Print Inspection: 2UGK

The findings of the re-licensure survey, conducted 11/13/23 through 11/16/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the relicensure survey of 11/16/23, conducted 06/12/24 through 06/13/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 11/16/23, conducted on 08/15/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to develop and implement written policies and procedures to respond to and resolve resident complaints. Findings include, but are not limited to:

During the entrance conference on 11/13/23 the survey team requested resident council meeting minutes or other forum for responding to resident grievances.

During an interview on 11/15/23, Staff 1 (Expressions Director) acknowledged an effective method of responding to and resolving resident complaints had not been implemented.

The need to ensure the facility developed and implemented written policies and procedures for responding to and resolving resident complaints was discussed with Staff 1 (Expressions Director) on 11/15/23. She acknowledged the findings.

Grievance Binder created and implemented for Expressions Side of the building. Grievance policy training and test completed with all staff in Expressions 12/6/23. Anonymous grievances can be made online. Letter lock box ordered and will be placed in Expressions upon delivery so Grievance forms can be placed in if wishing to be anonymous without going online. Executive Director, Expressions Director or designee will check letter lock box daily Monday - Friday. Any concern/grievance should be reviewed by Executive director or Expressions director Monday- Friday or as appropriate. Executive director and Expressions director will ensure grievances are completed with appropriate actions and follow-up.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 moved into the facility in 05/2023 with diagnoses including diabetes.

The resident's new move-in evaluation was reviewed and there was no documented evidence the following elements were addressed:

* Customary routines including sleeping, eating and bathing;

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

* Elopement risk or history; and

* Environmental factors that impact the resident's behavior including noise, lighting and room temperature.

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Expressions Director, RN and LPN to be trained/retrained on correct use of service planning tool, which includes addressing residents' customary routines and preferences. Expressions director, ED, Nurse or designee to monitor and review all new service plans weekly to ensure that evaluations are personalized and completed within specified timeline. Designee to report any concerns to Executive Director. Will review all current residents plan for corrections and update elopement risk or history; and environmental factors that impact the resident's behavior including noise, lighting and room temperature. Resident 3 passed away 12/9/23. Executive director and Expressions director will ensure corrections are completed.

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

Resident 5 moved into the facility in 05/2024 with diagnoses including Alzheimer's dementia. The resident's move-in evaluation documentation dated 05/16/24, 05/17/24, and 05/28/24 was reviewed and lacked the following required elements:

* Customary routines, including bathing;

* Dental status, assistive devices for eating;

* How the resident expresses pain or discomfort;

* Nutrition habits and fluid preferences; and

* History of dehydration or unexplained weight loss or gain.

The need to ensure the new move-in evaluation addressed all required elements was discussed with Staff 7 (ED), Staff 1 (Expressions Director), Staff 17 (Health Services Director/RN), Staff 2 (Assistant Health Services Director/LPN), and Staff 18 (Regional RN) on 06/13/24. They acknowledged the findings.

1.) The resident's assessment has been updated and will be signed during upcoming care conference.

2.) The health service team to be trained on the UDA (user defined assessment) in the Point Click Care system, to ensure that all areas are captured.

3.) The Excutive Director or designee will review each new assessment and ensure that all sections are being completed.

4.) The Executive Director or designee will discuss any new assessments with the Health Service team once a week.  

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

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

Observations of the resident, interviews with staff, and review of the service plan, dated 09/09/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Extremity/extremities affected by hemiplegia;

* Level of incontinence including bowel/bladder; and

* Level of physical assist required for toileting, transferring, ambulation/mobility, showering, dressing and grooming.

