The findings of the change of ownership survey, conducted 10/09/23 through 10/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the change of ownership survey of 10/11/23, conducted 03/20/24 through 03/21/24, 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 and OARs 411 Division 57 for Memory Care Communities.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 10/11/23, conducted 08/26/24 through 08/28/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with 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 third re-visit to the change of ownership survey of 10/11/23, conducted 10/22/24 through 10/23/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

The facility was toured on 10/09/23 at 1:00 pm and the following postings were not observed:

* The facility license;

* The name of the administrator or designee in charge;

* The current facility staffing plan; and

* Revisits and plans of correction from the most recent relicensure survey.

During an interview on 10/11/23 at 2:00 pm, Staff 1 (MC2 RCC) confirmed the above postings were not in the building.

The need to ensure all required postings were in an accessible and conspicuous location was discussed with Staff 1 on 10/11/23. She acknowledged the findings.

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

1. Resident 1, 2, and 3's records were reviewed during the survey and found to be incomplete, inaccurate, and not preserved in the following areas:

a. The facility documented information and monitoring about multiple residents' daily changes of condition in a 24-hour communication log. The documentation included information about multiple residents, was not a confidential document, and could not be included in each resident's individual record as required under 411-054-0040(1)(d)(B).

b. Quarterly service plans were requested during the survey for Residents 1 and 3. The facility was not able to provide documentation that service plans were completed or updated quarterly as required.

c. Resident 2's service plan that was available to staff was dated 06/13/23. During an interview on 10/11/23 at 1:00 pm, Staff 1 (MC2 RCC) was able to provide documented evidence that his/her service plan was last updated on 09/13/23, but the updated service plan was not available to staff.

Refer to C260 1b, 2b, and 3b.

d. The facility used the "Service Checkoff List" sheet as documented evidence staff completed an individual resident's ADLs. Resident 1, 2 and 3's Service Checkoff List sheets, dated 09/01/23 through 09/30/23, were reviewed and there were multiple blanks on the sheets. There was no documentation the Service Checkoff List had been completed for Residents 1, 2, and 3 from 10/01/23 to 10/09/23.

e. Current signed physician orders for Resident 1 and 2 were requested on 10/09/23. During an interview on 10/10/23, Staff 5 (Staff Nurse/LPN) reported there were no signed physician orders to administer medications for Residents 1 and 2.

Refer to C303 1a and 2.

2. Multiple non-sampled residents' Service Checkoff Lists dated from 09/01/23 to 09/30/23 were reviewed and there were multiple blanks on the ADL sheets. There was no documentation the Service checkoff list from 10/01/23 to 10/09/23 was completed for all non-sampled residents.

During an interview on 10/09/23 at 11:10 am, Staff 7 (CG) stated there was no October 2023 Service Checkoff List to all residents and he did not use or document on the sheet.

3. Records for three sampled staff for annual training requirements were requested on 10/10/23 and 10/11/23. The facility was unable to provide requested documents prior to survey exit.  

The need to ensure resident records were complete, accurate, and preserved was discussed with Staff 1 and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to promptly investigate a resident-to-resident altercation and failed to report the incidents to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (# 6) who experienced a resident to resident altercation. Findings include, but are not limited to:

Resident 6 moved into the facility in 08/2023 with diagnoses including dementia with behaviors and early onset Alzheimer's disease.

A facility progress note dated 12/28/23 indicated Resident 6 was involved in a physical altercation with another resident in which Resident 6 was the aggressor.

There was no documented evidence the facility completed an investigation which documented the following:

* Time, date, place and individuals present;

* Description of the event as reported;

* Response of staff at the time of the event;

* Follow-up action; and

* Administrator's review.

In addition, there was no documented evidence the facility Administrator or designee notified the local SPD office of the physical altercation. The survey team requested the facility report the incident to the local SPD office.

On 03/21/24, Staff 1 (Assistant ED) and Staff 5 (LPN) acknowledged the findings. No further information was provided.

1) Resident #6  incident report will be reviewed and reported to SPD.  In-service will be conducted on appropriate reporting to SPD on incident reports and investigations.

2) Incident reports will be reviewed during weekly clinical meetings.

3) Incident reports will be reviewed weekly for 6 weeks.

4)The Executive Director, DHW and /or designee responsible

2. Resident 10 was admitted to the memory care facility in 06/2023 with diagnoses including Alzheimer's disease and aphasia (language disorder).

The resident's service plan dated 07/19/24, incident investigation reports, progress notes from 06/17/24 through 08/26/24, observations of the resident, and interviews with care staff during the survey indicated the resident was only able to recall him/herself and spoke in repeated nonsensical comments.

The resident's clinical record revealed the following:

* 06/20/24 - "It has been reported this AM that on [06/13/24], [Resident 10] had been setting (sic) in a chair in the dinning (sic) room when another confused [resident] came up in back of [him/her] and grabbed the chair [s/he] was setting (sic) in and shook it, [the other resident] then reached around and grabbed [Resident 10] on the [left] upper arm...it is unclear if the [bruising identified on 06/19/24] is related."

The facility provided documentation indicating the resident-to-resident incident from 06/13/24 was reported to the local Seniors and Peoples with Disabilities Office (SPD) on 07/19/24, and the investigation was documented as completed on 07/21/24. There were 36 days between the resident-to-resident incident and the incident being reported to the local SPD office, and 38 days between the incident and the completion of the investigation.

Although the facility completed an investigation regarding the resident-to-resident altercation and reported it to the local SPD office, the facility failed to report the incident immediately and investigate it promptly.

The need to ensure physical altercations were immediately reported to the local SPD office was discussed with Staff 24 (ED), Staff 5 (Staff Nurse, LPN), Staff 25 (Director of Health and Wellness, RN), and Witness 1 (RN Consultant) on 08/28/24 at 10:12 am. They acknowledged the findings.

Based on observation, interview, and record review it was determined the facility failed to immediately report abuse to the local Seniors and People with Disabilities (SPD) office for 2 of 2 sampled residents (#s 9 and 10) who had resident to resident altercations. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 02/2024 with diagnoses including dementia.

Staff were interviewed and the resident's record was reviewed including 05/26/24 through 08/26/24 progress notes, incident reports and incident investigations. The following was identified:

Resident 9 was involved in multiple physical altercations with other residents. The facility did not immediately report the following incidents to their local SPD office:

* 5/27/24 -  Punched another resident in his/her arm, and was punched by the same resident. Reported to Adult Protective Services (APS) on 05/30/24;

* 06/08/24 - Hit and grabbed another resident. Reported to APS on 07/21/24; and

* 07/20/24 - Attempted to strangle another resident. Reported to APS on 07/26/24.

