Print Inspection: COZI

The findings of the re-licensure survey, conducted 07/29/24 through 08/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/01/24, conducted 02/24/25 through 02/25/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit, to the re-licensure survey of 08/01/24, conducted 05/08/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility, which posed a risk to the safety of residents. Findings include, but are not limited to:

During the re-licensure survey, conducted 07/29/24 through 08/01/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations.

Refer to deficiencies in the report.

1. The facility administrator will receive additional training from the Regional Operations Director and Elderwise consultant in the following areas: staff training, abuse reporting, fire and life safety, resident service plans and service plan team requirements, identifying changes in resident condition and monitoring for changes in condition, and ABST training.

2. The facility administrator will provide weekly updates on work completed in the above areas.

3. Facility will utilize Elderwise consultant for eight hours every other week.

4. Administrator will provide weekly updates to the RDO and consultant who will oversee the admin

Based on interview, and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse for 1 of 2 sampled residents (#2) who had reportable incidents. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in facility in 12/2023 with diagnoses including dementia.

The resident's 04/28/24 through 07/29/24 progress notes, service plan dated 04/25/24, temporary service plans, and incident reports were reviewed. The following was revealed:

*A progress note dated 07/04/24 indicated the resident was being placed on alert charting for a skin tear to the left calf.

On 08/01/24 at approximately 8:30 am, survey requested a copy of an incident report, temporary service plan, and/or investigation as to how the resident skin tear happened.

On 08/01/24 at 9:57 am, Staff 1 (Administrator) reported there was no documented evidence of an incident report, temporary service plan, or investigation of what caused the skin tear. Additionally, the was no documented evidence of how the facility ruled out abuse or neglect. Survey requested the facility report the injury of unknown cause to the local office.  

On 08/01/24 at 11:30 am, verification was received of reporting the injury of unknown cause to the local office.

On 08/01/24 at 12:00 pm, the need to ensure all injuries of unknown cause were reported to local SPD office, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse, was discussed with Staff 1 and Staff 3 (LPN). They acknowledged the findings.

1a. Resident 2 unknown injury was reported to APS the same day the deficiency was discovered.

1b. Facility administrator will conduct a staff inservice on abuse investigation and reporting. Inservice will be completed by 8/30/24. Training to include root cause analysis and fall prevention investigation.

2) All incident reports will be investigated within 24 hours and reported to APS if abuse, neglect or wrong doing can't be ruled out.

3) Incident reports will be investigated daily by the administrator.

4)Administrator will be responsible.

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

Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.

During an interview on 07/29/24 at 1:45 pm, Staff 1 (Administrator) stated she was still in the process of updating the quarterly service plan and was not finished with it yet. She also indicated the service plan which was available for staff was located in the service plan binder. The resident service plan in the service plan binder was dated 04/25/24.

Review of Resident 2's clinical record, interviews with care staff, and observations of the resident, determined the 04/25/24 service plan was not reflective of the resident care needs and lacked resident-specific direction for staff including what, when, how and/or how often to provide service in the following areas:

*Toileting;

*Dressing;

*Dietary texture; and

*Feeding assistance.

On 08/01/24 at 12:00 pm, the need to ensure a current service plan was available to staff, provided clear direction, and was reflective of current needs was discussed with Staff 1 and Staff 3 (LPN). They acknowledged the findings.

1a. Reisident 2 service plan has been updated.

1b. Service plans will be updated on or before the due date. Service plans will be updated with personalized detail for care.

2) Admin will run report weekly to see which service plans need updates. This report is run in PCC.

3) Weekly

4) Administrator

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 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 most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.

On 08/01/24 at 12:00 pm the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1. The facility administrator will establish a service plan team that meets weekly on Tuesdays. The team will include the administrator, LPN, resident, and family member/POA and case manager.

2.The service Plan team will meet weekly on Tuesdays to review service plan information for each resident.

3. Weekly

The facility admin will monitor weekly

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition, including resident-specific instructions communicated to staff on each shift, for 2 of 2 sampled residents (#s 1 and 2) who experienced a change of condition. Resident 1 had repeated falls with injury. Findings include, but are not limited to:

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

Resident 1's service plan dated 04/25/24 indicated the resident was at risk for falls due to a history of falls.

