been transcribed to the MAR accurately.

4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia, bipolar disorder and colitis.

a. The resident had orders for two PRN medications to be administered "for pain" - acetaminophen and ibuprofen. The MAR lacked clear instructions for unlicensed staff as to when to administer each medication.

b. The resident had an order for PRN Senna (for constipation) - "Give 1-2 tablets by mouth every 24 hours as needed for constipation." The MAR lacked instructions for unlicensed staff as to when to administer 1 tablet versus 2 tablets.

The need to ensure MARs included clear parameters for unlicensed staff regarding the administration of PRN medications was reviewed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the lack of parameters.

Based on interview and record review, it was determined the facility failed to maintain an accurate Medication Administration Record (MAR), for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia.

Review of Resident 1's most recent signed physician's orders, dated 07/24/22, and 08/01/22 through 09/06/22 MARs revealed the following:

Resident 1 had orders to be weighed weekly. In an interview on 09/08/22, Staff 7 (MT) stated he was unaware the resident needed to be weighed weekly and staff took one weight at the beginning of each month. Review of the 08/2022 MAR showed documentation of one weight on 08/01/22 and no weight on the 09/2022 MAR. Staff 7 stated staff sometimes wrote the weight on scraps of paper and, often, the scrap paper was discarded before the weight was documented on the MAR.

The need to ensure the facility documented weekly weights was discussed with Staff 1 (Owner/Administrator) and Staff 2 on 09/08/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 07/2022 with a diagnosis of dementia and obesity.

Review of Resident 4's most recent signed physician's orders and 09/01/22 through 09/06/22 MAR revealed the following:

Resident 4 was prescribed Nystatin cream to be applied to folds in the groin for a rash three times a day. There was no documented evidence the facility administered the Nystatin cream on night shift. In an interview on 09/08/22, Staff 7 (MT) stated Resident 4 refused medications after s/he was in bed and acknowledged staff failed to document the refusals from 09/01/22 through 09/06/22.

The need to ensure the facility documented when a resident refused medication was discussed with Staff 1 (Owner/Administrator) and Staff 2 on 09/08/22. They acknowledged the findings.

1. Resident 1 weight is being documented weekly on the MAR. Refusal of nystatin cream was corrected on the MAR for Resident 4. Resident 2 order to call provider before administering PRN lorazepam was reviewed with staff and MAR updated. Resident 3 parameters for ibuprofen and acetaminophen have been updated and order clarified when to give 1-2 tabs of Senna.

2. Consultant will provide staff training on MAR accuracy, MAR documentation and PRN parameters. MAR will be audited weekly for compliance and shift reports audited daily in the clinical meeting. The RN will complete full MAR review for ensure all PRNs have clear parameters. MAR audit will be scheduled weekly.

3. Weekly.

4. Administrator, RN.

Based on interview and record review, it was determined the facility failed to select and implement an Acuity-Based Staffing Tool (ABST), complete an ABST assessment for each resident and develop the facility's staffing plan based on the ABST. Findings include, but are not limited to:

In an interview on 09/08/22, Staff 1 (Owner/Administrator) stated the facility had not selected or implemented an ABST to use in developing the facility staffing plan.

The need to complete an assessment of each resident and implement an ABST was reviewed with Staff 1 and Staff 2 (LPN) on 09/08/22. They acknowledged the lack of an ABST.

1. The state ABST assessment is being completed for each resident in order to develop the facility's staffing plan.

2. The state ABST will be utilized and updated as needed to determine appropriate staffing levels. The ABST will be reviewed in QI meetings and with significant change of conditions.

3. Monthly and with significant changes.

4. Administrator, RN.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair and outdoor perimeter fencing was not secured to prevent exit. Findings include, but are not limited to:

The exterior patio and walkways of the building were toured on 09/06/22. There were two sections of the sidewalk with drop-offs of up to two inches measured from the concrete surface to the planting beds. These drop-offs represented tripping/fall risks for residents.

