Print Inspection: 15XX

The findings of the relicensure survey conducted 04/03/23 through 04/05/23 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 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

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

During the relicensure survey, conducted 04/03/23 through 04/05/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to deficiencies in report.

The licensee has brought all resources to the implementation of actions based on the findings in this survey. This includes resources related to staffing; education;  equipment, environmental needs and any additional resources that may be needed to ensure all deficiencies are corrected and a sustainable plan is implemented. Please refer to this plan of correction for further information.

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

During a tour of the environment on 04/03/23, a copy of the most recent survey was not in an accessible or conspicuous location.

The findings were reviewed with Staff 1 (ED) on 04/04/23. He acknowledged the findings.

The most recent survey is available at the entrance of the community and secured in place to prevent accidental relocation by residents or others.

Will be monitored weekly by Executive Director

Based on interview and record review it was determined the facility failed to ensure incidents and reports of suspected abuse were thoroughly investigated to rule about abuse for 1 of 2 sampled residents (# 3) whose records were reviewed. Findings include but are not limited to:

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

The resident's clinical record was reviewed during the survey.

On 02/08/23 staff documented on a Change in Service Plan form:

* "[Resident] complains of burning in [his/her] private area in [his/her] brief due to incontinence"; and

* "[Resident] not getting changed enough."

The 03/14/23 service plan indicated the resident was incontinent in both bowel and bladder management and used adult briefs at all times. The service plan also noted the facility would provide perineal care routinely each shift and as needed by his/her request as the resident was at risk for skin breakdown.

On 04/04/23, an investigation report was requested. On 04/04/23 at 11:35 am, Staff 1 (ED) confirmed there was no facility investigation completed to rule out neglect of care related to the resident not receiving brief changes timely.

The need to ensure reports of suspected abuse were promptly investigated to rule out abuse and neglect was discussed with Staff 1 and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings. The facility was asked to report the incident to the local Seniors and Peoples with Disabilities office. Confirmation was received by the survey team prior to the survey exit.

Resident 3 - Report was made to APS as the survey documents. We have conducted new evaluations and service plans in addition to RN assessments for this resident.

It is our policy to conduct investigations and to report per the requirements - no changes are needed to these policies. However, we have updated our 24-hour monitoring process and re-educated staff related to the Oregon requirements for abuse reporting.  

The process is evaluated daily Monday through Friday with our stand-up meeting that is utilized to assist with review of our 24-hour monitoring system and incidents requiring investigation and reporting. On weekends, the Medicaiton Aide is responsible for guiding staff relating to communication about abuse or potential abuse; and reporting to the ED.

The Executive Director is responsible.

4. Resident 3 was admitted to the facility in 08/2018 with diagnoses including senile dementia.

a. Review of the resident's 03/14/23 quarterly evaluation and interviews with staff identified the evaluation was not reflective in the following areas:

* Recent Falls;

* Assistive devices;

* Home health PT services received in the past 90 days; and

* Weight loss in the last month.

b. In addition the 03/14/23 evaluation was not accessible to staff.

The need to ensure Resident 3's quarterly evaluation was accurate and made accessible to staff was discussed with Staff 1 (ED) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/20/2023.

a. Resident 4's move-in evaluation, dated 02/20/23, lacked information regarding the following required elements:

* Customary routines;

* Interests, hobbies, social, leisure activities;

* Effective non-drug interventions;

* Ability to be understood;

* Housekeeping and laundry;

* List of treatments;

* Complex medication regime;

* History of dehydration or unexplained weight loss or gain;

* Unsuccessful prior placements; and

* Environmental factors.

b. Resident 4's quarterly evaluation was not accessible to staff.

The move-in evaluation was reviewed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia.

a. Resident 1's quarterly evaluation, dated 03/14/23, was reviewed and lacked the following required elements:

* Assistive devices for transfers and ambulation.

b. Resident 1's quarterly evaluation was not accessible to staff.

The need for the quarterly evaluation to be used as the basis of the resident's quarterly service plan and the most recent quarterly evaluation, with documented change of condition updates, available in the resident's current record and to staff was discussed with Staff 1 (ED)and Staff 3 (RN) on 04/05/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements and to ensure quarterly evaluations were reflective of the residents' current needs and available to staff for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia.

Observations, interviews with staff and review of the quarterly evaluation dated 03/20/23 identified the following:

a. Resident 2's quarterly evaluation was not accessible to staff.

b. The quarterly evaluation dated 03/20/23 was not accurate in the following areas:

* Customary routines including, but not limited to: eating, sleeping and bathing;

* Eating and dietary needs;

* Number of staff required for incontinent care;

* History of dehydration and fluid preferences;

* History of skin care issues and interventions;

* Home health nursing and PT received in previous 90 days;

* Indicators of nursing needs; and

* Socialization.

The need to ensure the quarterly evaluations were accurate and included sufficient information to be used as the basis of the quarterly service plan was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

The evaluation for residents #1, #2, #3 and #4 have been updated to include all required information.

We are in the process of completing new evaluations, service plans and service plan team meetings for all our residents.

Roles and responsibilities for evaluation completions, updates and service plans including team meetings have been established and will be reviewed monthly for effectiveness.

Resident Evaluations are kept in the resident file in the nursing office. These files are accessible to staff at all times.

