The findings of the re-licensure survey, conducted 11/14/22 through 11/17/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 first re-visit to the re-licensure survey of 11/17/22, conducted 05/23/23 through 05/24/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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 second revisit to the re-licensure survey of 11/17/22, conducted 08/28/23 through 08/29/23, 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 maintain the kitchen and kitchenette in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

1. Observation of the Main kitchen in the Assisted Living on 11/14/22 at 9:30 am revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Pipes, walls, gauges, disposal, drain and flooring behind/underneath the dish machine;

* Flour, powdered sugar and cornstarch bins;

* Spice shelves;

* Juice dispenser;

* Kitchen drains;

* Electrical outlets and light switches;

* Trash cans;

* Pipes and flooring underneath the three compartment sink;

* Interior and exterior of cabinets and drawers;

* Ceiling fire sprinklers;

* Walls above/adjacent to stove/grill and steamer;

* Cabinets under the steamtable;

* Stainless steel cart with plastic drawers with utensils;

* Toaster;

* Walk-in refrigerator door and shelves:

* Freezer floor;

* Interior and exterior of microwave;

* Walls throughout kitchen area;

* Stove/grill knobs, doors, interior, exposed piping and vents;

* Flooring underneath stove/grill and throughout;

* Wall behind hand wash sink and the sink;

* Rolling carts;

* Two radios;

* Bugs in the light fixtures;

* Open shelving throughout kitchen;

* Interior and exterior of walk-in refrigerator and freezer;

* Industrial mixer and slicer;

* The top of the dish machine had an accumulation of food matter; and

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges.

b. The following areas were in need of repair:

* Several cabinet doors had exposed wood corners and edges;

* The hand washing sink had black matter in the caulking; and

* Entry doors and jambs were scraped, gouged and had peeling paint.

c. Staff 7 (Cook) was asked about chemical sanitizer test strips. She was unable to locate test strips and could not explain how to use them.

d. Staff 10 (Dietary Aid) was observed cleaning off dirty dishes and touching clean dishes without washing her hands.

e. A non kitchen staff person was observed to enter the kitchen without a hair restraint and did not wash her hands. She proceed to grab a cart and exited out the side door while food was being prepared.

f. The kitchen did not have pasteurized eggs available for the residents who received soft-cooked eggs.

g. The walk-in refrigerator had a half cut tomato, onion, and jello uncovered.

h. There was a dented can in the dry storage, cup in the rice bin, and a spoon in the bag of brown sugar.

i. Clean glassware were stored on towels that were visibly dirty.

At 10:24 am, the Surveyors and Staff 1 (Executive Director) toured the kitchen. Staff 1 acknowledged the above areas needed to be cleaned and repaired. Staff 1 further indicated she would have staff clean the kitchen right away.

2. Observation of the Memory Care kitchenette on 11/14/22 at approximately 10:30 am revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter was visible on or top of the following:

* Walls;

* Cabinet fronts and inside;

* Microwave;

* Window sill;

* Heating/cooling device; and

* Top of the refrigerator.

b. The following areas were in need of repair:

* Laminate counter tops;

* Cabinets;

* Hole in the wall;

* The entrance half door jam had gouges exposing the wood underneath;

* The window sill had gouges, paint peeling off exposing the wound underneath, and

* The cabinet under the sink had a build-up of black matter and exposed particle board.

c. The upright refrigerator was found to be at 57 Degrees Fahrenheit. The food was removed to the main kitchen to be stored at the proper temperature.

At 11:17 am, the Surveyors and Staff 1 (Executive Director) toured the kitchenette. Staff 1 acknowledged the above areas needed to be cleaned and repaired.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the facility main kitchen on 05/23/23 at 9:15 am revealed the following:

An accumulation of food spills, splatters, debris, black matter, and grease was visible on or underneath the following:

* Bulk food bins in dry storage;

* Spice shelves;

* Food processor and blender;

* Kitchen drains;

* Trash cans;

* Interior and exterior of cabinets and drawers;

* Walls above/adjacent to stove/grill and steamer;

* Cabinets under the steam table

* Walk-in refrigerator shelves;

* Food thermometers;

* Clear plastic bin holding clean utensils;

* Refrigerator and freezer floors;

* Interior and exterior of microwave;

* Walls throughout kitchen area;

* Stove/grill knobs, doors, interior, exposed piping and vents;

* Flooring underneath stove/grill and throughout;

* Wall behind hand wash sink and the sink;

* Rolling carts;

* Plastic storage unit with drawers;

* Open shelving throughout kitchen;

* Metal rack shelving;

* Industrial mixer and slicer;

* The top of the dish machine had an accumulation of food matter; and

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges.

