The findings of the change of ownership survey conducted 01/29/24 through 02/01/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 02/01/24, conducted 09/10/24 through 09/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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 revisit to the re-licensure survey of 02/01/24, conducted 02/04/25, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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 revisit to the re-licensure survey of 02/01/24, conducted 06/18/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

Resident 1 moved into the facility in 11/2023.

Resident 1's initial evaluation failed to address the following required components:

* Customary routines;

* Spiritual, cultural, social, leisure activities;

* Mental health status including history of treatment and effective non-drug interventions;

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

* Pain including location of pain and pharmaceutical and non-pharmaceutical interventions;

* Skin condition;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Elopement risk or history; and

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

The need to ensure initial evaluations included all required components was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. The staff acknowledged the findings.

1.The Wellness Director will correct the required components and will receive retraining on the evaluation process.  ED and Community RN will audit every move-in within the next 45 days to ensure required components are there.

2.We have updated the electronic move-in evaluations to show the areas needing address and added boxes for more details.

3.New move-in evaluations will be reviewed by the ED and community RN prior to admission for every new admission.

4.Executive Director and community RN.

2. Resident 1 moved into the facility in 11/2023.

The resident's 01/06/24 service plan was reviewed and was not reflective of the resident's current needs, did not provide resident specific interventions, lacked clear direction to staff and/or was not consistently followed by staff in the following areas:

* Use of cushions;

* Use of side rails while in bed;

* Grooming/Hygiene;

* Bathing, including when and how often;

* Denture care;

* Housekeeping services, including how often;

* Laundry services, including how often; and

* Use of an air mattress.

The need to ensure the service plan was reflective of the resident's current needs, was implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, needs and preferences, and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 06/2022 with diagnoses including respiratory failure with hypoxia and was observed to be wearing oxygen via nasal cannula throughout the survey. Oxygen was supplied via a concentrator or by individual tanks when the resident was not near the concentrator.

The most recent service plan, dated 01/30/24, and interim service plans were reviewed. The service plan did not reflect the resident's needs and provide clear direction to staff in the following area:

* Use of oxygen, including setting, cleaning and tube replacement information.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. They acknowledged the findings.

1.The RCC will be reeducated on the service planning process as well as the requirements in this department.  RCC and ED will take the Oregon Care Partner "Dementia Care: Person Centered Care Plans" and "Service Plans for Assisted Living Facilities".  Resident 5's service plan has been updated to include oxygen setting, cleaning and tube replacement information.  Resident 1's service plan has been updated to include resident specific interventions, use of cushions, use of side rails while in bed, grooming/hygiene, bathing, denture care, housekeeping services, laundry services and use of air mattress.

2.Each resident service plan will be reviewed within the next 45 days by the clinical team for compliance.

3.The ED will conduct a meeting each week for quality assurance and service plan reviews as a clinical team on an ongoing basis.

4.Executive Director, RN, Wellness Director.

2. Resident 1 moved into the facility in 11/2023.

Resident 1's 01/01/24 through 01/29/24 MAR was reviewed during the survey. Staff documented on the MAR that the resident refused multiple medications and Bactroban (antibiotic) treatments on multiple occasions. There was no documented evidence the physician was notified of the refusals.

The need to ensure the facility notified physicians of medication and treatment refusals each time the resident refused to consent to orders was discussed with Staff 1 (ED) and Staff 2 (RN) on 2/01/24. The staff acknowledged the findings. No additional information was received.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 3) who had documented medication and treatment refusals. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 10/2023 with diagnoses including bipolar disorder and chronic pain.

A review of Resident 3's 01/01/24 - 01/30/24 MAR identified the resident refused medications on 67 occasions. There was no documented evidence the physician had been notified of the refusals.

The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. They acknowledged the findings.

1.Med Techs will be re-trained on the requirements of notifying the PCP when a resident refuses medication.   RN reviewed all refused medications for resident 3 and 1 and sent notifications to PCP.  Med Techs provided education.

2.A PCP notification request was sent out asking how often PCP would like to be notified of medication refusal.  A MAR Audit will be conducted weekly to ensure that PCP's are being notified.  The ED will sample MAR's weekly for compliance.

3.Weekly

4.Executive Director and Clinical Team

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, and provided clear instruction and parameters for administration of scheduled and PRN medications for 3 of 4 sampled residents (#s 1, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2023 with diagnoses including chronic pain.