There was no documented evidence the facility reported the following resident to resident physical altercations to their local SPD office:

* 05/28/24 - Pushed another resident to the ground; and

* 07/20/24 - Punched and smacked another resident.

During interviews on 08/27/24, Staff 24 (Executive Director) acknowledged the findings and no additional documentation was provided.

At the request of the survey team, the facility provided confirmation that all above incidents had been reported to the local SPD office prior to survey exiting the building.

The need to ensure all incidents of abuse were immediately reported to the local SPD office was discussed with Staff 5 (Staff Nurse, LPN), Staff 24 and Staff 25 (Director of Health and Wellness, RN) at 10:00 am on 08/28/24. They acknowledged the findings.

1) Resident #9 and #10 reportable incident's were reported to APS prior to State Survey's exit.

2) Clinical staff will be In-serviced on abuse and neglect reporting to SPD immediately per OAR, if abuse and neglect cannot be ruled out.  Abuse and neglect training will be conducted on a routine basis, upon hire and annually thereafter.

3) Incident Reports will be reviewed routinely by Administrator and/or Designee to rule out abuse and neglect. If abuse and neglect cannot be ruled out by Administrator and/or designee- report to SPD immediately per OAR.

4) Adminastrator and/or designee.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 10/10/23 at 10:30 am, the facility kitchen was toured and the following was observed:

1. Food spills, splatters, debris, dust and black matter were observed on or underneath the following:

* The ceiling vent above bread storage area had significant amount of dust build-up;

* The ceiling above prep area had significant splashes;

* The exterior (lids and sides) of the large food bins had food debris and black scuff marks;

* The flooring throughout the kitchen, including underneath the large mixer, counters, oven/stove/grill and the dishwashing area, had significant build-up of black matter;

* The oven doors, sides and knob area had food drips and splashes;

* The convection oven doors had grease drips and splatters;

* The sandwich refrigerator exterior doors and bottom shelf of interior had food drips and debris;

* The lower shelves beneath steamer, grill, serving, and prep areas had food debris;

* The interior and exterior of the microwave had splatters and the counter underneath had food debris and crumbs;

* The dishwashing room had black matter on the wall behind the spray hose; and

* A three-tiered black cart with shelves which contained clean cups and glasses had significant build-up of debris.

2. Staff with beards were not using any type of hair restraints on their beards.

The areas of concern were discussed with Staff 4 (Culinary Service Director) on 10/10/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure the resident move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) whose evaluation was reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 09/2023 with diagnoses including dementia. The resident's new move-in evaluation was reviewed and the following elements were not addressed:

* Customary routines, including eating and bathing;

* Mental health issues, including presence of depression, thought disorders or behavioral or mood problems, history of treatment, and effective non-drug interventions;

* Cognition, including orientation and decision-making abilities;

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

* Communication and sensory, including hearing and vision; and

* Ability to manage medications.

The need to ensure resident move-in evaluations addressed all required elements was discussed with Staff 1 (MC2 RCC) on 10/11/23 at 1:30 pm. She acknowledged the findings, and no additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure the resident move-in evaluation addressed all required elements for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 moved into the facility in 02/2024 with diagnoses including dementia. The resident's move-in evaluation was reviewed and the following elements were not addressed:

* Customary routines, including eating and bathing;

* Spiritual, cultural preferences and traditions;

* List of current diagnoses, medications and PRN use;

* Cognition, including decision-making abilities;

* Mobility including assistive devices;

* Eating including dental status and assistive devices; and

* Recent losses.

The need to ensure resident move-in evaluations addressed all required elements was discussed with Staff 1 (Assistant ED) and Staff 5 (LPN) on 03/21/24. They acknowledged the findings.

1)Community leadership will be inserviced on pre-admission process and documentation.

Resident 5 admission evaluation and service plan will be reviewed and updated according to OAR.

2) Admission evaluations will be reviewed before move in by the clinical team and Executive Director.

3) Pre-admission evaluations will be reviewed weekly for 6 weeks.

4) The Executive Director and DHW and/or designee will be responsible of ensuring pre-admission evaluations are reviewed

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 1 moved into the facility in 05/2022 with diagnoses including dementia.

a. Resident 1's service plan, updated 01/06/23, temporary service plans and progress notes dated 08/08/23 through 10/05/23 were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Storing clothes status; and

* Nail care, including who performed and how often.

b. The most recent service plan, dated 01/06/23, was accessible to staff. There was no documented evidence the facility completed quarterly service plans for Resident 1.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instructions was discussed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings.

2. Resident 3 moved into the facility in 04/2023 with diagnoses including age-related cognitive decline and type II diabetes.

a. Resident 3's service plan, updated 04/24/23, temporary service plans and progress notes dated 08/01/23 through 10/06/23 were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Ambulation status, use of wheelchair versus walker;

* Transfer assistance status;

* Toileting assistance status;

* Dressing assistance status;

* Fall and interventions;

* Nail care, including who performed and how often; and

* Skin status.

b. The most recent service plan, dated 04/24/23, was accessible to staff. There was no documented evidence the facility completed quarterly service plans for Resident 3.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instructions was discussed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 04/2023 with diagnoses including dementia and hypertension.

a. Observations were made, interviews with staff were conducted, and review of the resident's service plans dated 06/13/23 and 09/13/23 and temporary service plans revealed the service plan was not reflective and did not provide clear direction to staff in the following areas:

* History of significant weight changes;

* Devices, including a hospital bed and a fall mat;

* Transfer status, including how many staff were required to assist with transfers;

* Nail care, including who performed and how often;

* Meal assistance, including intake monitoring;

* Dressing assistance;

* Behaviors including resistance to toileting and direction to staff; and

* Use of barrier cream.

b. The resident's service plan dated 06/13/23 was available to staff. An updated service plan was requested and received at 1:00 pm on 10/11/23. The updated service plan, dated 09/13/23 was received, but the updated service plan was not available to staff.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (MC2 RCC) and Staff 5 (Staff Nurse/LPN) on 10/11/23 at 2:00 pm. They acknowledged the findings, and no additional information was provided.