* A plate of butter, a potentially hazardous food, was observed left out from 9:15 am until 1:30 pm, in excess of four hours.

* Beef was left in the sink to thaw in a bin of standing water.

* Yellow squash were stored in the refrigerator in a bin with thawed bloody beef.

* Food was stored on the floor in the walk in refrigerator and freezer.

* Open cabinets below the tray line had exposed wood corners and edges.

* Dish machine racks were stored directly on the floor.

* The auto-dispensed sanitizer was not reaching the required ratio.

* There was no documented evidence of monitoring of the sanitizer ratios, dish sanitizer temperatures, and refrigerator temperatures.

* There was no small probe thermometer available to measure the temperature of thin foods.

* Dietary staff were not changing gloves between tasks during meal plating and service.

* The kitchen did not have in the shell pasteurized eggs available for the residents who received soft-cooked eggs.

* Multiple food items in walk-in refrigerator were unlabeled, undated, and uncovered.

At 10:45 am, the surveyor, Staff 1 (ED), and Staff 19 (Executive Chef) toured the kitchen. They acknowledged the above areas needed to be cleaned and repaired.

Observation of the Memory Care kitchenette with Staff 1 revealed the following areas in need of cleaning and repair:

* Laminate counter tops damaged creating un-cleanable surfaces;

* The window sill had gouges, paint peeling off exposing the wood underneath, and

* The cabinet under the sink had a build-up of black matter.

There was no thermometer in the reach-in refrigerator. A thermometer was placed, and the refrigerator was at the appropriate temperature.

Staff 1 acknowledged the areas in need of cleaning and repair and the need for a thermometer in the refrigerator.

* During lunch preparation and service, staff were observed to not change gloves between tasks.

The observation of poor hand hygiene was reviewed with Staff 1. She acknowledge the findings.

Deep cleaning of the kitchen has been done.

A zone cleaning check list is now in place. Zones will be cleaned twice weekly.

Stickers will be ordered to make dating and labeling easier.

Cheat sheet for fridge storage will be posted outside of the fridge door.

We will be adding all applicances and rolling carts to the zone cleaning list

Fridge shelfing will be taken outside and scrubbed as needed.

Executive Chef will oversee and make sure zone cleaning gets done daily.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, for 1 of 1 sampled resident (#3) and failed to ensure quarterly evaluations were reflective of the residents' health status for 1 of 2 sampled residents (#2) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility on 09/23/22.

The initial evaluation failed to address the following required elements with sufficient information to develop an initial service plan:

*Current diagnoses;

*List of medications and PRN use;

*Cognition: Memory, orientation, confusion, and decision making;

*Dressing;

*Grooming;

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

*Elopement history or risk.

On 11/17/22, the need to ensure the initial evaluation addressed all required elements prior to the resident's admission was reviewed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2021.  

Observations, interviews, and review of Resident 2's clinical records, revealed the quarterly evaluation, dated 10/11/22, was not reflective of Resident 2's health status in the following areas:

*Falls and fall history; and

*Skin.

On 11/17/22, the need to ensure evaluations reflected residents' current status was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

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

Resident 4 moved into the facility in 04/2023.

The initial move-in evaluation failed to address the following required elements:

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

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

* Fall history;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements; and

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

The need to address all required elements on the move-in evaluation was discussed with Staff 3 (Business Office Manager/Administrator) on 05/24/23. Staff acknowledged the findings.

Retraining done on how to complete an initial assessment on paper.

RN/MCD/ED to ensure completion of intial assessment prior to move in.