The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented by staff was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Residents 1's service plan was updated 11/29/23. Updates included: extremity/extremities affected by hemiplegia; Level of incontinence including bowel/bladder; and Level of physical assist required for toileting, transferring, ambulation/mobility, showering, dressing and grooming. All service plans will be updated and provide clear instructions to staff which identify extremity/extremities affected by DX; Level of incontinence including bowel/bladder; and Level of physical assist required for toileting, transferring, ambulation/mobility, showering, dressing and grooming. Nurse and Expressions Director to complete service planning training through Oregon Care Partners by Dec 22nd: "Dementia Care: Person Centered Care Plans". Executive director, Expressions Director, RN and or LPN to discuss service plans due, at daily stand-up meeting (Monday-Friday).Service plans will be updated quarterly, and as needed and reflect all components of care, including diagnosis's. Executive director and Expressions director will ensure corrections are completed.

2. Resident 1 moved into the facility in 03/2022 with diagnoses including dementia, dysphagia and Type 2 diabetes.

The resident's progress notes, incident reports, investigations and service plan addendums (SPA's) dated 08/13/23 through 11/13/23 were reviewed and interviews with staff were conducted.

The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution and/or were not referred to the RN for assessment:

* 08/21/23 - Change in medication related to omeprazole (heartburn) and pantoprazole (gastroesophageal reflux disease);

* 09/05/23 - Fall;

* 09/10/23 - Resident to resident altercation;

* 10/11/23 - Change in medication related to omeprazole (heartburn), miralax (constipation) and Ensure (nutritional supplement);

* 10/18/23 - Flu vaccination; and

* Severe weight changes occurring on 05/02/23, 07/04/23, 09/02/23, 10/02/23 and 11/01/23.

The severe weight changes constitute significant changes of condition for the resident, requiring an RN assessment.  There was no documented evidence the severe weight changes were referred to the RN for assessment.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift and changes of condition were monitored through resolution was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition had resident-specific instructions or interventions developed, progress was documented weekly until resolution and/or changes of condition were referred to the RN as appropriate for 2 of 2 sampled residents (#s 1 and 2) who were reviewed with changes of condition. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2022 with diagnoses including dementia.

Interviews with staff and review of Resident 2's progress notes and service plan addendums (SPA's) dated 08/13/23 through 11/13/23 were completed during the survey.

The following short term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:

* 08/20/23 - Decreased dose of omeprazole (heartburn) medication;

* 08/24/23 - Wandering into another resident room and aggression towards staff;

* 09/02/23 - Physical aggression towards staff;

* 09/04/23 - Physical aggression towards staff;

* 09/07/23 - Found on floor fall without injury;

* 09/12/23 - Return from higher level of care;

* 09/12/23 - Change in pain medication;

* 09/13/23 - Resident to resident altercation;

* 09/17/23 - Taunting behavior toward another resident;

* 09/18/23 - Behavior toward another resident;

* 09/25/23 - Behavior toward residents;

* 10/09/23 - Change in pain medication; and

* 10/18/23 - Received flu and Respiratory Syncytial Virus (RSV) vaccine.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, changes of condition were monitored through resolution was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Resident 1 will have significant change of condition assessment and service plan completed by 11/29/23. Executive director, Expressions director, RN or designee will review progress notes and communications daily during SMART meeting Monday-Friday to observe for and monitor change of conditions. RN will assess residents for significant changes of condition and documented findings, resident status and interventions within 48 hours. Care plans will be updated to reflect significant changes of condition. Expressions director and RN or designee will have weekly weight meetings. Executive director and Expressions director will ensure corrections are completed.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition and documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#1) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia, dysphagia and Type 2 diabetes.

A review of the Resident's clinical record, including the current service plan, dated 09/09/23, progress notes dated 08/13/23 through 11/12/23, and weight records from 04/01/23 through 11/01/23 were completed, and staff were interviewed. The following was identified:

a. Review of weight records revealed the following:

* 04/03/23 - 182.0 pounds;

* 05/02/23 - 157.0 pounds, which constituted a severe weight loss of 13.7% in 30 days;

* 06/02/23 - 160.4 pounds;

* 07/04/23 - 177.0 pounds, which constituted a severe weight gain of 10.9% in 30 days;

* 08/03/23 - 170.0 pounds;

* 09/02/23 - 185.2 pounds, which constituted a severe weight gain of 8.9% in 30 days;

* 10/02/23 - 173.9 pounds, which constituted a severe weight loss of 6.1% in 30 days; and

* 11/01/23 - 161.6 pounds, which constituted a severe weight loss of 7.7% in 30 days.

