Print Inspection: CWR0

The findings of the re-licensure survey, conducted 04/25/22 through 04/27/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 04/27/22, conducted  11/01/22  through 11/03/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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

A situation was identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0025 (4) Reasonable Precautions.

The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the second revisit to the re-licensure survey of 04/27/22, conducted 05/23/23 through 05/24/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 re-licensure survey, conducted 04/25/22 through 04/27/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

OAR 411-054-0025 (1) Facility Administration: Operation

Please refer to all citations in this report.

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

During the revisit to the re-licensure survey of 4/27/22, conducted 11/01/22 through 11/03/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

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OAR 411-054-0025 (1) FACILITY ADMINISTRATION OPERATION

REFER TO DEFICIENCIES IN THE REPORT

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

A tour of the facility, conducted 04/26/22, identified the following required postings were not displayed or accessible:

* The name of the administrator or designee in charge, posted by shift;

* A copy of the most recent survey, including all revisits and Plans of Correction ; and

* The facility staffing plan.

The facility is comprised of four separate houses. Three of the houses had residents currently residing in them, and the fourth house was being used by administrative staff. One of the resident houses had a copy of the most recent survey, the other three houses did not.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) on 04/27/22. She acknowledged the findings.

OAR 411-054-0025 (5) Facility Administration: Required Postings

1(a). Effective 5/1/2022 the name of the administrator or designee in charge was posted and available for view in the common area near the front door

1(b). Effective 5/1/2022 the most current survey was posted and available for view in the common area near the front door.

1(c.) Effective 5/1/2022 the facility staffing plan was posted in an accessible and conspicuous location near the front door.

2 (a, b, c) The administrator will be trained on the importance of accurate postings and provided with a copy of the Oregon Administrative rules and regulations for reference.

3. Administrator will check at least weekly during campus walk through

4. The Administrator or designee will ensure corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure the preparation, completeness and accuracy of resident records. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia, lower extremity edema, and a history of hip fracture.

A review of Resident 4's clinical record revealed:

a. Resident 4 experienced falls on 02/15/11 and 04/20/22, both resulting in injuries. There was no documented evidence the facility investigated the fall on 02/15/22. The fall on 04/20/22 was identified as "the first fall for [Resident 4]...".

b. The facility was administering Lasix 20 mg daily and Potassium Chloride ER 10 meg daily to Resident 4. There were no signed physician's orders for the medications.

c. Resident 4 was receiving nursing care from a home health agency for a wound to the lower left leg. Some of the home health documentation was not available onsite. There was no evidence of review by the facility of the home health documentation. Staff 2 (RN) was not aware of the wound and had not completed an assessment.  

2. Resident 5 was admitted to the facility in 12/2020 with diagnoses including insulin dependent diabetes, used oxygen via nasal cannula, and had a supra-pubic catheter.

A review of Resident 5's record revealed:

a. Resident 5 was evaluated on 03/11/22 to smoke independently and safely. Resident 5 was observed to smoke while wearing oxygen on two occasions during the survey.

b. Resident 5 was observed with the catheter bag hung above the bladder on multiple occasions during the survey.

Resident 5's evaluation and service plan were not complete or accurate related to smoking and catheter managment.

The need to conduct and document investigations of all incidents, ensure documentation was accurate and complete, and part of the resident's record was, discussed with Staff 1 (Administrator) on 04/27/22. She acknowledged the findings.

3. Resident 3 was admitted to the facility in 12/2021 with diagnosis's including a history of substance abuse and addiction.

A review of Resident 3's clinical record revealed:

Resident 3 experienced multiple missed medications resulting in withdrawal symptoms and an ER visit on 04/19/22. There was no documented evidence the facility monitored the resident for withdrawal symptoms upon return from the hospital. Resident 3's record lacked any discharge information or instructions from the hospital.

Resident 3's record was found incomplete.