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

1. Resident 2 was admitted to the facility in 03/2021 with diagnoses including cognitive dysfunction.

Current service plans and quarterly resident evaluations were reviewed, observations were made, and staff were interviewed. The resident service plan was not being followed, reflective of the resident current status and/or failed to provide clear direction to staff in the following areas:

*Geri Chair;

*Gait belt;

*Meal assistance;

*Hospice services being provided;

*Falls and fall history; and

*Barrier cream.

On 11/17/22, the need to ensure service plans were being followed, provided clear direction to staff, and were reflective of resident needs was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2021 with diagnoses including dementia.                           

Current service plans and quarterly resident evaluations were reviewed, observations were made, and staff were interviewed. The resident service plan was not reflective of the resident current status and/or failed to provide clear direction to staff in the following areas:

*Falls and fall history; and

*Side rail use.

On 11/17/22, the need to ensure service plans were provided clear direction to staff, and were reflective of resident needs was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear caregiving instructions, and were implemented for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2023 with diagnoses including dementia and was receiving hospice services.

Resident 4 was observed using a wheelchair with footrests in place on all days of the survey. Resident 4 attempted to stand throughout the day, placing feet on the floor between or around the footrests.

Resident 4 had a hospital bed with bilateral side rails and an alternating pressure air mattress in operation. A fall mat was observed under the bed.

During lunch on 05/23/23, Resident 4 was served a lunch with a protein patty that was not cut up. Resident 4 was not able to cut the food independently.  

In interviews with care staff, they explained Resident 4:

*Required assistance with all care; and

*Frequently fell and attempted to get up forgetting limitations.

Resident 4's service plan, dated 04/28/23, did not provide direction to staff for:

* The use of side rails;

* The use of an alternating pressure mattress;

* The use of a fall mat; and

* The use of wheelchair footrests.

The service plan had instructions for staff to cut up food into bite sized pieces.

The need to ensure service plans provided clear direction to staff and were implemented was reviewed with Staff 1 (ED) and Staff 3 (Business Office Manager/Administrator) on 05/23/23. They acknowledged the findings.

2.  Resident 5 was admitted to the facility in 06/2021 with diagnoses including dementia and was receiving hospice services.

Resident 5 was observed in a hospital bed with bilateral side rails in the up position on all days of the survey.

An alternating pressure air mattress was in operation. A personal alarm was in place under a pillow beneath the resident's feet.

During lunch on 05/23/23, Resident 5 was served a lunch with a pork chop that was not cut up. Resident 5 was not able to cut the food independently.  

In interviews with staff, they explained Resident 5:

* Required assistance with all care;

* Spent most time in bed supported and padded with pillows; and

* A personal alarm was used to alert staff when the resident became restless and may want to get out of bed.

Resident 5's service plan, dated 05/05/23, did not provide direction to staff for:

* The use of side rails;

* The use of an alternating pressure mattress; and

* The use of a personal alarm.

The service plan had instructions for staff to cut up food into bite sized pieces.

The need to ensure service plans provided clear direction to staff and were implemented was reviewed with Staff 1 (ED) and Staff 3 (Business Office Manager/Administrator) on 05/23/23. They acknowledged the findings.

ISP in place to remove foot rests from resident 4 wheelchair so she can self propel instead of trying to stand around foot rests.

Resident 4 & 5 have ISP's in place for the pressure air mattress that give staff instruction on what level it needs to be set at and what to look for.

HSD to ensure paper assessment for restraining qualities is available to staff as well as placed in the next conducted service plan.

HSD to complete restraining qualities assessment prior to device being implamented.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed.  Findings include, but are not limited to:

Residents 1, 2, and 3's most recent service plans lacked documentation of a service planning team that consisted of the resident, the resident's legal representative, if applicable, or any person of the resident's choice.

On 11/17/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and the condition was monitored to resolution at least weekly for 2 of 2 sampled residents (#s 1 and 2) who were reviewed for changes of condition. Resident 1 experienced ongoing falls resulting in a fall with injury. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2021 with diagnoses including dementia.

Record review indicated the resident experienced multiple falls as follows:

*On 09/06/22, the resident was found on the floor and reported to staff s/he fell while trying to transfer to the commode. The resident reported experiencing pain in both knees, back, and right hip. Intervention to implement was to remind resident to pull their call light and wait for staff to help.