At the time of survey, 11/14/23, the resident weighed 171.0 pounds.

During the acuity interview, Staff 1 (Expressions Director), Staff 2 (Assistant HSD, LPN) and Staff 3 (Lead MT) stated that the resident had a diagnosis of congestive heart failure and history of edema.

Observations made during the survey and interviews with Staff 11/13/23-11/15/23 showed the resident refused 1-2 meals per day and ate less than 50% of the meals s/he accepted. He ate fewer than 50% of snacks provided.

There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN for any of the severe weight changes noted above.

During an interview with Staff 1 on 11/15/23 at 11:30 am, she stated no RN assessments had been completed for Resident 1 in the past 6 months.

The need to ensure an RN assessed all significant changes of condition including findings, resident status, and interventions made as a result of the assessment within 48 hours was discussed with Staff 1, Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Resident 1 will have significant change of condition assessment and service plan completed by 11/29/23. Executive director, Expressions director, RN or designee will review progress notes and communications daily during SMART meeting Monday-Friday to observe for and monitor change of conditions. RN will assess residents for significant changes of condition and documented findings, resident status and interventions within 48 hours. Care plans will be updated to reflect significant changes of condition. Expressions director and RN or designee will have weekly weight meetings. Executive director and Expressions director will ensure corrections are completed.

Based on observation, interview, and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, and the service plan was adjusted as necessary and services were implemented for 1 of 2 sampled residents (#2) who received services from outside providers. Findings include, but are not limited to:

Resident 2 moved into the facility in 09/2022 with diagnoses including dementia.

Resident 2's current service plan dated, 09/12/23, Service Plan Addendums (SPA's) and outside provider notes dated 08/13/23 through 11/13/23, and MARs dated 10/01/23 through 11/13/23 noted the following:

* 08/28/23 - Use of a "roho cushion"; and

* 10/11/23 - Use PRN zinc oxide for open area on bottom until healed.

There was no documented evidence the service plan was adjusted as necessary to reflect the implementation of the outside provider recommendations.

On 11/13/23 through 11/16/23, Resident 2 was observed using the wheelchair without the use of the roho cushion.

Review of the October MAR indicated the MT's had not implemented the use of the PRN zinc oxide cream.

During an interview on 11/15/23, Staff 3 (Lead MT) confirmed the outside provider note was reviewed and transcribed into the progress notes, however, the treatment for the zinc oxide was not administered. Staff 3 further confirmed the resident no longer had an open skin area.

The need to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, and that the service plan was adjusted as necessary and services were implemented was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Resident 2's service plan was updated to reflect use of ROHO cushion, and as needed zinc oxide for skin breakdown. Med techs will document outside agency visit notes in PCC. Health services team will review coordination of care notes daily Monday-Friday. The RN will document a weekly focus note regarding coordination of care, update and implement interventions, and service plan will be adjusted as necessary. Executive director and Expressions director will ensure corrections are completed.

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

Resident 1 was admitted to the facility in 03/2022 with diagnoses of dementia and Type 2 Diabetes.

Resident 1's MAR dated 11/01/23 through 11/12/23 and physician orders were reviewed. There were no signed physician orders in Resident 1's chart for the following medications:

* Aspirin 81 mg daily (for cardiac health);

* Polyethylene glycol 3350 17 g every other day (for constipation);

* Omeprazole 20 mg daily (for acid reflux);

* Guaifenesin 600 mg as needed (for cough); and

* Melatonin 3 mg as needed (for insomnia).