The Executive Director (ED) and the Resident Services Coordinator are responsible.

3. Resident 3 was admitted to the facility in 08/2018 with diagnoses including senile dementia.

Review of the resident's 03/14/23 service plan and temporary service plans (TSP's), observations and interviews with staff during the survey indicated the service plan was not reflective and did not give clear instruction to staff in the following areas:

* Assistive equipment, non-slip mat at bed side;

* Repositioning assistance; and

* Incontinence assistance including resident preferences.

In a 04/03/23 interview, Staff 2 (LPN), confirmed the 03/14/23 service plan was not made accessible to staff.

The need to ensure service plans were reflective of resident's needs and preferences, gave clear instruction and were accessible to staff was discussed with Staff 1 (ED) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

2. Resident 1 was admitted to facility in 01/2022 with a diagnosis of dementia.

Resident 1's service plan and 03/2023 MAR were reviewed. The service plan, dated 03/14/23, was not reflective of the resident's status, lacked clear instructions to staff or was not followed in the following areas:

* Fall mat;

* Wheelchair with a tab alarm device;

* Side rails; and

* Meal monitoring and supplemental shake.

The service plan instructed staff to notify MA if Resident 1 did not eat 50% of his/her meal and provide a supplemental shake.

In an interview, 04/05/26 at 9:05 am, Staff 7 (CG)  stated she had never seen resident offered a supplemental shake.

In an interview, 04/05/23 at 9:45 am Staff 18 (MA) stated there was no order to give Resident 1 a supplemental shake.

The need to ensure service plans were reflective, included clear direction to staff and were followed was discussed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, reflective of resident's current health status and care needs, provided clear direction to staff regarding the delivery of services and were followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the Memory Care facility in 02/2015 with diagnosis including dementia.

Observations, interviews with staff, review of the current service plan dated 03/20/23 and temporary service plans (TSP's) were reviewed during the survey.

a. The current service plan dated 03/20/23 was not available to staff.

b. Resident 2's current service plan was not reflective and lacked clear direction to staff in the following areas:

* Two person bathing and interventions when resident consistently declined bathing;

* Instructions for finger and toe nail care;

* Incontinent care provided in bed;

* History of dehydration and fluid preferences;

* History of chronic heel and ankle pressure ulcers and interventions;

* Use of pressure alternating mattress and monitoring instructions;

* Use of bilateral siderails including risk, precautions and caregiver instructions;

* Communication and ability to make needs known;

* Seizure protocols, monitoring instructions and who to report to;

* Difficulty swallowing and swallow precautions;

* Puree and mechanical soft diet;

* Ability to make food preferences known; and

* Ability to eat independently.

The need to ensure service plans were reflective of resident needs, included clear direction to staff was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Resident 2 - Evaluation and service plan have been updated to include information related to bathing, nail care, incontinent care provided in bed, history of dehydration and fluid preferences, history of chronic  heal and ankle pressure ulcers and interventions, use of pressure relieving mattress and monitoring instructions, bilateral siderails including risk, precautions and caregiver instructions, communicaiton and ability to make needs needs known, seizure protocols, monitoring instructions and who to report to, difficulty swallowing and swallow precautions, puree and mechanical soft diet, ablility to make food prefernece known and ability to eat independently.

Resident 1 - Evaluation and service plan have been updated to including information related to: fall mat, wheelchair with a tab alarm devices, use of side rails and meal monitoring and supplemental shake.

Resident 3 - Evaluation and service plan have been updated to include information on assistive equipment, non-slip mat at bedside, repositioning assistance and incontinecne assistance including resident preferences.

Roles and responsibilities for evaluation completions, updates and service plans including team meetings have been established and will be reviewed for effectiveness monthly.

The Executive Director (ED) and the Resident Services Coordinator (RSC) are responsible.

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 residents 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:

Resident's 1, 2 and 3's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Resident 1, 2 3 - New evaluations and service plans have been completed; service plan meetings are being scheduled and will be conducted prior to compliance date.

A new process for scheduling and conducting service plan team meeting has been implemented; roles and responsibilities of team members have been identified and staff educated. This process will be evaluated monthly for effectiveness.

The Executive Director (ED) and the Resident Services Coordinator (RSC) are responsible.

Based on observation, interview and record review, it was determined the facility failed to monitor residents consistent with evaluated and service planned needs and short term changes in condition through resolution for 2 of 3 sampled residents (#s 2 and 3) who experienced changes in condition. Resident 3 experienced ongoing discomfort from a skin condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2018 with diagnoses including senile dementia.

The resident's current service plan, dated 03/14/23, and temporary service plans (TSP's) were reviewed and revealed the following:

* 01/15/23 - Behaviors including yelling out, refusing care, exit seeking;

* 01/18/23 - "Skin irritation around [perineal] area, apply barrier cream twice daily for the next seven days and PRN";

* 01/25/23 - Med changes, discontinue Lantis Solostar insulin and increase Metformin 500 mg, take two tablets by mouth daily with breakfast and one tablet with dinner daily;

* 02/08/23 - "[Resident] complains of burning pain in his/her private area in his/her brief due to incontinence"; and

* 03/30/23 - Medication change, start acetaminophen 650 mg take one tablet two times daily, start Memantine five mg, take one tablet by mouth nightly.

a. There was no documented evidence of monitoring with progress noted at least weekly through resolution for Resident 3's behaviors and medication changes.

b. There was no documented evidence the implemented interventions were evaluated for effectiveness or if new interventions needed to be developed for the resident's skin condition. There was no documented evidence the condition was monitored with progress noted at least weekly through resolution. The resident continued to experience discomfort in his/her perineal area between 01/15/23 and 02/08/23.