The gate in the courtyard had a chain wrapped around the base and a padlock which needed a key to unlock the gate. In an interview on 09/06/22, Staff 3 (Maintenance) stated he was unaware of why the gate was locked shut using a chain and padlock.

The need to ensure pathways in common-use areas were kept in good repair and the courtyard gate was able to be exited without a key was discussed with Staff 1 (Owner/Administrator), Staff 2 (LPN) and Staff 3 on 09/08/22. They acknowledged the findings.

1. Exterior walkways were leveled to reduce tripping/fall risks for residents. The courtyard gate is now able to be exited through without a key.

2. Maintenace will be completing weekly walkthroughs to ensure safety of outdoor patio areas and walkways.

3. Weekly.

4. Administrator and maintenance manager.

Based on observation and interview, it was determined the facility failed to keep the interior of the facility free from unpleasant odors and all furniture clean, for 1 of 5 sampled residents (#3) whose rooms were inspected. Findings include, but are not limited to:

Resident 3's room was toured on 09/07/22 at 8:50 am. A brown cloth-covered recliner was noted to have a strong urine odor. Upon closer inspection, the seat cushion of the chair was heavily soiled and wet. The chair was shown to Staff 1 (Owner/Administrator) at 9:05 am - she acknowledged the wet cushion and odor.

On 09/07/22 at 10:40 am, a care staff was observed to clean the chair with a portable steam machine. On 09/08/22 at 12:15 pm, the chair was observed to be dry and free of stains. However, there was still a strong urine odor present.

The need to ensure resident furniture was kept clean and free of odors was discussed with Staff 1 on 09/08/22. She acknowledged the chair still had an unpleasant odor.

1. The chair was removed from resident 3s room and replaced.

2. Administrator and maintenance department will conduct routine walkthroughs and audits to ensure resident furniture is kept clean and free of odors.

Quarterly scheduled observations of resident apartments at the time of the service plan updates to identify odors and environmental issues

3. Weekly, monthly.

4. Administrator, Maintenance Director.

Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in resident rooms within a range of 110 - 120 degrees Fahrenheit (F). Findings include, but are not limited to:

On 09/07/22 at approximately 1:15 pm, water temperatures in three occupied resident rooms were measured using the surveyor's digital thermometer. The water temperatures were outside the required temperature range as follows:

* Room 101: 105.0 degrees F;

* Room 201: 107.2 degrees F; and

* Room 209: 107.7 degrees F.

In an interview on 09/08/22, Staff 3 (Maintenance) explained he tested room water temperatures when a resident was admitted but acknowledged he did not have a process for routinely re-testing water temperatures throughout the building.

The need to ensure hot water temperatures in resident rooms were maintained within 110 - 120 degrees F was discussed with Staff 1 (Owner/Administrator), Staff 2 (LPN) and Staff 3 on 09/08/22. They acknowledged the findings.

1. Maintenance department is reviewing and adjusting water temperature in resident apartments to assure they are maintained within 110 to 120 degrees.

2. Water temperature will be checked and regulated though routine environmental rotating weekly audits.

3. Weekly, monthly.

4. Administrator, Maintenance Director.

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

On 09/06/22, it was observed the four exit doors residents used to access an interior outdoor courtyard did not have an alarm or other system to alert staff when a resident exited the unit.

The need to ensure the facility provide an exit door alarm or other acceptable system for security purposes and to alert staff when residents exited the RCF was discussed with Staff 1 (Owner/Administrator), Staff 2 (LPN) and Staff 3 (Maintenance) on 09/08/22. They acknowledged the findings.

1. Exit doors are now equipped with an alarm to alert staff when residents exit.

2. Door alarms will be checked with walkthroughs by administrator and maintenance director. Staff will be trained to check and report status of alarm operation.

3. Daily, weekly.

4. Administrator, Maintenance Director.

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

Refer to C 150, C 160, C 231, C 240, C 295, C 361, C 510, C 513, C 545 and C 555.