The need to ensure signed physician orders were documented in the resident's record for all medications and treatments administered by the facility was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Resident 1's orders were fixed during survey. Expressions Director, RN, or designee will review all orders to ensure signed physician orders are documented in the resident's record for all medications and treatments administered by the facility. All new orders or medication changes will be verified to ensure there is a signature or electronic signature upon arrival. Expressions director, RN or designee will check order folder in med room daily Monday- Friday to ensure all new orders are signed and entered for administration. Any medications needing follow up or signature will be followed up on by Expressions director, RN or designee. Executive director and Expressions director will ensure corrections are completed.

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

Resident 2 was admitted to the facility in 09/2022 with diagnoses including dementia. The resident was dependent on staff for transfers.

Observation of the resident's room 11/14/23 identified the resident's bed mattress was on the floor.

During an interview on 11/14/23 at 9:03 am, Staff 3 (Lead MT) stated "we have a doctor's order for it to be on the floor because [the resident] kept falling out of bed."

There was no documented evidence an evaluation was completed and included the following:

* Thorough assessment by an RN, PT or OT;

* Documentation of less restrictive alternatives evaluated prior to lowering the bed to the floor;

* Instruction provided to staff on the correct use and precautions related to the resident's bed on the floor; and

* Documentation of the resident's bed lowered to the floor and proper technique for staff to assist resident in transferring from the floor mattress to the wheelchair, and wheelchair to floor mattress, in the resident's service plan.

The need to ensure a device with potentially restraining qualities was assessed by an RN, PT or OT, less restrictive alternatives prior to use were documented, instruction was provided to caregivers on the correct use of and precautions for the device, and use of the device was documented in the resident's service plan was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Resident 2 bed was removed from ground prior to survey exit. 0 potential for restraint at this time. Health services team will review residents every 90 days and as needed to ensure any devices with potentially restraining qualities are assessed by an RN, PT or OT, less restrictive alternatives attempted prior to use are documented, instruction are provided to caregivers on the correct use of device and precautions for the device, and use of the device will be documented in the resident's service plan.

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

Fire and life safety records dated 05/2023 through 10/2023 were reviewed and identified the following:

a. Fire drill records lacked the following components:

* Location of simulated fire;

* Escape route used;

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

* Evidence alternate escape routes were used.

b. Fire and life safety instruction was not consistently provided to staff on alternate months of the fire drills.

The requirements regarding fire drills and fire/life safety instruction for staff were reviewed with Staff 1 (Expressions Director) and Staff 4 (Maintenance Director) on 11/14/23. The findings were acknowledged.

Evacuation Preparedness Drill Training and Disaster and Emergency Training completed at all staff 12/6/23. All fire drills will be conducted by the Maintenance team or designee, as outlined in Oregon Fire Codes. On alternating months, the Maintenance team or designee will host fire and life safety training including location of simulated fire; escape route used; problems encountered and comments related to residents who resisted or failed to participate in the drills; and evidence alternate escape routes were used. Maintenance team will report findings and completed training's to ED monthly. Executive director and Expressions director will review records and ensure all components are completed.

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

Fire and life safety records were requested and reviewed during the survey. The following was identified:

* There was no documented evidence of fire and life safety training provided to residents within 24 hours of admission; and

* There was no documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed, at least annually, was reviewed with Staff 1 (Expressions Director) and Staff 4 (Maintenance Director) on 11/14/23. The findings were acknowledged.

All new residents will receive Fire and Life Safety Training as outlined in the Oregon Fire Codes. All residents will be offered the opportunity to participate in annual Fire and Life Safety Training. Training's will be conducted by the Maintenance team or designee by 1/15/24. Service plans will be updated to reflect refusals, ability to retain information. A Fire and Life safety training schedule will be implemented by the Maintenance team and reviewed by the ED or designee bi-monthly. Annual Fire and Life safety training's will be held in January.

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

Refer to C 252.