In an interview on 04/04/23, with Staff 10 (CG), she stated the skin condition had resolved within two weeks prior to the survey.

Resident 3's changes of condition, lack of interventions and monitoring were discussed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia. The resident was not able to communicate his/her needs during the survey.

Progress notes dated 01/01/23 through 03/08/23, HH provider notes from 12/28/22 through 02/01/23 and 03/01/23 through 04/04/23 MAR's were reviewed and identified the following changes of condition:

12/26/22 right ankle pressure wound and bilateral pressure wounds on the heels.

On 12/28/22 and 12/29/22, the facility RN assessed the wounds and documented two hour checks for repositioning, use heel/foot protectors, float heels while in bed, increase protein intake and HH wound care would be managing dressing changes.

On 01/04/23, the RN documented on a skin impairment sheet "right ankle one inch and left heel two inch with 1/8 inch depth, drainage, pale, reddened, dark, and a one-to-two stage on right ankle and stage two on left heel."

On 02/08/23, (26 days later), the RN documented "[one half] inch on left heel, dark scab and "now followed by HH wound care."

On 03/05/23, a progress note documented "heels and ankles are looking very good. Nice small scabs on both ...had to do wound dressing. Will continue to keep a close eye on them."

There was no documented evidence the wounds were monitored with progress noted at least weekly through resolution.

With permission from the resident, ADL care observations were done on 04/04/23 at 12:30 pm. The resident's skin on both ankles and heels were observed to be clean, dry and intact.

The need to ensure the facility monitored Resident 2's skin breakdown with weekly progress noted until resolved was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Resident 3 - We have re-evaluated this resident, updated the service plan and conducted a RN assessment. New interventions have been added to the service plan regarding skin integrity and behavioral needs. The LPN will provide weekly observation of any skin issues and work with RN for any additional skin care interventions needed.

Resident 2 - This resident's skin conditions are currently resolved. The Service plan has been updated to identifyu interventions for prevention of skin issues.

Skin issues will be monitored weekly by the LPN and/or RN as appropriate. All skin will be documented on a skin sheet and the sheets will be updated with healing progress weekly. Any new treatement changes will be communicated to staff via ISP and if appropriate, directions will be placed on MAR for MT's to follow. In addition, we have updated our documentation criteria for the RN to follow relating to significant change of condition.

The Executive Director (ED) and the Resident Services Coordinator (RSC) are responsible.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of  2 sampled residents (# 3) who experienced significant changes in condition. Residents 3 experienced ongoing severe weight loss. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 02/2018 with diagnoses including senile dementia.

The resident was observed to eat independently and was provided a dietary supplement each afternoon. The resident's 03/14/23 service plan instructed staff to offer the resident a peanut butter and jelly sandwich when s/he refused a meal.

The resident was observed to consume the following foods during the survey:

* On 04/03/05 for lunch, the resident ate one half of a peanut butter and jelly sandwich and a piece of cake; and

* On 04/04/23 for breakfast, the resident ate less than 25% of a bowl of hot cereal and a few bites of fruit. S/he refused the offer of an alternative meal. For lunch the resident ate a few bites of pork with gravy, one half of a peanut butter and jelly sandwich and one piece of pie.

It was documented Resident 3 weighed 155.6 pounds in 12/2022.

In 03/04/2023 Resident 3 was noted to weigh 138.3 pounds a 17 pound, or 11.1%, body weight loss in three months. This constituted a severe weight loss.

A current weight for Resident 3 was requested during the survey. Resident 3's weight on 04/04/23 was noted to be 134.8 pounds.   

Progress notes by Staff 3 (RN) revealed the following:

* 01/25/22 -"[Resident] blood sugars have been lower and staff report decreased appetite ...[physician] discontinued Lantis insulin";

* 02/08/23 -"[Resident] has lost five pounds in one month, this is desired weight loss and helping his/her reduce blood sugars, s/he is no longer taking insulin and blood sugars are becoming under control";

* 03/20/23 - "[Resident] continues to lose weight (17) pounds in three months. This is desired due to diabetes..."

In a 04/05/23 interview with Staff 3, she confirmed the the lack of a timely assessment including resident status and interventions made as a result of the assessment for Resident 3's severe weight loss.

The facility's failure to ensure an RN assessment was completed for Resident 3's severe and ongoing weight loss put the resident's health and safety at risk.

The need for the facility RN to assess significant changes in condition, document findings, resident status and interventions made as a result of the assessment was discussed with Staff  (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View) and Staff 15 (Regional Director). They acknowledged the findings.

Resident 3 - The RN assessed this residents weight as a desired weight loss due to the positive impact it had on her blood sugar and need for insulin. The RN has reassessed the resident and updated the service plan with new interventions related to weight management.

We had implemented a COC log to ensure that changes are communicated timely to the RN and followed through with appropriate assessment, monitoring and service plan changes. The RN will include a SOAP note for all significant changes of condition.