Review of Resident 1's clinical records, including progress notes, incident reports, investigations, and temporary service plans, revealed the following:

*On 06/23/24, the resident was assisted to the ground by facility staff due to the resident appearing weak and about to fall.

*On 07/12/24, the resident experienced an unwitnessed fall with injury. The resident suffered bruising, swelling, and a small abrasion to their right eyebrow. On 07/30/24 at approximately 11:55 am, Staff 1 (Administrator) reported the facility was unable to locate a temporary service plan or other documentation with actions or interventions needed to minimize the further occurrence of falls.

*On 07/22/24, incident reports and progress notes indicated the resident experienced an unwitnessed fall with injury. The resident suffered a two dime sized skin tears on the right arm, and a bump to their head. An updated quarterly service plan, dated 07/23/24, indicated the facility had implemented a pressure pad alarm to notify staff that assistance was needed due to the resident's inability to use the call light.

There was no documented evidence the facility determined or documented what resident specific actions or interventions was needed after the 07/12/24 fall to minimize the further occurrence of falls and communicated the interventions to staff on each shift, resulting in Resident 1 experiencing a repeated fall with injury on 07/22/24.

On 07/30/24 at 11:55 am, the need to ensure interventions were developed in response to changes of condition, the interventions were communicated to staff on all shifts, and were monitored for effectiveness was discussed with Staff 1 (Administrator). She acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.

Review of Resident 2's clinical records, including progress notes, incident reports, investigations, and temporary service plans, revealed the following:

*On 06/07/24, the resident experienced a witness non-injury fall. There was no documented evidence the facility determined or documented what resident specific actions or interventions was needed and communicated to staff on all shifts.

On 08/01/24 at 12:00 pm, the need to ensure interventions were developed in response to changes of condition, the interventions were communicated to staff on all shifts, was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1a. Temporary service plans were put into place for resident 1 and resident 2 that include interventions to help reduce the chances of the resident falling.

1b.  The facility administrator and LPN will conduct a staff training regarding resident changes in condition. Med Tech's will be trained to initiate the TSP for changes and communicate those changes to the RCC, LPN,  and Admin daily upon identification of the change. The LPN will notify the RN for all significant COC.

2) RCC, LPN, and Admin will conduct clinical meetings daily to ensure Tsp's are in place for each change and that the nursing staff are notified for follow up.

3) Daily

4) RCC, LPN, RN, and Admin

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#2) who was observed receiving ADL care. Findings include, but are not limited to:

On 07/31/24 at 1:45 pm, the surveyor observed Staff 4 (Resident Care Manager) and Staff 6 (Universal Caregiver) provide bowel care for Resident 2 after the resident had a bowel movement. During the observation, Staff 4 donned gloves and then proceeded to remove the resident's brief, wipe feces, and cleanse the resident. Staff 4 failed to doff the soiled gloves, perform hand hygiene, and don clean gloves before applying a new incontinence product and clothing.

On 08/01/24 at 12:00 pm, the need to ensure staff used universal precautions when providing incontinence care was discussed Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1. Administrator will conduct a staff training on proper doning and doffing of PPE. Training is scheuled for September 10, 2024

2) Staff will receive on going trainings quarterly.

3) Upon hire and quarterly

4) Administrator

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

Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia. Resident 1's clinical records and MARs/TARs were reviewed.

A review of the resident's 07/01/24 through 07/29/24 MAR identified the resident had refused medications on 13 occasions.

A physician order, dated 03/24/22, gave instructions to "Notify me each time resident refuses any medications or treatments" and "Do not notify me each time resident refuses any medications or treatments". There was no documented evidence of a clear physician order on when to notify for medication refusals. There was also no documented evidence the physician had been notified of the 13 medication refusals.

On 08/01/24, the need to ensure the facility notified the physician when a resident refused medications or treatments was discussed Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1a. Resident 1 physician was notified of the medication refusals and clear instructions were obtained by the physician on when she wants to be notified for med refusals.

1b.  Admin and LPN will conduct a staff training on resident medication refusals. Training will include where to find the documentation from the physician on when to notify them of resident refusals. Staff training will take place on September 10, 2024

2) Physician orders will be reviewed by RCC, LPN, and Admin any time a resident refuses medications and the physician notified if indicated. If no documentation of the physician's request for notificaion exists then the staff will notify the physician every time a resident refuses medication.