2. Resident 7 was admitted to the facility in 09/2023 with diagnoses including dementia with behavioral disturbance.

The resident's service plan, dated 01/29/24, the Service Checkoff List dated 03/01/24 through 03/19/24, and temporary service plans were reviewed. Interviews with care staff were conducted and observations were made of Resident 7. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Behavior intervention of giving the resident time when agitated;

* Behaviors relating to mistaking other residents as his/her spouse and not wanting staff or other residents around that person;

* Behavior interventions for when Resident 7 wanted to "go home" or questions why s/he was at the facility;

* Pain;

* Waking the resident up each morning;

* Recent losses;

* Conflicting information relating to ambulation status;

* Transfer assistance status;

* Toileting assistance status; and

* Frequency of when to check on the resident while sleeping.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instructions was discussed with Staff 1 (Assistant ED), Staff 2 (MC1 Administrator), Staff 5 (LPN), and Staff 25 (RN) on 03/21/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 6 and 7). This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 08/2023 with diagnoses including dementia.

Resident 6's service plan, updated 01/16/24, and interim service plans were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Weight loss and interventions;

* Nutritional habits;

* Behaviors and interventions;

* Pain including location of pain;

* Sleep routine including preference to sleep in the common areas verses his/her room;

* Transportation status and who provided the service; and

* Nursing needs including wound care status.

The need to ensure service plans were reflective and provided clear direction regarding the delivery of services was discussed with Staff 1 (Assistant ED) and Staff 5 (LPN) on 03/21/24. They acknowledged the findings.

1) Resident #6 and #7 will be reviewed and updated to reflect current resident needs with clear direction for deliver of services.  Service Plan in-service/training will be conducted to include OAR 411-054-0034(1-4).

2) Service plans will be reviewed during weekly clinical meeting

3) Service Plans will be reviewed weekly for 6 weeks, or until substantial can be met and maintained.

4) The Executive Director and DHW and/or designee responsible will be responsible for ensuring Service Plans are reviewed

2. Resident 1 moved into the facility in 05/2022 with diagnoses including dementia.

Resident 1's 08/08/23 through 10/05/23 facility progress notes, and Interim Service Plans (ISPs) dated 08/07/23 through 09/17/23 showed the following changes of condition:

* 08/07/23: The resident was involved in a resident to resident physical altercation.

The facility initiated an ISP for the altercation. However, there was no documented evidence the change was monitored at least weekly through resolution.  

The need to ensure short-term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings, and no further information was provided.   

Based on interview and record review, it was determined the facility failed to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift with weekly progress noted until the condition resolved for 2 of 3 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's 06/13/23 through 10/09/23 progress notes, service plan dated 06/13/23, temporary service plans (TSPs), interim service plans (ISPs), and incident reports were reviewed and the following was identified:

a. Progress notes indicated Resident 2 experienced a change in swallowing function on 07/01/23 and a non-responsive episode on 07/30/23. There was no documented evidence the facility communicated actions or interventions to staff on each shift and monitored the conditions at least weekly to resolution.

b. Progress notes indicated Resident 2 experienced a non-injury fall on 08/14/23, a sacral bruise on 08/22/23, left knee pain on 09/15/23, and a fall on 09/19/23 resulting in a "red mark above the right eyebrow." There was no documented evidence the facility monitored the conditions at least weekly to resolution.

The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (MC2 RCC) and Staff 5 (Staff RN/LPN) on 10/11/23 at 2:00 pm. They acknowledged the findings, and no further information was provided.

Based on interview and record review, it was determined the facility failed to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift with weekly progress noted until the condition resolved for 2 of 3 sampled residents (#s 6 and 7) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 09/2023 with diagnoses including dementia with behavioral disturbance.

The resident's 12/11/23 through 03/19/24 progress notes, alert charting logs, skin impairment and wound logs, and incident reports were reviewed. The following short-term changes were identified:

* 12/14/23 - Resident 7 had an unwitnessed fall which resulted in pain and brushing, and was sent to the hospital;

* 12/15/23 - The resident returned from the hospital with a medication change;

* 12/19/23 - Resident 7 had a witnessed, non-injury fall;

* 01/08/24 - Staff monitored the resident for behaviors; and

* 01/25/24 - Resident 7 moved rooms.

There was no documented evidence the facility monitored the conditions at least weekly to resolution.

The need to ensure changes of condition were monitored through resolution was discussed with Staff 1 (Assistant ED), Staff 2 (MC1 Administrator), Staff 5 (LPN), and Staff 25 (RN) on 03/21/24. They acknowledged the findings.

2. Resident 6 moved into the facility in 08/2023 with diagnoses including dementia. The resident's 12/17/23 through 10/09/23 progress notes, service plan dated 03/20/24, interim service plans, and incident reports were reviewed.

The following changes of condition lacked actions or interventions communicated to staff on each shift and/or monitoring the conditions at least weekly through resolution:

* 12/28/23 - Resident to resident altercation;

* 12/30/23 - Returned from hospital with new diagnosis "syncope and loss of consciousness";

* 01/03/24 - Injury fall;

* 01/03/24 - Multiple behaviors;

* 01/05/24 - Signs and symptoms of a cold;

* 01/09/24 - Non-injury fall;

* 01/24/24 - Non-injury probable fall (found on floor); and

* 03/14/24 - Fall from recliner and found laying on the left side of his/her body.

The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (Assistant ED) and Staff 5 (LPN) on 03/21/24. They acknowledged the findings

1) Clinical team will be in-serviced on Interim Service Plan and Alert Charting process and procedure related to short term change of condition. Resident 6 and 7 EHR will be reviewed and updated accordingly.

2) Clinical team will review/audit short term change of condition(s) and communicate changes to care staff accordingly.

3) Review at weekly clinical meeting for 6 weeks.

4) The Executive Director and DHW and/or designee responsible.   

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved for 2 of 2 sampled residents (#s 9 and 10) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 moved into the facility in 06/2023 with diagnoses including Alzheimer's disease, repeated falls, and myoclonus (uncontrollable jerking movements).

The current service plan dated 07/19/24, temporary care plans, and progress notes dated 06/17/24 through 08/26/24 were reviewed. Interivews with staff were completed between 08/26/24 and 08/28/24.

The facility failed to determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:

* 06/19/24 - Bruise to left arm;

* 06/20/24 - Resident to resident altercation;

* 06/26/24 - Non-injury fall from bed;

* 07/03/24 - Bruise to left hand;

* 07/15/24 - Discontinuation of medications;

* 07/15/24 - Bruising to hands following hospitalization;

* 08/12/24 - Bruising to mid-back following fall; and

* 08/12/24 - New scheduled acetaminophen for pain.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 24 (Executive Director), Staff 5 (Staff Nurse, LPN), Staff 25 (Director of Health and Wellness, RN), and Witness 1 (RN Consultant) on 08/28/24 at 10:12 am. They acknowledged the findings, and no additional information was provided.