The effectiveness of the COC log will be evaluated monthly.

The Executive Director (ED) and Resident Services Coordinator (RSC) will be responsible.   

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed staff. Findings include, but are not limited to:

Delegation records for Resident 4, reviewed on 04/03/23, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 13 (MT), Staff 14 (MT), Staff 16 (MT), Staff 17 (MT) and Staff 18 (MT) to include:

* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons;

* Skills, abilities and willingness of unlicensed persons;

* That taught task is client specific and not transferable; and

* That RN takes responsibility for delegating tasks and ensures supervision will occur for as long as RN is supervising performance.

The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.

Delegations are complete and for all staff members and residents.

We had a delegation process in place at the time of survey but did not have all the requirements were documented. The delegation form has been updated to include any elements missed by the RN at time of survey. Including the raitionale for deciding the task of nursing care could be safely delegated to unlicensed persons, skill, abilities and willingness of unlicensed persons, that taught task is client specific and not transferable and the RN takes responsibility for delegating tasks and ensures supervison will occur for  as long as RN is supervising performance.

No changes are needed to our process however the delegation form used by the nurse has been updated. Additionally, our RN has reevaluated her process has completed all delegations per requirement and best practice.

We will audit delegations and our process monthly.

The Executive Director is responsible.

Based on interview and record review, it was determined the facility failed to ensure an Infection Control Specialist was trained by 07/01/22, as required in OAR 411-054-0050 and failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:

1. In an interview on 04/04/23 Staff 1 (ED) was asked to provided training documentation for the facility's designated Infection Control Specialist. Staff 1 confirmed the facility had not designated an Infection Control Specialist who had completed the required training.

The need to ensure the facility designated an individual to be the facility's Infection Control Specialist and completed the specialized training in infection prevention and control protocols within the required timeframes was reviewed with Staff 1 and Staff 15 (Regional Director) on 04/05/23. They acknowledged the findings.

2. During meal observations on 04/04/23, Staff 2 (LPN) was observed assisting Resident 3 to his/her unit. Staff 2 touched the resident's walker with her bare right hand and then placed the same hand on the residents waist. Staff 2 walked back to the common area, noting she did not have keys to access the residents unit. She approached the window to the medication room, placed her right hand on the window frame and asked Staff 14 (MA) to borrow her keys. She then walked to Resident 3's unit and unlocked the door, touching the door handle. After assisting the resident into his/her room, Staff 2 walked back to the medication room window with the keys in her hand and handed the keys to Staff 14. She then sat across from an unsampled resident, picked up a spoon and began feeding the resident. Staff 2 was not observed to perform hand hygiene or don gloves prior to assisting the resident with meal assistance.

The need to ensure infection prevention and control  protocols and practices were maintained to provide a safe, sanitary and comfortable environment was discussed with Staff 1 (ED) on 04/05/23. He acknowledged the findings.

3. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia.

Observations of Resident 2 during the survey revealed s/he was dependent on two staff for all bowel and bladder care and needed assistance with incontinent care while in bed.

On 04/04/23 from 12:30 pm to 12:47 pm, the surveyor obtained permission and observed two CGs provide bowel care for Resident 2. Both CG's failed to change gloves after removing soiled clothing, soiled incontinent brief and wiping urine and fecal matter from Resident 2's perineum. The CGs touched the resident's clean clothing, clean incontinent brief, their uniforms, keys, a door handle, the resident's bed linens, heel protectors, the resident's lower legs and both sides of the resident's body when assisting the resident to roll from side to side for staff to place a clean incontinent brief on Resident 2.

After care was provided, one caregiver proceeded to change the bed linens and place a clean chux pad on the bed. Both staff removed their soiled gloves, one CG gathered the incontinent trash bag and took soiled gloves from the second caregiver with an ungloved hand and walked into the dining room. The other CG wheeled the resident down the hallway and into the dining room to wait for lunch. No hand hygiene was observed during ADL care or prior to entering the dining room and before handling the resident's wheelchair. The CG carrying the incontinent trash bag stopped to get keys from the housekeeper, touched the keys and doorknob to the laundry room, all before performing hand hygiene. The CG did perform hand hygiene in the laundry room sink before walking back to the dining room, picked up a tray of food from the kitchen and proceeded to provide one-on-one meal assistance for Resident 2 without using a barrier (apron) to prevent potential cross contamination from the staff's uniform.

The need to ensure the facility established and maintained infection prevention and control protocols to provide a safe, sanitary and comfortable environment was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View) during the exit interview on 04/05/23. They acknowledged the findings.

The community has identified an infection control specialist who has completed the required training through Oregon Care Partners and will fill this role.

All staff will be trained in the enhanced infection control practices prior to our compliance date.

All new staff will receive this training as part of their pre service training. Training will be documented and placed in the employees file.

Employee files will be audited  30 days after hire quarterly to ensure all required training has completed as required.

The Executive Director (ED) and the Infection Control Specialist will be responsible.

Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications administered to the residents for 2 of 4 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia. The resident's 03/01/23 through 03/31/23 MARs and physician's orders were reviewed.  