Refer to other citations.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired non-direct care staff (#5) completed all required orientation and pre-service training, and employees received infectious disease prevention training. Findings include, but are not limited to:

Training records were reviewed on 09/08/22. The following deficiencies were identified:

a. Staff 5 (Kitchen) was hired 07/13/22. There was no documented evidence Staff 5 completed orientation and pre-service dementia training prior to performing his job duties independently.

b. Review of training records for newly-hired and longer-employed staff lacked documentation the staff had completed Department-approved training in infectious disease prevention. In an interview on 09/08/22, Staff 1 (Owner/Administrator) acknowledged the facility had not provided training as required.

The need to ensure required training was provided, completed and documented was reviewed with Staff 1 and Staff 2 (LPN) on 09/08/22. They acknowledged the findings.

1. Staff 5 completed orientation and pre-service dementia training. All training records are being reviewed to ensure all employees have necessary training as required.

2. Training requirements will be reviewed upon hire, within first 30 days of hire. All current employess files will be reviewed and then audited twice monthly to ensure that staff continue to complete their training on time.

3. Bi-monthly.

4. Administrator, Business Manager.

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 262, C 270, C 280, C 282, C 290, C 300, C 303, C 305 and C 310.

Refer to other citations.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, 4 and 5's service plans were reviewed during the survey.

There was no documented evidence the facility created a daily meal program for nutrition and hydration which highlighted residents needs during waking hours.

In an interview on 09/08/22, Staff 1 (Owner/Administrator) and Staff 2 (LPN) stated they were unaware of the rule requiring an individualized nutrition and hydration plan to be created and documented in the resident service plans.

The need to develop individualized nutrition and hydration plans as part of the service plan was discussed with Staff 1 and Staff 2 on 09/08/22. They acknowledged the findings.

1. Residents 1, 2, 3, 4, and 5 service plans are being updated to include daily meal program for nutrition and hydration.

2. Consultant is providing training on development of individual nutrition and hydration service plans and staff implementation of the updated hydration and nutrition plan. Twice daily snack and hydration pass is now scheduled. Administrator will complete walkthroughs ensuring snack and hydration passes are properly occuing.

3. Daily.

4. Administrator.  

Based on observation, interview and record review, it was determined the facility failed to develop an individualized activity plan for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms or walked around the facility.

Though service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's past and current interests, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for participation and activities that could be used as behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

The need to develop individualized activity plans which were based on a thorough assessment of the resident's interests, abilities and needs was discussed with Staff 1 (Owner/Administrator) and Staff 2 (LPN) on 09/08/22. They acknowledged the facility had not thoroughly evaluated each resident and developed an individualized activity plan based on that evaluation.

1. Residents 1, 2, 3, 4, and 5 service plans are being updated to include individualized activity plans based on a thorough assessment of the resident's interests, abilities, and needs.

2. All residents will be assessed and an activity plan developed that details what, when, how, and how aften staff should offer and assist each resident with individualized activities. Each service plan will be updated and revised quarterly and as needed.

3. Monthly.

4. Administrator, Activities Director.

Based on observation and interview, it was determined the facility failed to ensure the courtyard fencing was no less than six feet in height and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:

A tour of the facility courtyard on 09/06/22 revealed the fencing around the perimeter of the secured outdoor area was less than six feet in height. The shortest sections were approximately 5 feet 8 inches.

There were 14 patio chairs and three patio tables which were easily moveable and not of sufficient weight or design to prevent potential elopement.

The need to ensure outdoor courtyard fencing was no less than six feet in height and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement was discussed with Staff 1 (Owner/Administrator), Staff 2 (LPN) and Staff 3 (Maintenance) on 09/08/22. They acknowledged the findings. The facility removed the chairs and tables from the patio prior to the end of the survey.

1. The fence was fixed to ensure minimum height of six feet. Furniture was removed that was not of sufficient weight and design to prevent resident injury or aid in elopement. Furniture of appropriate design and weight is in place.

2. Maintenance Director will complete weekly and monthly environmental audits with administrator.

3. Weekly, monthly.

4. Administrator, Maintenance Director.