See 252  

Based on observation and interview, it was determined the facility failed to ensure facility grounds were kept orderly and free of litter and refuse, and garbage was stored in a covered refuse container. Findings include, but are not limited to:

Facility grounds were toured from 11/13/23 through 11/15/23 and the following was identified:

* On 11/13/23, the outside dumpster was open and overflowing with garbage bags; greater than 10 garbage bags lay on the ground, along with non-contained litter and refuse.

* On 11/14/23 and 11/15/23, the outside dumpster was noted to have been emptied, but the lid remained open, and multiple bags of garbage and non-contained litter and refuse lay on the ground in front of the dumpster.

The facility grounds were toured with Staff 1 (Expressions Director) on 11/15/23. She acknowledged the above findings.

Maintenance Director or designee will do daily/weekly walk-through to ensure facility grounds are kept orderly and free of litter and refuse, and garbage is stored in a covered refuse container. Maintenance Director or designee will report any deficiencies or areas of concern to the ED.

Based on observation and interview, it was determined the facility failed to have handrails installed at one or both sides of resident-use corridors. Findings include, but are not limited to:

During observations of the facility 11/13/23 through 11/15/23, residents were noted to be using corridors which did not have a handrail, including:

* Right side of the corridor by the nurses' station;

* Left side of the dining room, leading to the secured outdoor courtyard;

* Adjacent to living room; and

* Left side entry to kitchenette/serving area

The need to ensure handrails were installed along one or both sides of resident-use corridors was discussed with Staff 1 (Expressions Director) on 11/15/23. She acknowledged the findings.

Handrails will be ordered by 12/15/23 and installed by 1/15/24. Handrails will be added to right side of the corridor by the nurses' station; left side of the dining room, leading to the secured outdoor courtyard; adjacent to living room; and the left side entry to kitchenette/serving area. No further need for evaluation upon installation. Maintenance director, Executive director, and Expressions director will ensure corrections are completed.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were clean and in good repair, including all equipment necessary for the health, safety, and comfort of the resident. Findings include, but are not limited to:

Observations of the facility 11/13/23 through 11/16/23 revealed the following:

* A blue couch in the living room with brown debris along one side;

* Handrails throughout the facility were sticky to the touch;

* Multiple doorframes leading to resident units were observed with chipped wood and paint; and

* A cushioned chair in Resident 1's room was covered with large brown staining on the seat and extensive food debris on both cushioned arms, as well as areas where the fabric was torn and foam was visible.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Expressions Director) on 11/15/23. She acknowledged the findings.

All interior and exterior surfaces will be kept clean and in good repair. All areas of concern will be addressed and on going will be kept clean and in good repair. Maintenance team or designee will walk the community weekly and report any areas of concern to ED. The Maintenance team or designee will monitor weekly and report any deficiencies or areas of concern to the ED. All handrails will be replaced in building with material that is easy to clean without causing decay or sticky surfaces. Executive director and Expressions director will ensure corrections are completed.

Based on observation and interview, the facility failed to ensure there was space and equipment to handle soiled linen and clothing separate from regular linens and clothing, and there was a one-way flow of soiled linens and clothing from the soiled area to the clean area to preclude potential of contamination of clean linens and clothing. Findings include, but are not limited to:

Observations of the laundry room 11/13/23 through 11/15/23 revealed the following:

On 11/13/23 through 11/15/23, the soiled laundry processing area was observed to be inaccessible due to the storage of items including multiple four-wheeled walkers, cardboard boxes, a storage cart and a large trash bin. The storage cart and trash bin blocked all access to the flushing rim sink.

During an interview and tour of the laundry area with Staff 13 (MT) on 11/14/23, the following was noted:

Staff 13 was unable to open the door to the soiled laundry processing area. The laundry area was inaccessible due to the storage of items listed above. Staff 13 stated they consistently performed laundry tasks, and demonstrated that all soiled laundry was currently transported to the laundry room down a corridor which contained clean laundry. Staff 13 stated the flushing rim sink was currently not accessible.