There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following medications and treatments that the facility was responsible to administer:

* Ferrous sulfate;

* Setraline (for mood);

* Acetaminophen (for pain);

* Atorvastatin (for cholesterol);

* Benzonatate (for cough);

* Loperamide (for loose stool);

* Oxycodone (for pain);

* Alum & Mag Hydrox-simethicone (for upset stomach);

* Polyethylene Glycol (for constipation);

* Acetaminophen PRN (for pain);

* Risperidone (for agitation);

* Boost very high calorie supplement;

* Milk of magnesia (for constipation);

* Triamciolone ointment (for rash);

* Sodium fluoride (for teeth);

* Inzo antifungal cream:

* Eye itch relief drops;

* Miconazole cream (for peri area); and

* Bisacodyl suppository (for constipation).

The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia.

A review of the resident's clinical record identified the following:

There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications and treatments that the facility was responsible to administer.

The need to ensure the facility had a system in place to ensure current signed physician orders were available in the residents record was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN) on 04/05/23. They acknowledged the findings.

Residents 1 and 2 - Signed physicians orders have been obtained and placed in the resident chart.

Signed physician orders will be obtained for all residents prior to move in, upon changes in medication  and every 120 days.

Review of physician orders will be done with quarterly care plan updates.

The Executive Director (ED) and the Resident Services Coordinator (RSC) are responsible.

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

1. Resident 1 was admitted to the facility in 01/2022 with a diagnosis of dementia.  

Resident 1's 03/01/23 through 03/31/23 MAR was reviewed.

Resident 1's MAR revealed two PRN pain medications, Oxycodone and acetaminophen lacking specific indications and parameters for use. There were also three bowel care medications, milk of magnesia, polyethylene glycol and bisacodyl suppository, lacking specific indications and parameters for use.

In an interview with Staff 2 (LPN) at 11:45 am on 04/04/23, she acknowledged the lack of parameters for PRN pain and bowel care medications.

The need to ensure there were clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the MARs were not accurate.

2. Resident 2 was admitted to the facility in 02/2015 with diagnosis including dementia.

Review of Resident 2's 03/01/23 through 04/04/23 MAR identified the following inaccuracies:

* Treatment for wound care to heels;

* Gently wash [heels] with baby shampoo;

* Paint ulcers with betadine liquid using a cotton ball and apply to ulcers, cover with dry gauze, tape to secure; and

* Change dressing every other day and as needed.

With permission, observation of ADL care on 04/04/23, showed the resident's heels were clean, dry and intact. The heels were not painted with betadine and were not covered with dry gauze and tape.

During an interview on 04/04/23, Staff 14 (MA) stated she thought the order was discontinued. The MA further confirmed the treatment wasn't done and she was not able to locate the betadine in the med cart or the resident's room.

The MAR's reviewed showed MA's had initialed that the betadine treatment, dry gauze and tape was administered, daily.

On 02/01/23, a HH provider note documented Resident 2's heel wounds were resolved, however there was no documented evidence the wound orders were clarified, needed to be discontinued and the treatment removed from the MAR.

The need to ensure MARS were accurate to include clarified wound orders, clear instructions for unlicensed staff to follow and MA's only initialing the MAR for medications and treatments that were administered was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Residents 1 and 2 MARs that were cited during the survey have been updated to include specific reasons and paramaters for use.

All MARs will be reviewed and all will be updated as needed related to use of medication and parameters for PRN medication use.  

Med Tech staff have been educated on how to accurately document a treatment or medicaiton that was not given.

There will be weekly  and routine MAR audit by the resident service coordinator and lead Med Tech.

The Executive Director (ED) and Resident Services Coordinator (RSC) will be responsible.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions and documentation of the use of the device in the resident's evaluation and service plan for 1 of 2 sampled residents (#2) who had bilateral siderails on their hospital bed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia.

On 04/04/23 the resident's bed was observed to have bilateral half-length siderails in the down position while the resident was laying in the bed.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the device in the resident's evaluation and service plan.

The above information was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Resident 2 - obtained MD orders for use of bilateral side rails, RN completed assistive device assessment. Service plan was updated to include instructions and precautions for use of device and who to report any concerns realted to the safety/use of the device.

Staff will be retrained on supportive devices with restraining quailities prior to our compliance date.

All devices will be checked for safety monthly. The device assessement will be updated quarterly by the RN.

The Executive Director (ED), Resident Services Coordinator (RSC) and RN will be responsible.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care, and failed to have an accurate and effective Acuity Based Staffing Tool (ABST) that defined an appropriate number of caregivers and general staff based on resident acuity and service needs. Findings include, but are not limited to:

Observations, interviews and record review, during the survey revealed the following:

* At the time of the relicensure survey, the facility was a single level home to 18 residents with memory care diagnoses.

* During the acuity interview on 04/03/23, the facility was noted to have numerous residents with high ADL care needs which included four residents who required two staff transfers with mechanical lift assistance, multiple residents who required one to two person incontinent care or toileting, three residents who needed meal oversight and/or eating assistance, and six residents who were identified as having behaviors.

* According to the UDS (Uniform Disclosure Statement), the facility used Medication Aides and Universal Workers (whose job duties included providing care and services to residents in addition to having other tasks, such as housekeeping, laundry and activities.) The UDS indicated the facility would schedule five staff (one MA and four universal workers) between 7:00 am - 11:00 pm (day and evening shifts), and one MA and one universal worker from 11:00 pm - 7:00 am the following morning.