*The service plan, dated 10/03/22, described the resident as high fall risk and having multiple falls since their last evaluation. The service plan indicated staff were to remind the resident to use their call light for assistance with transfers. The service plan also indicated that the resident struggled with poor safety awareness and often tried to transfer themselves and forgot to use the pull cord for assistance with transfers. There were no other resident specific interventions to minimize further occurrences of a fall.  

*On 10/25/22, the resident was found on the floor yelling for help from falling out of their chair. The resident reported experiencing pain in his/her lower back. The resident was sent out to the hospital and diagnosed with a fractured left rib. There was no documented evidence the resident's status was evaluated after hospital visit or referred to the facility nurse.

*On 10/26/22, the resident was found on the floor during a med pass. An interim service plan indicated the resident was to be placed on 30-minute safety checks and monitoring. There was no documented evidence of the 30-minute safety checks.

On 11/15/22, observations of the resident indicated the facility was not consistently conducting 30 minute checks on the resident.

There was no documentation to show ongoing evaluation of existing interventions, determination and implementation of any new interventions and monitoring of those interventions for effectiveness.

Resident 1 had repeated falls with and without injury, including a left rib fracture, without an evaluation, monitoring and interventions by the facility to minimize further injuries and falls.

On 11/17/22, the need to ensure changes of condition had clear, resident-specific interventions was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2021.

Resident 2's clinical record and charting notes, reviewed from 08/15/22 through 11/14/22, revealed the facility initiated alert monitoring on 10/04/22 for a blister found on the resident's inner left thigh. The resident was placed on alert charting. However, no monitoring until resolution was documented for the change in condition.

On 11/17/22, the need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved for 2 of 2 sampled residents (#s 4 and 5). This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted in 04/2023 with diagnoses including dementia and a recent hip fracture.

Resident 4 was observed with facial bruising and skin tears and wound dressings to the forearms.

Resident 4's clinical record and charting notes, reviewed from 04/18/23 through 05/23/23, revealed the following:

* On 04/15/23, Resident 4 fell and hit his/her head and was sent to the emergency department.

* On 04/18/23, Resident 4 fell and sustained a "goose egg" and a skin tear to the left hand.

* On 04/20/23 Resident 4 fell and hit his/her head and was sent to the emergency department.

* On 04/23/23, a skin tear was identified on Resident 4's left hand.

* On 04/24/23, Resident 4 fell and sustained a skin tear to the left elbow.

The facility initiated short-term monitoring for the incidents and implemented interventions. However, no monitoring until resolution was documented for the short-term changes in condition.

During an interview on 05/24/23, Staff 2 (RN) and Staff 3 (Business Office Manager/Administrator) reviewed the resident's record and acknowledged the lack of documented resolution for injuries.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (ED) and Staff 3 (Business Office Manager/Administrator) 05/24/23. They acknowledged the findings.

2. Resident 5 was admitted in 06/2021 with diagnoses which included dementia. Resident 5 was identified to have very fragile skin and was receiving hospice services.

Resident 5 was observed to have a wound dressing to the left elbow.

Resident 5's clinical record and narrative charting notes, reviewed from 02/22/23 through 05/23/23, revealed the following:

* On 03/23/23, a skin tear was discovered on Resident 5's right leg.

* On 04/04/23, a skin tear was discovered on Resident 5's right arm.

* On 04/28/23, a blister was discovered on Resident 5's right thigh.

* On 05/07/23, a skin tear was discovered on Resident 5's left arm.

The injuries were investigated and abuse was reasonably ruled out.

The facility initiated short-term monitoring for the injuries and implemented interventions. However, no monitoring until resolution was documented for the short-term changes in condition.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) Staff 2 (RN), and Staff 3 (Business Office Manager/Administrator) on 05/24/23. They acknowledged the findings.

Resident 4 and 5

RN implamented a wound documentation paper which is kept in a wound binder to see short term COC to resolution. RN also is now making a chart note of resolution at the end of the alert charting.

HSD to oversee weekly short term COC to resolution.

Based on observation, interview and record review, it was determined the facility failed to ensure  1 of 1 sampled resident (#1) who experienced a significant change of condition was assessed by the RN. Findings include but are not limited to:

Resident 1 was admitted to the facility in 05/2021 with diagnoses including dementia.