The need to ensure there was space and equipment to handle soiled linen and clothing separate from regular linens and clothing, and there was a one-way flow of soiled linens and clothing from the soiled area to the clean area to preclude potential of contamination of clean linens and clothing was discussed with Staff 1 (Expressions Director) on 11/15/23. She acknowledged the findings.

Laundry room cleaned, including removing four-wheeled walkers, cardboard boxes, storage cart and large trash bin. The storage cart and trash bin were relocated to ensure access to the flushing rim sink. Laundry room, equipment and walkways will remain clean and free of clutter and debris. Soiled linen and clothing will be separate from regular linens and clothing, and there will be a one-way flow of soiled linens and clothing from the soiled area to the clean area to preclude potential of contamination of clean linens and clothing. Maintenance Director or designee will monitor weekly and report any deficiencies or areas of concern to the ED. Executive director and Expressions director will ensure corrections are completed.

Based on observation and interview, the facility failed to ensure units had entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. Findings include, but are not limited to:

During an interview with Staff 1 (Expressions Director) on 11/16/23, she stated no residents currently had a key to their unit. She stated that all resident unit locks were keyed to the same key, which all care staff had access to.

On 11/16/23, the survey team observed that one key unlocked multiple separate resident units.

The need to ensure units had entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit, was reviewed with Staff 1 on 11/16/23. She acknowledged the findings.

All doors will be re-keyed by 12/7/23. Health services care staff working during shift will have a master key to all rooms to assist with care and/or emergencies. Care staff will knock prior to opening door and only enter upon approval or for safety reasons. Keys will remain onsite and be passed from shift to shift. Residents and or POA will have access to a separate key to room that only opens room door. Will evaluate all current residents and all new residents upon move in. Resident and POA will be offered a key at time of move in and key will be documented in the service plans. Executive director and Expressions director will ensure corrections are completed.

Concerns were identified and technical assistance was provided in the following:

H 1518: OAR 411-004-0020(2)(e): Individual Door Locks: Key Access.

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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 154, C 420, C 422, C 510, C 511, C 513, and C 530.

See C 154 (page 1) , C 420 (page 10), C 422 (page 11), C 510 (page 12), C 511(page 13), C 513 (page 14), and C 530 (page 15) Expressions Director has reviewed and corrected.

Based on interview and record review, it was determined the facility failed to ensure long term direct care staff completed 16 hours of in-service training which included six hours of Department approved dementia care training, annually, for 2 of 3 long term direct care staff. Findings include, but are not limited to:

Training records were reviewed with Staff 1 (Expressions Director) on 11/15/23 at 9:00 am. Annual training records for long term direct care staff reviewed from their respective anniversary dates of hire, identified the following:

Staff 3 (Lead MT), hired 08/04/21, completed eight hours of the required ten hours related to the provision of care;

Staff 14 (CG), hired 10/22/21, completed three hours of the required ten hours related to the provision of care; and

Staff 14 completed four hours of the required six hours of dementia care training through a training course titled "Health Care Academy."

There was no documented evidence the facility requested and received approval from the Department to use Health Care Academy dementia training curriculum.

During an interview on 11/14/23, Staff 1 and Staff 7 (ED), confirmed the facility didn't have approval to use the training program.

The need to ensure annual in-service training was provided by an approved dementia training course and 16 hours of annual in-service training was completed was discussed with Staff 1 and Staff 7 on 11/15/23. They acknowledged the findings.

Staff 3 and 14 will have all required training's assigned and completed. All long term direct care staff will complete 16 hours of in-service training. 6 of the 16 hours will be dementia care training. Dementia care training will be completed through Oregon Care Partners. The Administrative Assistant or designee will oversee employee files and update Expressions Director weekly on any missing or incomplete training's. All staff will be reviewed for compliance with 16 hours of training including Dementia Training and Infection control annually, through Oregon Care Partners. Executive director and Expressions director will ensure corrections are completed.

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 252, C 260, C 270, C 280, C 290, C 303, and C 340.