The resident's 01/01/24 through 01/29/24 MAR and physician orders were reviewed and revealed the following:

* Multiple PRN pain medications including Tylenol 1000 mg, Tramadol 50 mg and Norco 5/325 mg, lacked clear parameters related to when and in what sequence they should be administered; and

* Multiple PRN bowel management medications lacked clear parameters related to when and in what sequence they should be administered.

The need to ensure MARs were complete and included clear direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. The staff acknowledged the findings.

2. Resident 4 moved into the facility in 09/2020 with diagnoses including chronic constipation.

The resident's 01/01/24 through 01/29/24 MAR and physician orders were reviewed and revealed the following:

* The resident had a physician's order to receive lactulose 10 mg at bedtime for constipation. On 01/12/24, 01/13/24 and 01/20/24, the MAR was blank.

In an interview on 01/31/24, Staff 2 (RN) verified the medication had been held due to "hold" parameters, however, the MAR had not been marked to document the "hold".

The need to ensure MARs documentation was completed was discussed with Staff 1 (ED) and Staff 2 on 02/01/24. They acknowledged the findings.

3. Resident 5 moved into the facility in 06/2022 with diagnoses including constipation.

The resident's 01/01/24 through 01/29/24 MAR and physician orders were reviewed and revealed the following:

* The resident had a physician's order to receive docusate sodium 100 mg twice daily as needed for constipation.  

The MAR lacked clear parameters to instruct staff on when the medication should be administered.

The need to ensure MARs provided instructions to staff on when to administer PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. They acknowledged the findings.

1.New 90-day orders have been requested for each resident from their PCP for clear parameters and will be compared to the MAR over the next couple of weeks for correction.

2.Med Techs/Clinical will be retrained within the next 30 days to ensure understanding of the medication delivery system and orders with clear parameters.

3.Weekly

4.RN and Wellness Director.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to accurately reflect all the ADLs for each resident, including the amount of staff time needed to provide care for 4 of 4 sampled residents (1, 2, 3 and 4). Findings include, but not limited to:

The facility's ABST was reviewed with Staff 1 (ED) on 01/31/24.

During interviews with staff and observations of resident care, the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care.

The need to ensure all time needed for providing ADL care to residents was accurate in the ABST tool was reviewed with Staff 1 on 01/31/24 and 02/01/24. The staff acknowledged the findings. No additional information was provided.

1.The ED has updated ABST ALD's to reflect the care needs for each resident.  Residents 1, 2, 3, and 4 ABST Plan has been updated.  Staffing Plan has been updated.

2.ED will review the ABST Training and will update residents to reflect ADL required needs based on care plan reviews at 30, 60, and 90 days, or at COC.

3.Every 90 days or upon COC.

4.Executive Director.

Based on observation, interview, and record review, it was determined the facility failed to ensure the posted staffing plan was reflective of the staffing needs calculated and the staffing levels exceeded the number of staff indicated by the acuity-based staffing tool. This is a repeat citation, Findings include, but are not limited to:

Review of the facilities ABST entries, staff schedule, calculated staffing hours and posted staffing plan were completed and showed the following:

* Three newly admitted residents were not entered into the ABST;

* One resident who no longer resided in the facility, was still reflected in the ABST resident list;

* Updates to the ABST were not made at least quarterly for 23 of the residents currently residing in the facility;

* The posted staffing plan did not reflect the number of staff working on the floor; and

* Observations of resident care and interviews with staff indicated the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care.

The need to ensure all residents were accurately entered in the ABST, updated at least quarterly and with changes in condition and that the facility staffing plan and staff working on the floor, exceeded ABST staffing calculations was discussed with Staff 2 (RN), Staff 21 (Sister Facility ED) and Staff 24 (VP of Health Services/RN) on 09/11/24 and 09/12/24. The staff acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

oAction:The ABST will be updated to reflect the current residents and their current needs.

oTarget Date for Correction: 10/5/2024

2.How will the system be corrected so this violation will not happen again?

The ABST will be immediately implemented for each new resident. The current resident's ABST will be reviewed quarterly at the time of their 90 day evaluation for accuracy.The ABST will also be updated anytime that a resident service plan is changed due to a change of condition.

3.How often will the area needing correction be evaluated?

This will be evaluated monthly by the RCC as a whole, and quarterly or on change of condition of individual residents.

4.Who will be responsible to see that the corrections are completed/monitored?

The RCC and Wellness Director will be responsible for corrections and monitoring with the oversight of the Executive Director.

Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for multiple unsampled residents and failed to develop an accurate staffing plan for each shift, that met the scheduled and unscheduled needs of all residents. Findings include, but are not limited to:

On 02/04/25 at 11:30 am, Staff 2 (RN, Manager on Duty) provided the surveyor with a list of the current residents residing in the facility. The facility's ABST was reviewed and compared to the current resident list and the following was identified:

* Five unsampled residents were not entered into the ABST;

* Two unsampled residents who shared a unit were not listed as separate individuals in the ABST; and

* Four residents were entered into the facility's ABST but were not in the facility at the time of the survey.

On 02/04/25 at 2:30 pm, Staff 2 acknowledged the facility's ABST did not have all the current residents entered and four of the residents were no longer in the building. Therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents and could not meet the scheduled and unscheduled needs of the residents.

The need to ensure the facility's ABST included all residents to determine appropriate staffing levels for the facility to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 2 on 02/04/25. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to complete or update and review the ABST evaluation for each resident before a resident moved in and no less than quarterly, and use the results of an ABST to develop and routinely update the facility's posted staffing plan. Findings include, but are not limited to:

Review of the facility's ABST entries, staff schedule, calculated staffing hours, and posted staffing plan were completed and showed the following:

* Five residents were not entered into the ABST;

* Four residents who no longer resided in the facility were still reflected in the ABST resident list;

* Updates to the ABST were not made at least quarterly for 35 residents currently residing in the facility; and

* The posted staffing plan did not reflect the number of staff working on the floor.

The need to ensure the ABST was completed, updated, or reviewed for each resident before a resident moved in and no less than quarterly and to use the results of an ABST to develop and routinely update the facility's posted staffing plan was reviewed with Staff 2 (RN, Manager on Duty) on 02/04/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 11 and 12) had documentation of first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 01/31/24 with Staff 3 (Business Office Manager) revealed the following:

* Staff 11 (CG) and 12 (CG), hired on 09/22/23 and 11/20/23 respectively, lacked documentation of abdominal thrust/first aid training within 30 days of hire.

On 01/31/24, the lack of documentation, staff training program and regulations were discussed with Staff 1 (ED) and Staff 3. The staff acknowledged the findings.

1.BOM and ED have reviewed all employee files and have given all employees behind on training their class list to ensure compliance with deadlines.  Staff 11 and 12 have completed CPR/First Aid training and provided BOM with certificates.

2.All new hires will be required to complete all pre-hire training and classes and provide BOM with certificates prior to the first day of training on the floor.

3.Upon hiring of employees and prior to the first day on the floor.     

4.Executive Director, Business Office Manager, Resident Care Coordinator

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 15, 17 and 18) had documentation of first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 09/10/24 with Staff 20 (RCC) and Staff 21 (Sister Facility ED) revealed the following:

* Staff 15 (CG) and 17 (CG), hired on 08/12/24 and 07/15/24 respectively, lacked documentation of abdominal thrust/first aid training within 30 days of hire.

* Staff 18 (MT), hired 07/04/24, lacked documentation of abdominal thrust/first aid training within 30 days of hire.

On 09/11/24, the need to complete first aide and abdominal thrust within 30 days of hire and that documentation was maintained, was discussed with Staff 2 (RN) and Staff 21. The staff acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Each staff member will have a review of their training records and obtain a CPR card that includes abdominal thrust training and First Aid training , All pre-service training including dementia training and infection control training will be completed  per Lenity Management policy and Oregon Administrative Rules.

2.How will the system be corrected so this violation will not happen again?

Onboarding and Training of staff will be completed using Orientation and Competency forms to assure completion of all required trainings within the time frame standard as identified in the

3.How often will the area needing correction be evaluated?

Evaluation will occur with each new hire and ongoing to assure compliance with required training.

4.Who will be responsible to see that the corrections are completed/monitored?

The Business Office manager will maintain employee files for compliance and this will be overseen by the Executive Diretor.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Fire drill and fire and life safety training records, dated 06/2023 through 01/2024, were reviewed during the survey. The following deficiencies were identified:

1. The facility failed to conduct fire drills every other month.

2. Fire drills were conducted in 08/2023, 11/2023 and 01/2024 and lacked the following documentation:

* Location of simulated fire origin;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and

* Evacuation time period needed.

3. Fire and life safety instruction was not consistently provided to staff on alternate months.

The requirements regarding fire drills, and fire and life safety instruction for staff on alternating months was reviewed with Staff 5 (Facility Services Director) on 01/31/24 and Staff 1 (ED) on 02/01/24. The staff acknowledged the findings.

1.Facility Service Director and ED will take Oregon Care Partner Fire Saftey and Emergency Preparedness class this week.