A review of progress notes indicated the resident was sent to the emergency room on 10/25/22 after experiencing a fall. S/he returned with a diagnosis of a fractured left rib on 10/25/22. The new diagnosis of a fractured rib represented a significant change of condition for the resident. There was no documented evidence an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment.

Staff 15 (MT), in an interview on 11/15/22, indicated the resident had needed more assistance with transfers and other ADL's since experiencing a fall with injury on 10/25/22.

On 11/17/22, the need to conduct an RN assessment following a significant change in condition was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

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

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

During the acuity interview on 11/14/22, Resident 1 was identified to be administered insulin injections by non-licensed staff.

Resident 1's MARs, reviewed from 11/01/22 - 11/16/22, revealed insulin had been given by Staff 14 and 15 (MTs) on multiple occasions.

Review of Resident 1's delegation documentation on 11/15/22 revealed the following:

a. The re-delegation for Staff 15 (MT), completed by Staff 2 (RN) on 06/20/22, revealed:

* No RN assessment of the condition of the resident had been completed when the re-delegation occurred; and

* Staff 2 indicated Staff 15 would be re-delegated within 90 days. As of the survey, no re-delegation had occurred.

b. There was no documented delegation completed for Staff 14.

In an interview on 11/15/22 at 3:40 pm, Staff 2 (RN) acknowledged the delegation for Staff 15 was incomplete, and she had not documented the delegation for Staff 14. Staff 2 stated Staff 14 would not give insulin until the delegation had been completed.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Executive Director) on 11/16/22. She acknowledged the findings.

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

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

During the acuity interview on 05/23/23, Resident 1 was identified to be administered sliding scale insulin injections based on blood sugar readings done by non-licensed staff.

Resident 1's MARs, reviewed from 05/01/23 - 05/23/23, revealed blood sugar level checks and insulin injections had been done by Staff 18 (MCC Administrator in training), 20 and 22 (MTs) on several occasions.

Review of delegation documentation on 05/24/23 revealed the following:

a. The initial delegation for Staff 18 dated 03/07/23 lacked:

* RN assessment of the condition of the resident to determine stability and predictability, and rationale for frequency of reassessment; and

* Frequency and rationale for how often the unlicensed person should be supervised and reevaluated based on the competency of Staff 18.

b. The initial delegation for Staff 20, completed on 02/03/23, lacked:

* RN assessment of the condition of the resident to determine stability and predictability, and rational for frequency of reassessment; and

* Frequency and rationale for how often the unlicensed person should be supervised and reevaluated based on the competency of Staff 20.

Re-delegation of Staff 20, completed 03/05/23, lacked:

* RN assessment of the condition of the client to determine it remains stable and predictable;

* Individual observation/return demonstration of competence of Staff 20 to determine they remained capable and willing to safely perform task; and

*Frequency and rationale for how often the unlicensed person should be supervised and reevaluated based on the competency of Staff 20.

c. The initial delegation for Staff 22, completed on 02/11/23, lacked:

* RN assessment of the condition of the resident to determine stability and predictability, and rationale for frequency of reassessment; and

* Frequency and rationale for how often the unlicensed person should be supervised and reevaluated based on the competency of Staff 22.

Re-delegation of Staff 22, completed 03/05/23, lacked:

* RN assessment of the condition of the client to determine it remains stable and predictable;

* Individual observation/return demonstration of competence of Staff 22 to determine they remained capable and willing to safely perform task; and

* Frequency and rationale for how often the unlicensed person should be supervised and reevaluated based on the competency of Staff 22.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 05/24/23 at approximately 10:15 am. She acknowledged the findings.

RN completed Roles of the RN class December 8, 2022.

RN will do her diabetic assessment on residents monthly.

Form for Justification for Delegation edited to add information missing to meet regulations.

Justification for Delegation to be done quarterly or PRN by RN

Based on observation and interview, it was determined the facility to consistently comply with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

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

Observations of staff during the survey revealed multiple instances of staff working with residents who failed to wear their mask properly by covering both their mouth and nose.