2. Resident 9 moved into the facility in 02/2024 with diagnoses including dementia.

Staff were interviewed and the resident's record was reviewed including the current service plan dated 08/01/24, temporary care plans and progress notes dated 05/26/24 through 08/26/24.

The facility failed to determine resident-specific actions or interventions needed, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:

* 05/28/24 - Resident to resident altercation;

* 06/06/24 - Bruising to lateral forearm and wrist;

* 06/08/24 - Resident to resident altercation;

* 06/15/24 - Bruising to left hand;

* 07/15/24 - Broken skin on right wrist; and

* 07/30/24 - Bruises and scratches on forearms.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 5 (Staff Nurse, LPN), Staff 24 (Executive Director), Staff 25 (Director of Health and Wellness, RN), and Witness 1 (RN Consultant) at 10:00 am on 08/28/24. They acknowledged the findings, and no additional information was provided.

1) Resident #9 and #10 charts will be reviewed by clinical team.

2) Staff will be in-serviced on short term and significant change of condition monitoring systems which include Alert Charting, implementing new TSP/ISP's, and utilizing the skin log.

3) Alert Charting, TSP's/ISP's, and skin logs will be reviewed weekly during clinical meeting for four weeks.

4) Administrator, Director of Health and Wellness (RN), and/or designee.

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

Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia.

Progress notes dated 06/13/23 to 10/09/23 and the resident's weight records were reviewed and revealed the following:

* 05/04/23 - 158.2 pounds;

* 07/01/23 - 134.4 pounds;

* 08/10/23 - 138.4 pounds; and

* 09/12/23 - 133.8 pounds.

From 05/04/23 to 07/01/23 the resident experienced a weight loss of 23.8 pounds or 15% of his/her body weight in two months. The weight loss constituted a significant change of condition and required a timely RN assessment. Facility records requested and received revealed the RN assessment was completed on 08/10/23.

The resident was observed consuming a snack on 10/09/23 at 2:45 pm, breakfast on 10/10/23 at 9:05 am, and lunch on 10/10/23 at 11:45 am. The resident consumed 95-100% of all meals and snacks offered. S/he was observed to be able to feed him/herself, using his/her fingers or utensils.

The need to ensure RN assessments were completed timely for significant changes of condition was discussed with Staff 1 (MC2 RCC) and Staff 5 (Staff Nurse/LPN) on 10/11/23 at 2:00 pm. They acknowledged the findings, and no additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment and to comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010. Findings include, but are not limited to:

1. The facility had 17 residents at the time of survey. There were 15 residents in the dining room for lunch on 10/09/23 and 14 residents in the dining room for lunch 10/10/23. During the survey, meal observations were made of staff in the dining room. Staff were observed removing dirty dishes, assisting residents with their napkins and utensils, touching residents, touching the meat to cut in small pieces, and serving residents their meals without changing their gloves or performing hand hygiene.

2. Resident 1 was observed eating lunch from 11:50 am until 12:40 pm on 10/10/23. S/he used his/her fingers and a fork to hold onto all food, including steamed vegetables, rice and chicken. The resident was observed frequently putting his/her fingers in his/her mouth as well as wiping his/her hands on his/her pants. Care staff observed in the dining room at the time of lunch did not wash the resident's hands following the meal.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (MC2 RCC) and Staff 3 (MC1 Administrator) on 10/11/23. The findings were acknowledged.

3. Observations of meal service and ADL care were made from 10/09/23 to 10/11/23 and revealed the following:

a. Staff 7 (CG) was observed during breakfast service on 10/10/23 at 9:00 am. He was observed collecting dirty plates and cups from tables then approaching Resident 2 and feeding him/her three bites of fruit without first discarding dirty gloves and performing hand hygiene. He was observed taking dirty plates to the kitchen, then came back to the dining room, removed his dirty gloves, put them in his pants pocket, pulled gloves from his scrub top, and donned them without performing hand hygiene.

b. Resident 2 was observed eating breakfast from 9:00 am until 10:06 am on 10/10/23. S/he used his/her fingers to pick up all food, including oatmeal, butter, and cream cheese. The resident was observed frequently putting his/her fingers in his/her mouth as well as wiping his/her hands on his/her pants. Care staff observed in the dining room at the time of breakfast did not wash the resident's hands prior to the resident being wheeled to the activity room.

c. Staff 7, 8, and 10 (CG, CG, and MT) were observed eating food in the staff break room at 10:17 am on 10/10/23. Staff proceeded to leave the break room and began assisting residents without washing their hands.

d. Staff 8 (CG) was observed providing toileting care for Resident 2 at 12:55 pm on 10/10/23. Staff 8 donned gloves in the dining room without performing hand hygiene. Staff 8 wheeled the resident to his/her bathroom. In the bathroom, Staff 8's left glove was observed to be torn. Staff 8 proceeded to assist the resident with transferring to the toilet and pulling down his/her pants and brief. He then removed the soiled and torn gloves and donned clean gloves without performing hand hygiene.

4. Upon entrance to the MCC on 10/09/23, the facility's documentation of monthly COVID-19 reporting on vaccination status to the Oregon Health Authority (OHA) for residents and staff was requested. No information was provided.

On 10/11/23 at 1:00 pm, Staff 1 (MC2 RCC) confirmed the facility was unable to find any documentation regarding the monthly COVID-19 reporting on vaccination status to OHA.

The need to ensure establishment and maintenance of infection prevention control protocols and compliance with vaccination requirements as prescribed in OAR 333-019-1010 was discussed with Staff 1 (MC2 RCC) and Staff 5 (Staff RN/LPN) on 10/11/23 at 2:00 pm. They acknowledged the findings and no further information was provided.

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication and treatment administration system. Findings include, but are not limited to:

Refer to C155 1e, C303, C310, and C330.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including dementia and diabetes. The resident's MAR dated 09/01/23 through 10/09/23 and physician orders were reviewed and revealed the following:

Signed orders were not in the resident's facility record for the following medications:

* Acetaminophen 975 mg for pain;

* Atorvastatin 80 mg for cardiovascular disease;

* Calcium 500 mg for supplement;

* Clotrimazole 1 % cream for athletes foot treatment;

* Ferrous sulfate 324 mg for iron deficiency;

* Glipizide 5 mg for diabetes;

* Metformin ER 2000 mg for diabetes;

* Pantoprazole 40 mg for reflux;

* Pradaxa 150 mg for history of stroke;

* Quetiapine 37.5 mg for dementia;

* Sertraline 100 mg for depression;

* Trazodone 25 mg for anxiety;

* Multi-vitamin daily for supplement;

* Vitamin B12 2500 mcg for supplement;

* Vitamin C 500 mg for supplement;

* Vitamin D3 1000 iu for supplement; and

* Oxycodone 5 mg - 10 mg PRN for pain.