2.The forms we use to document fire drills have been updated so that all areas are covered.

3.This will be reviewed monthly by the ED and FSD for compliance during the Safety Comity Meeting.

4.Executive Director and Facility Services Director

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records, dated 06/2023 through 01/2024, were reviewed during the survey and identified the facility lacked documented evidence of the following:

* Fire and life safety training for residents, at least annually, included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building.

The requirements regarding fire and life safety instruction for residents was reviewed with Staff 5 (Facility Services Director) on 01/31/24 and Staff 1 (ED) on 02/01/24. They acknowledged the findings.

1.FSD and ED will take the Oregon Care Partner "Fire Safety and Emergency Preparedness" class this week.  All residents will be trained in the next 30 days of Fire Safety and Emergency Evacuation.     

2.New Resident Orientation check list has been created to ensure all tasks and training are completed within 24 hours of resident move-in on Fire and Life Safety.  Signatures will be taken on completion of training and signed copies will be placed in resident rooms on their doors.  Each resident will also be trained on Fire and Life Safety on their anniversary date of move-in.

3.This will be reviewed monthly by the ED and FSD for compliance during the Safety Comity Meeting.

4.Executive Director and Facility Services Director.

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 C 361 and C 372.

1.What actions will be taken to correct the rule violation for each example/resident?

The community will be in substantial compliance the date alleged on this report.

2.How will the system be corrected so this violation will not happen again?

The community will continue to maintain substantial compliance by the date of alleged compliance and ongling.

3.How often will the area needing correction be evaluated?

Community compliance with all Oregon Administrative Rules will be evaluated weekly and ongoing.

4.Who will be responsible to see that the corrections are completed/monitored?

Community department managers will assure compliance in their respective departments and will be overseen by the Executive Director.

Based on 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 Z 155.

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

Observations on 01/30/24 and 01/31/24 identified the following areas in need of cleaning or repair:

1. Handrails throughout the assisted living unit halls were in disrepair, including chips, gouges and splintered wood.

2. Flooring in the memory care unit dining room had black streaks and gouges.   

The areas needing cleaning and repair were reviewed with Staff 5 (Facility Services Director) on 01/31/24 and Staff 1 (ED) on 02/01/24. They acknowledged the findings.

1.For area 1-FSD assistant has sanded handrail and patched deep gouge areas and the stained for cleanability.  For area 2-FSD is obtaining bids for the replacement of floor and will be scheduling the floor repair for the next 60-90 days.

2.Maintenance and housekeeping will meet weekly report needs.  ED and FSD will meet weekly and round the community to review needs and discuss solutions and plan of action.

3.Weekly

4.Executive Director and Facility Services Director

Based on observation, interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:

Refer to C361, C372, C420, C422 and C613.

1.Refer to (C613, C420, C422)

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

Refer to C 361 and C 372.

1.What actions will be taken to correct the rule violation for each example/resident?

The community will be in substantial compliance the date alleged on this report.

2.How will the system be corrected so this violation will not happen again?

The community will continue to maintain substantial compliance by the date of alleged compliance and ongling.

3.How often will the area needing correction be evaluated?

Community compliance with all Oregon Administrative Rules will be evaluated weekly and ongoing.

4.Who will be responsible to see that the corrections are completed/monitored?

Community department managers will assure compliance in their respective departments and will be overseen by the Executive 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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 362 and C 363.

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation for 4 of 4 newly hired staff (#s 8, 10, 11 and 12), pre-service dementia training completed for 2 of 3 newly hired staff (#s 10, 11 and 12), demonstrated competency completed in all required areas within 30 days of hire for 2 of 3 newly hired staff (#s 11 and 12), and a total of 16 hours of in-service training completed annually including six hours related to dementia care topics for 4 of 4 long-term direct care staff (#s 6, 7, 9 and 13). Findings include, but are not limited to:

On 01/31/24, training records were reviewed with Staff 3 (Business Office Manager). The following deficiencies were identified.

1. Staff 8 (Housekeeping), Staff 10 (CG), Staff 11 (CG), and Staff 12 (CG), were hired on 12/12/23, 11/17/23, 09/22/23, and 11/20/23 respectively.

a. Staff 8, Staff 10, Staff 11 and Staff 12 lacked pre-service orientation documentation in the following areas:

* Infectious Disease Prevention.

Additionally, Staff 11 lacked documentation of the following:

* Fire safety and emergency procedures.

b. Staff  10, 11, and 12 lacked pre-service dementia training in multiple required areas.

c. Staff 11 and 12 lacked documented evidence of competency demonstration in multiple required areas within 30 days of hire.  