On 11/17/22, the need to ensure all staff were properly wearing a face mask was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the residents record for 2 of 2 sampled residents (#s 1 and 2) whose orders and MARs/TARs were reviewed. Findings include, but are not limited to:

On 11/14/22, survey requested copies of signed physician orders for all medications Resident's 1 and 2 were receiving. Staff 1 (ED) reported the facility did not have signed physician orders for all medications Resident's 1 and 2 were receiving and were working with the physicians to obtain new signed orders.

On 11/16/22, survey obtained signed physician for Resident 2, and survey obtained signed physician orders for Resident 1 on 11/17/22.

On 11/17/22, the need to ensure signed physician orders were documented in resident records for all medications and treatments being administered was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear medication specific instruction and resident specific parameters for administration of PRN medications for 2 of 2 sampled residents (#s 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2023 with diagnoses including dementia and was receiving hospice services for end of life care,

Resident 4's May 1st through 23rd MARs and current medication orders were reviewed.

Resident 4 had orders for:

* Acetaminophen 650 mg as needed for pain;

* Morphine sulfate 0.25 ml as needed for pain; and

* Oxycodone 5 mg as needed for pain.

Both the Morphine and Oxycodone were administered multiple times in May 2023.

There were no resident specific parameters or instructions directing non-licensed staff when to use which PRN medication and in which order.

The need to ensure MARs included clear directions for as needed medications to direct non-licensed staff for administration was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Business Office Manager/Administrator) on 05/24/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 06/2021 and was receiving hospice services for end of life care.

Resident 5's May 1st through 23rd MARs and current medication orders were reviewed.

Resident 5 had orders for:

* Lorazepam 0.5 mg as needed for anxiety or restlessness; and

* Haldol 1 mg as needed for agitation or restlessness.

The Lorazepam was administered multiple times in May 2023.

There were no resident specific parameters or instructions directing non-licensed staff when to use which PRN medication and in which order.

The need to ensure MARs included clear directions for as needed medications to direct non-licensed staff for administration was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Business Office Manager/Administrator) on 05/24/23. They acknowledged the findings.

Resident 4 and 5 now have specific PRN parameters for when to use and in which order

Weekly audit for discrepancies in parameters. Will go through MAR and make sure

PRN parameters are in place for all PRN meds that are resident specific.

HSD will audit weekly

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications included resident specific reasons for use and staff documented non-pharmacological interventions had been tried with ineffective results prior to administration, for 2 of 2 sampled residents (#s 4 and 5) who were prescribed PRN medications to treat behaviors. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2023 and was recently admitted to hospice.

Resident 4 had hospice orders for Lorazepam 0.5 mg as needed for  anxiety.

Resident 4 was administered the psychotropic medication 20 times in May 2023 with no documented evidence staff had first attempted non-drug interventions with ineffective results.

There were no resident specific reasons for use, indicating how Resident 4 expressed anxiety, to guide non-licensed staff in the use of the PRN psychoactive medication.

The need for resident specific reasons for use and to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Business Office Manager/Administrator) on 05/24/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 06/2021 and was receiving hospice services.

Resident 5 had hospice orders for Lorazepam 0.5 mg as needed for  anxiety and restlessness, and Haldol 1 mg as needed for agitation and restlessness.

Resident 5 was administered the Lorazepam four times in May 2023 with no documented evidence staff had first attempted non-drug interventions with ineffective results.

There were no resident specific reasons for use, indicating how Resident 5 expressed anxiety or agitation, to guide non-licensed staff in the use of the PRN psychoactive medications.

The need for resident specific reasons for use and to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Business Office Manager/Administrator) on 05/24/23. They acknowledged the findings.

PRN parameters were added to residents 4 and 5 with non pharmacologial interventions in place.

HSD will conduct audits on QMAR parameters and interventions weekly at High Risk meeting

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT which included documentation of less restrictive alternatives evaluated prior to use, the resident was informed of the risks and benefits of the device, and instruction to caregivers on the correct use and precautions of the device was included on the service plan for 1 of 2 sampled residents (#2) who utilized a device with restraining qualities. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 03/2021 with diagnoses including cognitive dysfunction.

During an observation on 11/14/22, Resident 2 was observed sitting in a Geri chair with a lap tray.

There was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT or OT, including documentation of less restrictive alternatives evaluated prior to use, the resident had been informed of the risks and benefits of the device or the service plan had identified the correct use and precautions related to the device.