During an interview on 10/10/23 at 1:50 pm, Staff 5 (Staff Nurse/LPN) acknowledged the above written, signed orders were not in the resident's facility record.

The need to ensure written, signed physician or other legally recognized practitioner medication orders were documented in the resident's facility record was discussed with Staff 1 (MC2 RCC) and Staff 5 on 10/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia and a history of lower extremity cellulitis. The resident's MAR dated 09/01/23 through 10/09/23 and physician orders were reviewed and revealed the following:

a. Signed orders were not in the resident's facility record for the following medications:

* Quetiapine 25 mg for dementia;

* Bisacodyl 10 mg for constipation;

* Haloperidol 1 mg for agitation or delirium;

* Hyoscyamine .125 mg for oral secretions;

* Lorazepam .5 mg for agitation or anxiety;

* Odansetron 4 mg for nausea;

* Oxycodone 5 mg for pain; and

* Cephalexin 250 mg for lower extremity cellulitis.

During an interview on 10/10/23 at 1:00 pm, Staff 5 (Staff Nurse/LPN) acknowledged the above written, signed orders were not in the resident's facility record. The missing orders were obtained by the facility and provided to the survey team prior to survey exit.

b. Resident 2 had orders for the following:

* Cephalexin 250 mg tab, 1 tablet by mouth every 8 hours for 7 days for lower extremity cellulitis. The resident's MAR was reviewed and the following was identified:

* Two dosage times were blank on the MAR; and

* Four dosage times were documented as not given for the following reasons: "completed order," and "on hold until medication is available."

During an interview on 10/09/23 at 1:30 pm, Staff 10 (MT) could not confirm whether the medication had been given on the above dates. There was no documented evidence the facility notified Resident 2's primary care physician that the medication was unavailable or requested instructions from the physician.

The need to ensure medication orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record was discussed with Staff 1 (MC2 RCC) and Staff 5 on 10/11/23 at 2:00 pm. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 04/2023 with diagnoses including age-related cognitive decline and chronic pain syndrome.

The resident's 09/01/23 through 10/09/23 MAR was reviewed and revealed the following orders were prescribed:

* Acetaminophen, 325 mg tab, two tablets by mouth every four hours as needed for fever or pain; and

* Hydrocodone/Acetaminophen 5-325 mg tablet by mouth two times daily as needed for pain.

The resident was administered the acetaminophen 325 mg tab on one occasion.

During an interview on 10/10/23 at 11:07 am, Staff 10 (MT) stated there was "no system in place" and it was "hard to say" which medication to administer when the resident was experiencing pain.

The need to ensure PRN medications included resident-specific parameters was discussed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's 09/01/23 through 10/09/23 MAR was reviewed and revealed the following orders were prescribed:

* Acetaminophen, 325 mg tab, two tablets by mouth every six hours as needed for pain; and

* Oxycodone, 5 mg tab, .5 mg tablet by mouth every four hours as needed for moderate pain.

The resident was administered the following:

* Acetaminophen 325 mg tab on three occasions; and

* Oxycodone .5 mg tab on four occasions.

Observations made of Resident 2 on 10/09/23 and 10/10/23 revealed s/he was unable to verbally express wants and needs. During an interview on 10/10/23 at 1:30 pm, Staff 10 (MT) confirmed the resident was unable to verbally express pain. She stated there was "really no way to tell" if the resident was experiencing moderate pain.

The need to ensure PRN medications included resident-specific parameters was discussed with Staff 1 (MC2 RCC) and Staff 5 (Staff Nurse/LPN) on 10/11/23 at 2:00 pm. They acknowledged the findings, and no further information was provided.

Based on interview and record review, it was determined the facility failed to ensure documentation of the MAR was accurate and complete, and included resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 6 and 7) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 09/2023 with diagnoses including dementia with behavioral disturbance.

The resident's 02/01/24 through 03/20/24 MARs and Nurse Practitioner orders were reviewed and revealed the following:

a. Resident 7 had a Nurse Practitioner's order for scheduled quetiapine (to treat dementia with behavioral disturbance), three times a day. There were blanks on the MAR for the 03/13/24 and 03/15/24 6:00 pm administration.

On 03/21/24 at 10:51 am, it was verified the resident did receive the medication as there was no pill in the bubble packaging for those two days. There was no documented evidence the facility had administered the medication.

b. Resident 7 had an order for staff to monitor his/her bowels. Staff were directed to, "chart bowel movements twice a day, if no [bowel movement] in [three] days start bowel protocol."

The MAR reflected the facility should have administered a PRN bowel medication on 02/11/24 and 02/15/24 at 5:00 am as staff had documented no bowel movement in three days. There was no documented evidence the bowel protocol had been started.

On 03/21/24 at 10:51 am, Staff 15 (MT) confirmed the resident was independent with toileting. He continued to explain the difficulty of monitoring Resident 7's bowel movements as s/he was an inaccurate historian in the matter. Staff 15 reported he would frequently check the resident's bathroom to see if there was "remnants" of a bowel movement in the toilet as there was no other way to complete the monitoring.

c. Resident 7 had orders for the following PRN medications to treat constipation:

* Milk of Magnesia; and

* Senna.

In an interview with Staff 15 on 03/21/24 at 10:51 am, it was confirmed there was no documented evidence of which order to administer the PRNs.

The need to ensure MARs were accurate and complete, and included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Assistant ED), Staff 2 (MC1 Administrator), Staff 5 (LPN), and Staff 25 (RN) on 03/21/24. They acknowledged the findings.

2. Resident 6 moved into the facility in 08/2023 with diagnoses including dementia with behaviors.

The resident's 02/01/24 through 03/20/24 MARs and current signed orders dated 01/22/24 were reviewed and identified the following PRN bowel medications lacked parameters regarding the sequence of use:

* Bisacodyl 10 mg suppository; and

* Milk of Magnesia.

During an interview with Staff 15 (MT) on 03/21/24 at 10:22 am, it was confirmed there was no documented evidence parameters instructing unlicensed staff on which order to administer the PRN bowel medications.

The need to ensure MARs included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Assistant ED) and Staff 5 (LPN) on 03/21/24. They acknowledged the findings.

1) Staff will be in-serviced on medication administration, documentation, and communication related to orderings needing clarified by PCP. Resident 6 andf 7 Bowel Movement monitoring and medication list will be sent to PCP for review and clarifcication related to PRN medications for bowel movements to include resident-specific parameters.