2. Staff 6 (CG), Staff 7 (MT), Staff 9 (CG) and Staff 13 (MT), all hired on 05/01/22, lacked documented evidence of completion of 16 hours of annual in-service training which included at least six hours of dementia care training, reviewed by the anniversary date of the staff's hire.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (ED) and Staff 3 on 01/31/24. The staff acknowledged the findings.

Refer to (C372)

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation for 4 of 4 newly hired staff (#s 15, 17, 18 and 19), demonstrated competency completed in all required areas within 30 days of hire for 3 of 4 newly hired staff (#s 17, 18 and 19), and annual infectious disease training was completed for 2 of 2 long term direct care staff (#s 9 and 23). This is a repeat citation. Findings include, but are not limited to:

On 09/10/24 and 09/11/24, training records were reviewed with Staff 20 (RCC) and Staff 21 (Sister Facility ED). The following deficiencies were identified.

1. Staff 15 (CG), Staff 17 (CG), Staff 18 (MT) and Staff 19 (CG), were hired on 08/12/24, 07/15/24, 07/04/24, and 07/15/24 respectively.

a. Staff 15, Staff 17, Staff 18 and Staff 19 lacked pre-service orientation documentation for, Infectious Disease Prevention.

b. Staff 17, Staff 18 and 19 lacked documented evidence of competency demonstration in multiple required areas within 30 days of hire.  

2. Staff 9 (MT) and Staff 23 (MT), hired on 05/01/22 and 11/16/22 respectively, lacked documented evidence of annual Infectious Disease Prevention training, reviewed by the anniversary date of the staff's hire.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 21 (Sister Facility ED) on 09/11/24. She acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Each staff member will have a review of their training records and obtain a CPR card that includes abdominal thrust training and First Aid training , All pre-service training including dementia training and infection control training will be completed  per Lenity Management policy and Oregon Administrative Rules.

2.How will the system be corrected so this violation will not happen again?

Onboarding and Training of staff will be completed using Orientation and Competency forms to assure completion of all required trainings within the time frame standard as identified in the

3.How often will the area needing correction be evaluated?

Evaluation will occur with each new hire and ongoing to assure compliance with required training.

4.Who will be responsible to see that the corrections are completed/monitored?

The Business Office manager will maintain employee files for compliance and this will be overseen by the Executive Diretor.

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation training for 4 of 4 newly hired staff (#s 26, 27, 28 and 29), and demonstrated competency completed in all required areas within 30 days of hire for 2 of 4 newly hired staff (#s 28 and 29). This is a repeat citation. Findings include, but are not limited to:

On 02/04/25 at 12:30 pm, training records were reviewed with Staff 25 (Business Office Manager). The following deficiencies were identified:

Staff 26 (MT), Staff 27 (Dietary Aide), Staff 28 (CG) and Staff 29 (MT), were hired on 12/09/24, 12/13/24, 12/06/24, and 12/13/24 respectively.

a. Staff 26, Staff 27, Staff 28 and Staff 29 lacked pre-service orientation documentation for Infectious Disease Prevention.

b. Staff 26, Staff 27, and Staff 29 lacked pre-service orientation documentation of HCBS and LGBTQIA2s+ approved courses.

c. Staff 28 and Staff 29 lacked documented evidence of competency demonstration in multiple required areas within 30 days of hire.  

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 2 (RN, Manager on Duty) and Staff 25 on 02/04/25. They acknowledged the findings.

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

Refer to C252, C260, C305 and C310.

Refer to (C260, C310)

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled memory care residents (#s 4 and 5), whose records were reviewed. Findings include, but are not limited to:

Residents 4 and 5's service plans, "Life Stories", and evaluations were reviewed. There was some historical personal information included, but the records lacked documented evidence the facility had fully evaluated the residents including:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities.

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (ED) and Staff 14 (Activities Director) on 02/01/24. They acknowledged the findings.

1.The Life Enrichment Director and Wellness Director along with RCC will update the service plan and care plan to include an individualized activity plan for each resident.

2.All service plans and care plans to address history, likes, dislikes, etc.  The Life Enrichment Director or Clinical team will update current care plans to reflect activity needs, likes and dislikes.

3.Upon move-in and then at 30, 60 and 90 days.  Then every 90 days thereafter.  ED and Clinical review every 90 days.

4.Executive Director, Resident Care Coordinator, RN, Wellness Director, Life Enrichment Director