3) Upon move in and as needed

4) Admin, RCC and LPN

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated no less than quarterly. Findings include, but are not limited to:

On 07/30/24, the facility ABST was reviewed with Staff 1 (Administrator). 15 out of 16 residents in the facility lacked documented evidence their ABST had been reviewed and updated quarterly.

On 08/01/24 at 12:00 pm, the need to ensure resident ABST's were updated quarterly was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1) ABST will be brought up to date for each resident by 8/30/2024.

2) ABST will be kept updated at move in/move out, every 90 days and as care changes occur.

3) As changes occur, on going

4) Administrator

Based on interview and record review, it was determined the facility failed to include and document all required elements of fire drills, and to provide fire and life safety instruction to staff on alternate months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 07/31/24, review of facility fire drills and fire life safety trainings, from February 2024 to July 2024, identified the following deficiencies:

*Documentation of fire drills failed to include escape routes used, including alternate routes; and

*Fire and life safety instruction to staff was not consistently provided on alternating months.

On 07/31/24, the need to document all required elements for fire drills and provide fire and life safety instruction to staff on alternate months, in accordance with the OFC, was discussed with Staff 1 (Administrator) and Staff 5 (Maintenance). They acknowledged the findings.

1)We will conduct a fire drill this month to include all the elements needed: including alternate routes used. Admin will ensure that live drills are alternated every other month with normal training as per regulation.

2) A fire drill/fire safety event will happen monthly with proper documentation.

3) Monthly

4) Administrator and maintenance director

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

Refer to Z 155.

Refer to Z155

Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to:

Review of records for Residents 1 and 2 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.

During an interview on 07/31/24, Staff 1 (Administrator) reported none of the 16 residents residing in the facility had been given keys to their rooms.

On 07/31/24, the need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1) Keys have been provided to each resident. They are located on a hook inside of the closet. The ability to use a key is also care planned.

2) Extra keys have been made and will be offered to every new move in.

3) At time of move in and quarterly

4) Administrator

Based on interview and record review, it was determined the facility failed to apply individually-based limitations when residents were not provided with a key to their room. Findings include, but are not limited to:

Refer to H 1518.

Please refer to H1518

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 150, C 231, C 295, C 361, and C 420.

Please refer to C150, C231, C295, C361, and C420

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 7 and 8) completed all required pre-service dementia trainings and demonstrated competency in all assigned job duties within 30 days of hire, to have a system to ensure all care staff completed 16 hours of annual in-service training including at least six hours of dementia care, and 1 of 2 (#9) long-term employees completed annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 07/31/24 with Staff 1 (Administrator).

a. There was no documented evidence Staff 7 (Med Tech) and Staff 8 (Universal Caregiver), hired 06/18/24 and 06/21/24, respectively, completed one or more of the following pre-service dementia training topics:

* Environmental Factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.);

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

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

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

b. There was no documented evidence Staff 7 (Med Tech) and Staff 8 (Universal Caregiver), hired 06/18/24 and 06/21/24, respectively, demonstrated competency within 30 days of hire in one or more of the following areas:

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

* General food safety, serving, and sanitation.

c. During an interview on 07/31/24 with Staff 1 (Administrator), it was reported the facility currently did not have a process to ensure direct care staff completed annual training hours.

d. There was no documented evidence Staff 9 (Cook), hired 12/06/18, completed required annual infectious disease training.

On 08/01/24, the need to ensure staff completed all pre-service dementia trainings, direct care staff demonstrated competency in all assigned duties within 30 days of hire, systems in place to ensure long-term direct care staff completed required number of annual training hours, and all staff completed annual infectious disease training, was discussed with Staff 1 (Administrator). She acknowledged the findings.

1a. The facility admin will ensure that staff receive all of the required orientation training before they are allowed to work with residents. A copy of the completed transcript will be maintained in the employee file.

1b. The facility admin will assign monthly training for the employees on revelant topics including the annual state required trainings. These trainings will be maintained by the admin.

2. The facility admin will receive training on employee trainings by the business office manager from Kinsington Oak Grove as well as Elderwise Consultant.