2) PRN medications will be audited for parameters by the staff nurse. Weekly for 3 weeks then monthly thereafter. New prn medication orders will be reviewed following three way check processes.

3) New orders will be reviewed at clinical weekly for 6 weeks.

4) Executive Director and DHW and/or designee responsible.  

Based on interview and record review, it was determined the facility failed to ensure PRN medications given to treat a resident's behavior had written, resident-specific parameters and were used only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#2) who had PRN psychotropic medications prescribed. Findings include, but are not limited to:

Resident 2 was admitted to the facility with diagnoses including dementia.

Review of the resident's 09/01/23 through 10/09/23 MAR revealed the resident had a prescription for lorazepam, .5 mg tab, one tablet by mouth every six hours as needed for anxiety or agitation. There was no documented evidence of resident-specific parameters that directed staff as to how the resident demonstrated anxiety or agitation.

The MAR included two non-pharmacological interventions but did not instruct staff to attempt prior to administering the medication. Staff administered the medication on 09/07/23 and 09/18/23. There was no documented evidence staff attempted non-pharmacological interventions with ineffective results prior to administering the medication.

The need to ensure resident-specific parameters and documented evidence that non-pharmacological interventions were attempted and ineffective prior to administering PRN psychotropic medications was discussed with Staff 1 (MC2 RCC) at 1:30 pm on 10/11/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure an administrator was scheduled to be on site in the facility at least 40 hours per week. Findings include, but are not limited to:

Survey entered the facility on 10/09/23 at 9:00 am and requested to speak with the administrator. Staff 16 (MC LLD) reported the administrator was not in the facility. When asked who was in charge in the administrator's absence, she stated she was not sure. Staff 5 (Staff RN/LPN), who was also present at the time of survey entrance, stated the facility administrator on record "no longer work[ed for the company]."

A tour of the facility on 10/09/23 revealed there was no sign posted with the name of the administrator or designee in charge.

During an interview on 10/10/23 at 1:00 pm, Staff 1 (MC2 RCC) confirmed there was no full time administrator for the facility.

The need to have an administrator on-site in the facility at least 40 hours per week was discussed with Staff 1 on 10/11/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that addressed all the following activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care. Findings include, but are not limited to:

1. The facility's ABST was reviewed on 10/11/23 at 9:00 am and discussed with Staff 1 (MC2 RCC) Staff 2 (MC1 Administrator), Staff 18 (Staff Nurse), and Staff 19 (Vice President of Health and Wellness.

a. Staff could not confirm all 22 required ADLs contributed to the generated minutes used to create a staffing plan.

b. The documents provided for all 17 residents lacked evidence the ABST addressed all 22 required ADLs for each resident.

2. ABST data was reviewed for Residents 1, 2, and 3.

a. Data for Resident 1 included only 13 of the required 22 ADLs. Data for Resident 2 included only 15 of the 22 required ADLs. Data for Resident 3 included only 10 of the 22 required ADLs.

b. Resident 1 had zero minutes added for monthly vitals checks; however review of the 09/01/23 through 10/09/23 MAR indicated staff were to measure vital signs monthly. Resident 2 had zero minutes added for monthly vitals checks; however review of the 09/01/23 through 10/09/23 MAR indicated staff were to perform temperature checks three times daily. Resident 3 had zero minutes added for laundry services, to be completed once a week. Interviews and observations made during the survey revealed caregivers were universal workers and provided laundry services to residents.

The need to have all required ADLs on the ABST with the amount of staff time needed to provide care and to ensure service plans were reflective so the ABST would be accurate was discussed with Staff 1 on 10/11/23 at 2:00 pm. She acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure 4 of 4 sampled newly hired direct care staff (#s 6, 7, 14 and 15) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/11/23. The following deficiencies were identified:

Staff 6 (CG), Staff 7 (CG), Staff 14 (CG) and Staff 15 (MT), hired on 04/14/23, 03/02/23, 08/31/23, and 07/21/23 respectively, did not have documented evidence first aid and abdominal thrust training had been completed within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings. No other information was provided prior to survey exit.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled newly hired direct care staff (# 13) completed first aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 03/21/24. The following deficiencies were identified:

Staff 13 (CG) was hired on 02/15/23 and did not have documented evidence first aid and abdominal thrust training had been completed within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Assistant ED), Staff 5 (LPN), Staff 19 (Vice President of Health and Wellness), Staff 24 (ED), and Staff 25 (RN) on 03/21/24. They acknowledged the findings.

1) Employes hired in the last 6 months personal file will be audited for completed of on boarding documentation per policy and OAR requirements. Staff 13's trainings will be completed by 5/5/2024

2) Employees whose files are not complete will be required to complete training and/or be suspended until the training is completed.

3) Audits will be conducted weekly for 8 weeks by Assistant Execuative Director.   

4) The Executive Director and/or designee responsible.  

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

Review of fire and life safety records from 04/2023 through 09/2023 and an interview with Staff 1 (MC2 RCC) on 10/11/23 revealed the facility lacked documentation of the following:

* Fire drills conducted and recorded every other month according to the Oregon Fire Code and documented required components.

On 10/11/23, the need to ensure the facility conducted fire drills every other month, and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1, Staff 2 (MC1 Administrator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills had documentation of all required components in accordance with the Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:

Review of fire and life safety records from 12/2023 through 03/2024 and an interview with Staff 1 (Assistant ED) on 03/21/24 revealed the facility lacked documentation of the following required components on the 01/31/24 fire drill:

* Location of simulated fire origin;

* Escape route used;

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

* Evacuation time period needed; and  

* Number of occupants evacuated.

Due to the escape route not being documented, there was no evidence if alternate exit routes were being used during fire drills to react to varying potential fire origin points.

Additionally, there was no documented evidence if any residents resisted or failed to participate in the drill, so it could not be determined if the facility ensured efforts were made for meeting the evacuation standard.  

The need to ensure fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1. She acknowledged the findings.

1) Fire Drills and disaster drills will be completed per OAR's.

2) The Maintenance Director and Administrator will be inserviced of Fire Drills per OAR/OFC by Executive Director. Implementation of consultant fire drill report fillable form.

3) Documentation of fire drills including but not limited to (the escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, the number of occupants evacuated, evacuation time period.) Disaster drills will be reviewed monthly during administrator and maintence 1:1 weekly meeting.

4)Maintenance Director, Administrator, and/or Designee.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and had documentation of all required components. This is a repeat citation. Findings include, but are not limited to:

Review of fire and life safety records from 05/05/2024 through 08/28/24 and an interview with Staff 24 (Executive Director) revealed the facility completed two fire drills, 06/20/24 and 07/24/24 respectively. The drills lacked documentation of one or more of the following required components:

* Evacuation time period needed; and  

* Number of occupants evacuated.