During an interview with Staff 11 (Housekeeper) on 04/04/23, reported "I always provide direct care for [an unsampled resident] because [the resident] doesn't like anyone else. I'm able to help [him/her] shower, bring him food, everything." I do everything around here, I clean the bathrooms, cook, help with feeding residents, do showers, yeah, I do it all, all except meds."

* Review of the posted staffing plan and interview with Staff 1 (ED) during the survey revealed the facility scheduled one MA and two CG from 6:00 am - 2:00 pm and 2:00 pm - 10:00 pm shifts, and one MA and one CG at night (10:00 pm - 6:00 am).

* Observations during meal service on 04/05/23 at 8:52 am, multiple residents were in the dining room. The facility cook, the only staff member present, was seated at a table supporting a resident with their meal. A resident who was seated in a large recliner in the sitting area adjacent to the dining room, made contact with a tall wooden stand next to his/her chair and an artificial plant fell off the top of the stand onto the residents right shoulder. A few moments later the resident stood up from the recliner and pushed the back of the chair until it flipped over. The resident then walked to the front of the chair, bent forward and lifted it until it landed in it's normal position. No facility staff responded to either incident until a surveyor brought the incidents to the MA's attention.     

* On 04/03/23, the surveyor requested the facility's ABST and the defined number of staff that the tool had generated. Upon review of the ABST, multiple residents that had been entered into the ABST had no minutes of caregiver time spent on care that was observed to be needed and/or that they were service planned to receive.

The need to increase staffing levels to compensate for increased staff duties when utilizing universal workers and to ensure unscheduled resident needs could be met was discussed with Staff 1 on 04/05/23. He acknowledged the need for increased staff.

Refer to C 361

DHS ABST has been updated to reflect current needs of all residents. Care staff do not provide meal prep or housekeeping for residents.  

Staffing plan will be adjusted as necessary to meet the scheduled and unscheduled needs of the residents.

ABST will be updated at move in, quarterly, with any significant Change of condition (added to our internal COC communication form, and at move out.

The ABST will be reviewed for accuracy of resident needs monthly.

Executive Director (ED) will be responsible.

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

In a interview on 04/03/23, Staff 1 (ED) confirmed the facility utilized the Oregon Department of Human Services ABST.

The ABST tool showed all 19 residents had information entered into the system and generated a staffing plan. Observations, interviews with the staff and review of the ABST indicated it was not reflective of current ADL needs for Resident 2, Resident 3 and three unsampled residents in the following areas:

* Transferring in or out of bed or chair;

* Repositioning in bed or chair;

* Ambulation, escorting to and from meals and activities;

* Supervising, cueing or supporting while eating;

* Cueing or redirecting due to cognitive impairment or dementia; and

* Monitoring behavioral conditions or symptoms.

The generated staffing plan did not reflect the total of weekly minutes required to meet the scheduled and unscheduled needs of the residents.

In addition, the ABST had not been updated at least quarterly and with changes of condition for Resident 2, Resident 3 and the three unsampled residents.

Staff 1 acknowledged the tool was not reflective of resident's current ADL needs and had not been updated at least quarterly and with changes of condition.

The need to complete an accurate assessment of each resident, update the information at least quarterly and with changes of condition into the ABST to generate a staffing plan was reviewed with Staff 1, Staff 4 (LPN, Clackamas View) and Staff 15 (Regional Director). No further information was provided.

DHS ABST has been updated to reflect current needs of all residents. Care staff do not provide meal prep or housekeeping for residents.  

Staffing plan will be adjusted as necessary to meet the scheduled and unscheduled needs of the residents.

ABST will be updated at move in, quarterly, with any significant Change of condition (added to our internal COC communication form, and at move out.

The ABST will be reviewed for accuracy of resident needs monthly.

Executive Director (ED) will be responsible.

Based on interview and record review, it was determined the facility failed to ensure direct care staff were trained in the use of abdominal thrust and First Aid within 30 days of hire for 2 of 2 sampled direct care staff (#s 7 and 12) whose training records were reviewed. Findings include, but are not limited to:

On 04/04/23, staff training records and interview with Staff 1 (ED) identified the following deficiencies:

There was no documented evidence that Staff 7 (CG) and Staff 12 (MT) had completed training on First Aid and abdominal thrust within 30 days of hire.

The need to ensure direct care staff had completed First Aid and abdominal thrust within 30 days of hire was discussed with Staff 1 on 04/05/23. He acknowledged the findings.

Staff member 7 and 12 have received training on adominal thrust and first aid.

We have a new hire checklist that will be utilized to both training is completed and document per requirements.

We have established roles and responsibilities to ensure training / orientation is performed per requirements.

Prior to scheduling for job duties, each employee file will be audited to ensure documentation of training and competencies. A second audit will be performed within thirty days of hire. No employee will remain on schedule until all training is performed and documented.

We will audit all employee files annually.

The Executive Director is responsible.

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

Fire drill and fire and life safety training records from 10/03/22 to 04/03/23 were reviewed on 04/04/23. The following deficiencies were identified:

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

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

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED), Staff 4 (LPN, Clackamas View) and Staff 15 (Regional Director) on 04/05/23. Staff 1 acknowledged the facility did not conduct  and record unannounced fire drills every other month and did not consistently provide fire and life safety instruction to staff.