3. Weekly and on-going

4. The facility Administrator

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 12, 13, and 14) completed all required pre-service dementia training and demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 02/25/25 with Staff 10 (Administrator).

a. There was no documented evidence Staff 11, (MT/Universal CG), Staff 12 (Universal CG), Staff 13 (Universal CG) and Staff 14 (Universal CG) hired 12/10/24, 12/16/24, 01/03/24, and 01/14/25 respectively, completed one or more of the following pre-service dementia training topics:

* Environmental factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.);

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

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

b. There was no documented evidence Staff 11, Staff 12, Staff 13, and Staff 14  demonstrated competency within 30 days of hire in one or more of the following areas:

* Providing assistance with ADLs; and

* Medications and Treatments.

During an interview on 02/24/25, Staff 1 stated Staff 11 was due to work the overnight shift beginning on 02/24/25. Staff 1 confirmed an experienced staff member would be scheduled to meet with Staff 11 that evening to verify competencies for medication and treatment  administrations. Confirmation was received on 02/27/25.

The need to ensure newly hired staff completed all required pre-service dementia training and demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 10 and Staff 15 (Administrator Designee) on 02/25/25 at 3:20 pm. They acknowledged the findings.

1. The administration will conduct a comprehensive audit of all employee files to ensure that all mandated training requirements have been fulfilled. In cases where training is incomplete, staff members will be given a period of two weeks to complete the necessary training modules. This initiative aims to uphold compliance standards and enhance overall professional development within the organization.

2.Upon the onboarding of a new employee, the administration will assign a designated trainer who will provide a comprehensive checklist for the new hire to complete. Once this checklist is filled out, the trainer will present it to the Resident Care Manager (RCM) for a review with the new employee. Additionally, all necessary new hire paperwork must be completed before any floor training can commence, and it is imperative that the new employee satisfies all preservice requirements. The administration and RCM will collaborate to conduct an audit of the employee files to ensure compliance and completeness. Furthermore, to support ongoing professional development, the administration will schedule a one-hour continuing education class each month. As a proactive measure, one month prior to each employee's anniversary, the administration will assign all required yearly classes to ensure continual growth and adherence to training standards.

3. An audit will be conducted prior to an employee's first shift on the floor to ensure that all preservice classes have been completed. Following this, a review will take place during the second week of the employee's tenure to confirm that they have successfully completed all necessary check-

off procedures and are prepared to provide care for residents. Additionally, a comprehensive assessment will be conducted 30 days after hire to verify that all required classes have been fulfilled. Subsequently, audits will be performed every 90 days to ensure compliance with all training requirements, including CPR, First Aid, and Food Handlers' certification, as well as to confirm that background checks are completed before their expiration.

4. The person responsible for overseeing this process will be the Administration, with support from the Resident Care Manager (RCM). Together, they will ensure that all audits, training requirements, and compliance checks are executed efficiently and effectively, fostering a structured onboarding and continued education experience for all employees. This collaborative effort will help maintain high standards of care and operational excellence within the organization.

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

Refer to C 260, C 262, C 270, and C 305.

Please refer to POC for C260, C262, C270 and C305.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed, and included in the service plan for 1 of 2 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 12/2023 with diagnoses including dementia.

The current service plan for Resident 2 was reviewed and lacked an individualized nutrition and/or hydration plan.

On 08/01/24 at 12:00 pm, the need for individualized nutrition and hydration plans was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1a. Resident 2 service plan has been updated to include a nutrition and hydration plan.

1b.  individual meal and hydration plans have now been added to each service plan

2) Our service plan format has been changed.

3) With each service plan created and at every review.

4) Administrator

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

Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.

Review of Resident 2's service plan and individual activity plan offered some information about the resident's interests, however, the facility had not fully evaluated the resident's:

*Physical abilities and limitations;

*Adaptations necessary for the resident to participate; and

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

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

On 08/01/24 at 12:00 pm, the need to ensure the facility completed an individualized activity plan for each resident was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings.

1a. Resident 2 service plan has been updated to include an activity plan.

1b. Activities/Life enrichment plans have been added to all service plans.

2) Our service plan format has been changed.

3) With each service plan created and at every review.

4) Administrator