During an interview on 08/28/24, Staff 24 (Executive Director) acknowledged the facility had not completed a fire drill which ensured the evacuation standard was met. Based on facility documentation, the fire drill on 07/24/24 occurred with the simulated fire located in an office behind a fire door which was inaccessible to residents and therefore residents were not moved to a point of safety.

During interviews on 08/28/24, staff were unable to identify the designated point of safety.

The need to ensure fire drills were conducted according to the OFC and documentation included required components was reviewed with Staff 5 (Staff Nurse, LPN), Staff 24 and Staff 25 (Director of Health and Wellness, RN) at 10:00 am on 08/28/24. They acknowledged the findings, and no additional information was provided.

1) Regional Director of maintenance will in-service the Maintenaince staff on evacuation time period and the number of occupants evacuated.

2) Regional Director of Maintenance will in-service staff on required components stated in the OFC. Regional Director of Maintenance will complete pre-fire drill with Maintenance team.

3) Monthly.

4) Regional Director of Maintenance, Executive Director, and/or designee.   

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed during the survey, and the following deficiencies were identified:

* Documentation of instruction to residents on general safety procedures, evacuation methods, responsibilities during the fire and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings. No additional information was provided.

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

Refer to C 252, C 260, C 270, C 310, C 372, C 420, C 513, C 545, Z 142, Z 155, Z 162, and Z 164.

Refer to C 252, C 260, C 270, C 310, C

372, C 420, C 513, C 545, Z 142, Z 155,

Z 162, and Z 164.

Based on observation, interview, and record review, it was determined the facility failed to ensure their plan of correction from the first revisit to their change of ownership survey was approved and satisfied the Department. This is a repeat citation. Findings include but are not limited to:

Refer to C231, C270, and C420.

Refer to C231, C270, and C420.

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

The building was toured on 10/09/23 at 10:30 am and the following was observed:

* The carpet throughout the facility and resident rooms had large stained areas and was torn in the main hallway;

* There was dust build-up on the air conditioner grills and dirt, dust, and garbage in the air conditioner vents in all resident rooms;

* There were five overhead lights with burned out lightbulbs in the living room;

* Three windows along the hallway walls on either side of the courtyard were in poor repair, unable to be closed, and covered in dirt, dust, and dead bugs;

* The linoleum floor in the activity room had multiple scrapes and scratches;

* The chairs and sofa in the activity room had large stains on the seat cushions, arms, and sides;

* One chair in the activity room had a four-inch tear in the seat;

* The dining room tables had peeled and worn laminate tops rendering them uncleanable;

* There was a pervasive odor in Room 410 that did not dissipate during the survey;

* The shower curtain in Room 410 had foul-smelling brown smears;

* The toilets in Rooms 405 and 414 had brown smears on the seat and base;

* The bathroom door in Room 412 had a large gouge on the bottom corner; and

* The light fixture in the bathroom of Room 414 had five light bulbs burned out.

The need to ensure the building was maintained in clean and good repair was discussed with Staff 1 (MC2 RCC) on 10/11/23 at 2:00 pm. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to:

The building was toured on 03/20/24 at 10:02 am with Staff 1 (Assistant ED).

The following was observed:

* The carpet had a stained area down the hallway where the main entry was located;

* The carpet was frayed in two places in the living room and outside of the medication room;

* The linoleum floor in the activity room had multiple scrapes and scratches;

* The dining room tables had peeled and worn laminate tops rendering them uncleanable; and

* The exterior ramp leading up to the facility's front door had damaged and rotting wood with rusted nails protruding out of the wood.  

The need to ensure the building was maintained in clean and good repair was discussed with Staff 1 and Staff 2 (MC1 Administrator). They acknowledged the findings.

1) This POC has approval to extend the 513 tag for compliance until completion of remodel per Jeanne Bristol

2) Community is undergoing remodal. This will include replacement of of carpet, new linoleum floor, new dining table. exterior ramp will have wood and nails

3) Executive Director and Maintenance Director will review weekly during 1:1 meeting.

4) Executive Director and Maintenance Director and/or designee.

Based on observation and interview, it was determined the facility failed to ensure separate handling of soiled linens and soiled clothing and a minimum rinse temperature of 140 degrees Fahrenheit or use of a chemical disinfectant when washing soiled linens and clothing. Findings include, but are not limited to:

The soiled laundry room was toured on 10/10/23 at 2:00 pm. Observation revealed there was no gauge on the washing machine to ensure a minimum rinse temperature of 140 degrees Fahrenheit. The laundry detergent observed in the soiled linen room did not appear to contain a disinfectant.

During an interview on 10/10/23 at 2:45 pm, Staff 17 (Laundry Aide) confirmed the laundry detergent did not have a chemical disinfectant. She stated caregiving staff or the facility housekeeper were supposed to notify her when the facility was out of bleach pods for soiled linens.

During an interview on 10/11/23 at 11:00 am, Staff 12 (CG) stated the facility had not been using bleach pods for soiled linens for "at least two weeks."

Staff 8 (CG) and Staff 12 (CG) both stated during interviews they only used the soiled linen room for clothing and bedding soiled with solid waste. They stated clothing or bedding soiled with blood or urine were washed with the rest of the non-soiled laundry. Staff 12 stated if clothing or bedding was "really bad," staff would rinse the items in the residents' showers.

The need to ensure all soiled linen and clothing were handled and washed separately and a chemical disinfectant was used unless the washer had a minimum rinse temperature of 140 degrees Fahrenheit was discussed with Staff 1 (MC2 RCC) on 10/11/23 at 1:00 pm. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

On 10/09/23 at 11:30 am, water temperatures measured in Rooms 409 and 410 were 97 and 100 degrees Fahrenheit, respectively.

The building was toured with Staff 3 (Maintenance Director) on 10/10/23 at 11:00 am. He stated he would increase the water temperature and recheck the following day.

Water temperatures in Rooms 409 and 410 were rechecked with two surveyor thermometers on 10/11/23 at 8:30 am and the readings had not changed.

The need to ensure water temperatures were monitored and maintained within a range of 110 - 120 degrees Fahrenheit was discussed with Staff 1 (MC2 RCC). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit (F). This is a repeat citation. Findings include, but are not limited to:

On 03/20/24 at 10:02 am, the building was toured with Staff 1 (Assistant ED).

Water temperatures were measured in the following units:

* 401 - The water at the sink was at 102.9 and the water in the shower was at 105 degrees F;

* 411 - The water at the sink was at 96.4 degrees F; and

* 419 - The water at the sink was at 122.5 degrees F.