Fire drills will be conduct every other monthly at different times of day and on different shifts. The fire drill record will be completed and kept in the life safety binder.

Fire and life safety education will be provided to staff every other month and a record of this training will be kept in the life safety binder.

These records will be reviewed monthly for completion.

Executive Director (ED) or maintenance staff will be responsible.

Based on observation and interview, it was determined the facility failed to ensure an effective pest control system was in place and that any toxic materials were properly stored in locked storage. Findings include, but are not limited to:  

A review of the facility environment was conducted on 04/03/23. The following was identified:

* There were ants present in the TV room next to the dining room; and

* Chemical disinfectant was observed in unlocked cupboards in the common bathrooms. The bathrooms were observed to not be consistently locked throughout the day.  

On 04/05/23, in an interview with Staff 1 (ED), the need to ensure an RCF takes measures to prevent the entry of rodents, flies, mosquitoes, and other insects, and all poisons, chemicals, rodenticides and other toxic materials were contained in a locked storage unit was discussed.  He acknowledged the findings.

We had our pest control company address the ants in the activity room. The company is scheduled monthly but will be utilized more often as needed. Staff have been educated on reporting any insects in the community.

We will have installed new locking cabinet in our common bathroom to prevent resident access to chemicals.

We will review these areas weekly.

Executive Director (ED) and housekeeping will be responsible.

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:

Observation of the facility on 04/03/23 revealed:

* The carpet throughout the facility had multiple stains and was worn;

* There was paint missing on the wall under the soap dispenser in the shower room (next to room 17);

* The doors and/or frames to all three shower rooms and rooms 22, 28, nurses station and shower rooms were scratched, gouged and missing paint;

* The arm chair outside nurses station had fabric that was torn;

* The couch in the back TV/lounge area had ripped seams and stuffing protruding;

* The shower room (next to room 28 and 21) had broken tiles and missing grout in the shower; and

* The transition strip to the laundry room was missing.

A walk through of the facility was completed on 04/04/23 with Staff 1 (ED).

On 04/04/23, the surveyor discussed and reviewed the areas requiring cleaning and repair with Staff 1. He acknowledged the findings.

The items listed on survey will be repaired or replaced prior to our compliance date.

An environmental check off sheet will be completed weekly and arrangements will be made to address any issues noted.

The Executive Director (ED)  and mainentance staff will be responsible.

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

The facility laundry rooms were observed on 04/03/23. The following was identified:

The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) on 04/04/23. He acknowledged the findings.

We have contacted our laundry supply company and added a disinfectant to our soap dispenser.

We will observe for function and supply of disinfectant weekly.

Executive Director and maintenace staff will be responsible.  

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

On 04/04/23 the surveyor measured water temperatures in occupied resident unit bathrooms and common bathrooms throughout the building. Water temperatures were below 110 degrees Fahrenheit.

The need to ensure hot water temperatures were monitored and maintained within a range of 110 - 120 degrees F was discussed with Staff 1 (ED). He acknowledged the findings. He stated he would inform maintenance staff to adjust the water heaters on 04/05/23.

The hot water heater was repaired at time of survey.

Hot water tempuratures will be measured in different area of the building weekly and a temperature log with location will be maintained.

The log will be reviewed monthly for completion and verification of hot water temperatures in the community.

The Executive Director (ED) and maintenance staff will be responsible.

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

Refer to: C 150,  C 152, C 231, C 295, C 360, C 361, C 372, C 420 , C 510, C 513, C 530 and C 545.

Refer to C150, C152, C231, C295, C360, C361, C372, C420, C510, C513, C530 and C545.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation, pre-service dementia training and competency demonstrated within 30 days of hire was completed and documented for 2 of 2 newly hired direct care staff (#s 7 and 12) and annual in-service training was completed and documented for 3 of 3 long term direct care staff (#s 9, 10 and 13). Findings include, but are not limited to:

On 04/04/23 training records were reviewed with Staff 1 (ED).

1. Staff 7 (CG), hired on 01/27/23 and Staff 12 (MA), hired on 01/06/23 lacked documented evidence of completing all required pre-service or competency training in the following areas:

a. Pre-service orientation prior to performing any job duties:

* Resident rights;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures;

* If preparing food, food handler's card; and

* Written job description.

b. Pre-service dementia training prior to providing care and services independently:

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

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

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, 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 in the resident's condition and report behaviors that require on-going assessment;

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

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

c. Demonstrated competency training within 30 days of hire:

* Changes associated with normal aging; and

* Identification, documentation and reporting changes of condition.

2. Staff 9 (CG), hired on 10/23/15, Staff 10 (CG), hired on 03/19/19 and Staff 13 (MT), hired on 12/20/16 failed to complete 16 hours of annual in-service training which included six hours related to dementia care.

The need to ensure all newly hired staff completed pre-service orientation, pre-service dementia training, demonstrated competency within 30 days of hire and all long-term direct care staff completed 16 hours of annual in-service training was discussed with Staff 1 on 04/05/23. He acknowledged the findings.

New hire packets will be updated to include all staff training requirements.

Staff receive preservice dementia and other training through our Relias system.  

Prior to scheduling for job duties, each employee file will be audited to ensure documentation of training and competencies. A second audit will be performed within thirty days of hire.