See C 252 (page 3), C 260 (page 4), C 270 (page 5), C 280 (page 6), C 290 (page 7), C 303 (page 8), and C 340 (page 9). Prestige Arbor Place Memory Care will have a facility RN in the community a minimum of 15 hours per week.

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

Refer to C 252.

See 252  

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

Resident 1 was admitted in 03/2022 with diagnoses including dementia, Type 2 diabetes, dysphagia and hemiplegia.

The resident experienced five severe weight changes between 04/01/23 and 11/01/23.

The current service plan for Resident 1, dated 09/09/23, was reviewed. The service plan included some food and drink preferences, but lacked an individualized nutrition plan based upon the resident's needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Residents 1's was evaluated and significant change of condition service plan was updated to include nutrition preferences and interventions. Weights will be monitored per physician order on the 1st and 2nd of each month. Weight change of 5 pound increase or decrease will reweighed by the 5th of the month. Physicians will be notified of a 5 pound weight increase or decrease. Executive director, Expressions director, RN, or designee will review weights weekly to develop and implement appropriate individualized interventions addressing residents' nutrition and hydration and update the service plan as needed. Any significant findings will be reported to the RN. RN will update and monitor and significant change of conditions related to weight. Executive director and Expressions director will ensure corrections are completed.

Based on interview and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

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

The need to ensure activity evaluations were completed for all residents, and individualized activity plans developed and implemented was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Activity evaluation completed for resident 1 and 2 service plan was updated. Expressions Director or designee will complete activity evaluations for all residents, and individualized activity plans developed and implemented. Evaluations will include current abilities and skills; emotional and social needs and patterns; physical abilities and limitations; adaptations necessary for the resident to participate; and activities which could be used as behavioral interventions, if necessary. Executive director and Expressions director will ensure corrections are completed.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service plan for 1 of 2 sampled residents (#2) who had behaviors in the MCC. Findings include, but are not limited to:

Resident 2 moved into the facility in 09/2022 with diagnoses including dementia.

Resident 2's current service plan dated 09/12/23, Service Plan Addendums (SPA's), progress notes and incident reports from 08/13/23 through 11/13/23 were reviewed during the survey. The following behaviors were identified:

* 08/24/23 - Wandered into another resident's room. When attempting to redirect the resident from room, the resident redirection attempted to hit staff with his/her walker and then grabbed the MT's arm and attempted to bite the staff;

* 09/02/23 - Started to be aggressive, cussing and hitting staff and banging walker into the caregiver station;

* 09/04/23 - "Resident pushed med tech several times";

* 09/04/23 - Telling staff they were stupid and using derogatory name calling;

* 09/10/23 - "Resident was very agitated today making other resident upset and not wanting other resident to be in the TV room, not very friendly today calling other resident with different names";

* 09/14/23 - Yelling, name calling towards staff, kicking and hitting the kitchen door, and "threw [his/her] oatmeal across the table which startled several other residents";

* 09/14/23 - "Resident is on alert for being aggressive with another resident;

* 09/17/23 - "Incident of aggressive taunting towards another resident"; and

* 09/25/23 - "On alert due to an incident of aggressive instigating towards another resident."

The facility had contracted with behavior support services to evaluate the resident and had a behavior plan written for staff, however, the behavior plan lacked evaluation of the above behaviors towards staff and other residents in the community and was not included on the service plan.

The need to ensure the facility developed an individualized service plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was discussed with Staff 1 (Expressions Director), Staff 5 (Operations Systems Specialist), Staff 6 (Health Services Director, RN) and Staff 7 (ED) on 11/15/23. They acknowledged the findings.

Resident 2 behaviors were evaluated and service plan was updated to reflect interventions. Behavioral home health requested on 11/16/23. Health services team will review progress notes and communications daily Monday-Friday. Behavioral symptoms which negatively impact any resident and others in the community will be evaluated and included on the service plan. All new behaviors will be evaluated upon incident. Interventions will be implemented and documented including ineffective interventions. Executive director and Expressions director will ensure corrections are completed.