The need to ensure water temperatures were maintained within a range of 110 - 120 degrees Fahrenheit was discussed with Staff 1. She acknowledged the findings.

1) Mixing valve was replaced to regulate temperatures between 110 to 120 degrees fahrenheit. Recirculating pump has been ordered to make the temperature consistent throughout the community.

2) Recirculating pump will be installed upon arrival. Water temperatures will be monitored to verify temperatures are within 110-120 degrees fahrenheit.

3) Water temperatures will be monitored weekly for 6 weeks and then monthly thereafter.

4) Maintenance Director, Administrator, and/or Designee.

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

Refer to C 152, C 155, C 240, C 295, C 350, C 361, C 372, C 420, C 422, C 513, C530, and C 545.

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 231, C 372, C 420, C 513, and C 545.

Refer to C 231, C 372, C 420, C 513,

and C 545.

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 C231 and C420.

Refer to C231 and C420.

Based on interview and record review, it was determined the facility failed to ensure documented evidence all pre-service orientation and pre-service dementia training was completed prior to beginning job duties, competency demonstration was completed within 30 days of hire for 4 of 4 newly hired staff  (#s 6, 7, 14, and 15), and 16 hours of annual in-service, including six hours of dementia care training was completed for 1 of 1 long-term staff (#9) whose training records were reviewed. Findings include, but are not limited to:

On 10/11/23 training records were reviewed with Staff 1 (MC2 RCC). The following deficiencies were identified:  

1. Staff 6 (CG), Staff 7 (CG), Staff 14 (CG) and Staff 15 (MT), hired on 04/14/23, 03/02/23, 08/31/23 and 07/21/23 respectively, lacked documented evidence pre-service orientation and pre-service dementia training had been completed in the following required areas prior to providing care and services independently.

a. Staff 6 lacked documentation in the following areas:

* Abuse reporting requirements;

* Fire safety and emergency procedures;

* Food handler's certificate;

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

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

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

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

* Environmental factors that are important to a resident's well-being;

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

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

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

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

b. Staff 7 lacked documentation in the following areas:

* Abuse reporting requirements;

* Fire safety and emergency procedures;

* Food handler's certificate;

* A written job description;

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

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

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

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

c. Staff 14 lacked documentation in the following areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures;

* Food handler's certificate;

* A written job description;

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

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

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

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

d. Staff 15 lacked documentation in the following areas:

* Abuse reporting requirements;

* Fire safety and emergency procedures;

* Food handler's certificate; and

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

2. The facility lacked documented evidence of competency demonstration within 30 days of hire in the following required areas.

a. Staff 6 lacked documentation in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

b. Staff 7 lacked documentation in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

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

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

* General food safety, serving, and sanitation.

c. Staff 14 lacked documentation in the following areas:

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

d. Staff 15 lacked documentation in the following areas:

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

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

3. Staff 9 (MC MT), hired on 01/09/20, did not have documented evidence of completing the required minimum of 16 hours of in-service training annually, based on anniversary date of hire, on topics related to the provision of care for persons in a CBC, including required annual infectious disease training and training on chronic diseases in the facility population with six of the 16 hours being dementia care topics.

The need to ensure newly-hired staff completed all required training prior to beginning their job duties, documented methods to determine competency of direct care staff, and on-going required 16 hours of annual training including infectious disease training and six hours related to dementia care training was reviewed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documented evidence all pre-service orientation and pre-service dementia training was completed prior to beginning job duties, and competency demonstration was completed within 30 days of hire for 2 of 2 newly hired staff (#s 13 and 20) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 03/21/24. The following deficiencies were identified:

1. Staff 13 (CG) and Staff 20 (CG), hired 02/15/23 and 11/15/23 respectively, lacked documented evidence pre-service orientation and pre-service dementia training had been completed in the required areas prior to providing care and services independently.

a. Staff 13 lacked documentation in the following areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

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

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

2. The facility lacked documented evidence of competency demonstration within 30 days of hire in the following required areas:

a. Staff 13 lacked documentation in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

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

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

b. Staff 20 lacked documentation in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

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

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

The need to ensure newly-hired staff completed all required training prior to beginning their job duties and documented methods to determine competency of direct care staff was reviewed with Staff 1 (Assistant ED), Staff 5 (LPN), Staff 19 (Vice President of Health and Wellness), Staff 24 (ED), and Staff 25 (RN) on 03/21/24. They acknowledged the findings.

1) Staff 13 and 20 will complete required training elements per the OAR

2) Administrator will complete and audit of training requirments of new hires prior to providing direct care

3) Administrator will review new hire checklist and training completion prior to providing direct care.

4) Administrator and or designee.  

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

Refer to C 252, C 260, C 270, C 280, C 300, C 303, C 310 and C 330.

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

Refer to C 252, C 260, C 270, and C 310.

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

310.

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

Refer to C270.

Refer to C270.

Based on observation, interview, and record review, it was determined the facility failed to evaluate each resident for activities and develop an individualized activity plan for each resident based on the activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose activity 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. All residents were diagnosed with some type of dementia.

The activity section of Resident 1 and 2's current service plans were reviewed. Though there was some information about each resident's past or current interests, the facility had not fully evaluated the residents':

* 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 individualized activities. There were no instructions for providing activities for residents who did not participate in group activities.

During an interview on 10/10/23 at 2:40 pm, Staff 16 (MC LLD) confirmed she did not evaluate the residents' individual activities status and was not part of the service planning team to develop individualized activity service plans.

The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (MC2 RCC) and Staff 2 (MC1 Administrator) on 10/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate each resident for activities and develop an individualized activity plan for each resident based on the activity evaluation for 3 of 3 sampled residents (#s 6, 7 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

The activity section of Residents 6, 7 and 8's current service plans were reviewed. Though there was some information about each resident's past or current interests, the facility had not fully evaluated the residents:

* 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 individualized activities. There were no instructions for providing activities for residents who did not participate in group activities.

The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (Assistant ED), Staff 5 (LPN), Staff 16 (Activities Director), Staff 19 (Vice President of Health and Wellness), Staff 24 (ED) and Staff 25 (RN) on 03/21/24. They acknowledged the findings.

1) All residents will have an activity evaluation conducted at move in. And updated as needed to reflect likes and wants specific to resident.

2) Acitvity Support will meet with newly admitted residents and family to obtain information on likes, intrest, hobbies and previous activties engaged in.

3) On admission, 30 days, quarterly.

4) Administrator designee,Activity support persons to be trained to accuratley collect data and report data.