All monthly inservice and training records will be kept in a training binder.

Relias will be audited monthly for completion of scheduled trainings.

We will audit all employee files annually.

The Executive Director is responsible.

Based on 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 252, C 260, C 262, C 270, C 280, C 282, C 303, C 310 and C 340.

Refer to C252, C260, C262, C303, C310, C340, C270, C280, C282

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

Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia. The resident was unable to make his/her needs and food preferences known.

Observations during the survey identified Resident 2 preferred to eat breakfast in his/her room every day, needed two-person mechanical lift transfer and wheelchair escorts to attend meals and snacks offered in the dining room.

During the acuity interview on 04/03/23, Staff 10 (CG), reported Resident 2 needed a puree diet.

Review of outside provider notes from 01/01/23 through 03/08/23, identified Resident 2 had a speech therapy evaluation due to difficulty swallowing. The evaluation recommended mechanical soft and/or puree diet.

The current service plan dated 03/20/23 offered the following information:

* [Resident] is able to make [his/her] food preferences known;

* [S/he] may not sit through the meal if there are no sweets with the meal;

* [Resident] requires one-on-one supervision while eating and drinking for safety reasons;

* Staff to prop up right arm with a rolled towel or pillow when sitting in wheelchair at meals;

* Staff to offer fluids and snacks between meals;

* Staff to offer alternate menu items if s/he expressed s/he didn't like the food or staff notice s/he isn't eating; and

* Staff to offer coffee with each meal.

Observations throughout the survey noted the following:

* Resident 2 would nod his/her head yes or no at intermittent times when responding to staff, otherwise was non-verbal.

* On 04/03/23 Resident 2 was offered whole cooked vegetables and a whole bread roll during lunch. The resident ate less than 50 % of the meal. Staff 10 (CG) who provided one-on-on meal assistance failed to offer alternate menu items.

* On 04/03/23, snack pass between breakfast and lunch was offered to residents who were out in the community. Resident 2 remained in his/her room and was not offered the snack or fluids.

* On 04/04/23 at 10:50 am, a snack pass was offered to residents who were out in the community, Resident 2 remained in his/her room and was not offered the snack or fluids.

* Resident 2 was observed in a tilt back wheelchair during lunch on 04/03/23 and 04/04/23 without the use of a rolled towel or pillow propped under the right arm.

On 04/05/23, the need for an individualized nutrition and hydration plan was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View). They acknowledged the findings.

Resident 2 - a nutritional evaluation was completed, diet reviewed and service plan was updated to include accurate information for staff to regarding food and fluid intake.

A nutritional evaluation will be completed for all residents prior to our compliance date. Service plans will be updated to reflect individual preferences and needs for all food and fluid intake.

All resident nutritional plans will be updated with any change of condition and quarterly.

Reviewed as part of change of condition monitoring and quarterly.

Executive Director (ED) and Resident Services Coordinator (RSD) will be respoinsible.  

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's service plans offered some information about the residents' interests, however, 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 the resident to participate; and

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

There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

Observations and interviews indicated the residents were dependent on staff to initiate activities.

On 04/05/23 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED), who acknowledged the findings.

Residents #1, #2, and #3 were updated to include activity preferences including: current ability and skill, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to particapte and activities that could be used as behavioral interventions.

We will complete an activity profile for all residents prior to our compliance date.

The Life Enrichment Director will be part of the service planning team.

We will evaluate these plans quarterly.

The Executive Director (ED) and Life Enrichement Director (LED) will be responsible.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:

Observations during the survey between 04/03/23 and 04/05/23 indicated the doors to the interior courtyard were locked and did not allow residents to exit and return without staff assistance.

During a tour of the building on 04/04/23 at 12:15 pm with Staff 1 (ED).  He acknowledged the courtyard doors were locked and there was no inclement weather policy.

Refer to Z 173.

We have educated our staff on when to lock and unlock the courtyard doors.

A reminder sign has been placed in the Med Room for the Med Tech on duty.

Courtyard doors will be checked daily.

The Executive Director (ED) and Med Tech on duty will be responsible.

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:

During the survey, between 04/03/23 and 04/05/23, the doors to the interior courtyard were observed to be locked.

During a tour of the building on 04/04/23 at 12:15 pm with Staff 1 (ED), he acknowledged the facility did not have a written policy which described under what circumstances the doors to the courtyard would be locked.

A sign has been placed by the courtyard doors to notify all staff, resident or visitors of when the courtyard door may be locked for resident safety.

The placement of signs will be reviewed weekly.

The Executive Director will be responsible.

Based on observation and interview, it was determined the facility failed to ensure residents' rooms were unlocked. Findings include, but are not limited to:

During environmental observations on 04/03/23 and 04/05/23, it was noted seven residents' rooms were locked.

The need to ensure residents were not locked out of or inside of their rooms at any time was discussed with Staff 1 (ED) on 04/04/23. He acknowledged the findings.

Staff were reeducated on not locking resident doors unless requested by the resident and the directions are part of the service plan.

Service plans will be reviewed and updated with resident prefence to have door lock is applicable prior to our compliance date.

Randomly selected resident doors will be checked weekly to assure staff are following policy to keep door open.

The Executive Director (ED) and Resident Services Coordinator (RSD) will be responsible.