On 11/17/22, the need to ensure devices with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT which included documentation of less restrictive alternatives evaluated prior to use, the resident was informed of the risks and benefits of the device, and instruction to caregivers on the correct use and precautions of the device was included on the service plan was discussed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 4 (Vice President of Operations). They acknowledged the findings.

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

Fire and Life Safety records for the previous six months were reviewed on 11/16/22.

Review of the documentation provided identified the following:

a. There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills; and

b. Fire drill records did not contain the following required elements:

* Number of residents evacuated; and

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

The requirements regarding fire and life safety instruction for staff and fire drill record components were reviewed with Staff 1 (Executive Director), Staff 3 (Business Office Manager), and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

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

Refer to C240, C252, C260, C270, C282, and C513.

See C240, C252, C260, C270, C282, C513, Z142, Z162

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:

The interior of the facility was toured on 11/15/22. The following areas needed cleaning or repair:

* Scuffs on handrail and on wall above handrail between Resident Rooms 108 and 109;

* Drips and spills on wall of the dining room;

* Brown debris build-up on baseboards of the dining room; and

* Gouges on window frames and windowsills in the dining room.

The building was toured and areas needing cleaning or repair were discussed with Staff 1(Executive Director) and Staff 11 (Environmental Services Director) on 11/17/22. They acknowledged the areas needing cleaning and repair.

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. This is a repeat citation. Findings include, but are not limited to:

The interior of the facility was toured on 05/23/23. The following areas needed cleaning or repair:

* Drips and spills on the walls throughout the dining room;

* Brown debris build-up on baseboards throughout the dining room;

* Gouges on window frames, windowsills, and walls in the dining room; and

* Two visibly stained and soiled chairs in the common area hallway.

The building was toured and areas needing cleaning or repair were discussed with Staff 1 (ED) and Staff 3 (Business Office Manager/Administrator) on 05/23/23. They acknowledged the areas needing cleaning and repair.

Cleaning check list will be implemented on daily task sheet for noc shift caregivers to complete.

Walk through with ESD/MCD weekly to identify repairs needed.

MCD to do daily walk through to check for soiled furniture.

Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:

The facility laundry process was observed on 11/15/22. The washing machines had general temperature settings but no device to determine the water temperature. Soiled linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant.

The facility's failure to properly launder soiled resident linens and clothing was reviewed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

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 240, C 295, C 420, C513, and C 530.

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 C240 and C513.

See C240 and C513

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 6, 12, 13 and 14) completed all required pre-service orientation training prior to beginning their job responsibilities, and 2 of 2 long-term staff (#s 7 and 8) completed approved infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to:

Staff training records were reviewed on 11/16/22. The following deficiencies were identified:

a. There was no documented evidence Staff 6 (Dietary Aide), Staff 12 (CG), Staff 13 (CG), or Staff 14 (MT), hired 07/21/22, 10/04/22, 07/21/22, and 10/12/22, respectively, completed approved infectious disease prevention training prior to beginning their job responsibilities.

b. There was no documented evidence Staff 7 (Cook), hired 09/08/20, and Staff 8 (Cook), hired 01/01/19, had completed approved infectious disease prevention training prior to 07/01/22 as required.

c. There  was no documented evidence Staff 14 (MT) had completed competency training in medication pass duties within 30 days of hire. Staff 1 (Executive Director) stated Staff 14 would not perform MT duties until competencies had been completed.

The need to ensure newly hired staff completed all required pre-service orientation training prior to beginning their job responsibilities and all long-term staff completed approved infectious disease prevention training in a timely manner was discussed with Staff 1 and Staff 3 (Business Office Manager) on 11/16/22. 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, C 260, C 262, C270, C 280, C 282, C303, and C 340.

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 C252, C 260, C270, C282, C310, and C330.

See C252, C260, C270, C282, C310 and C330

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

During an environmental tour on 11/15/22, it was noted that all occupied rooms in the memory care unit lacked identifying information to assist residents with locating their rooms. Though resident names were posted, there were no additional individual identifiers to assist residents in recognizing their room.

These findings were discussed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 11/17/22. They acknowledged the findings.