On 04/26/22, the need to ensure resident records were complete was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0025 (8) Facility Administration: Records

1. (a) Effective 5/5/2022 All facility staff were trained on proper reporting of incidents to the facility Administrator and Facility RN. Facility Administrator will ensure all Incidents are followed up on by the close of the next business day.

1. (b) Effective 4/27/2022 facility Administrator provided a copy of Resident 4's signed physician orders. Facility Administration will ensure all signed orders are available upon receipt of any new or existing medication orders. Orders will be placed in Resident binders under the Physicians order tab.

1. (c) Administrator will ensure that outside provider forms are available for Home Health/Hospice when they come for visits. RN will review all outside provider documentation at least weekly to ensure documentation in place and followed up on accordingly.

1. (d) Resident 5's service plan was updated as was the smoking assessment by 4/27/22. Service plan update included both smoking and proper catheter management. Staff were immediately inserviced on the changes to the service plan and signed an inservice acknowledging the changes.

1. (e). Resident 3 went to the ER for signs and symptoms of withdrawl. Upon return Staff failed to intiate monitoring for continuation of symptoms. Effective 5/5/2022 all staff were re-trained on incident report steps and procedures, which include filling out the report, notifying the RN, Admin and any family, and the Physician, initiating Alert charting, and initiating a temporary plan of care for the incident. Management and Faciltiy RN will check daily to ensure the proper steps are being followed after incidents are reported.

2. The system will be corrected so this violation does not happen again by ensuring that the service plan is created to reflect the Residents current status prior to  Move in, within 30 days, every 90 days thereafter or with any significant change of condition per company policy and Oregon State Rule.

All updates to the service plan should be initialed and dated. Leadership to provide observations to ensure service plans are being followed.

All Resident Service plans should be reviewed and updated to reflect any changes or personalization via "Temporary service plan". Clinical staff, care staff, Administrator and Resident participate with this process to ensure accuracy, as well as family upon approval/request by the Resident. All updates to the service plan are placed in the 24 hr. book for all staff to review and sign off on.

3. The area needing correction will be evaluated Quarterly. Changes to service plans will be reviewed daily by management team.

4. Administrartor and registered nurse will be responsible to ensure corrections are completed and maintained.

Based on observation and interview, it was determined the facility failed to exercise precautions against any condition that could threaten the health, safety, and welfare of residents and failed to practice effective methods of infection control. Findings include, but are not limited to:

During the survey, conducted 04/25/22 through 04/27/22, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID 19 and made available to all facilities, were not being followed by the facility.

Observations made during the survey from 04/25/22 through 04/27/22 revealed the following:

1. On 04/25/22 at approximately 12:00 pm, the Surveyors entered the facility building Manzanita 1 and observed Staff were wearing cloth masks below their noses. Surveyors were directed to building Manzanita 2. Staff in Manzanita 2 were not wearing masks. Staff were informed of the need to wear medical masks and masks were donned. Staff did not complete any COVID 19 screening of the surveyors.

2. During an observation on 04/25/22 and 04/26/22, the common area restrooms and resident bathrooms were without hand soap and paper towels.

3. On 04/25/22, soiled bed linens were observed directly on the floor of a resident room.  Staff carried the un-contained linens through the living room and placed them on a dining room table.

4. A small plastic trash can labeled, "Med destruction only", filled approximately half full with cat litter with a plastic bag on top, was on the back deck of the Sage 1 house.

On 04/25/22, Staff 1 (Administrator) confirmed the can was filled with disposed medications and cat litter.

5. On 04/25/22 and 04/26/22, Resident 5 was observed smoking with oxygen on via a nasal cannula and oxygen canister on his/her wheelchair. Staff were asked to immediately intervene on 04/25/22 and the oxygen was turned off.

On 04/26/22 a plan was requested to ensure the unsafe smoking practice was prevented.  Resident 5's cigarettes and lighter were removed and a Service Plan update for staff was initiated.

The failure to ensure universal workers consistently utilized appropriate infection control and there were precautions against conditions that could threaten the health, safety, and welfare of residents was discussed with Staff 1. She acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions

1.(a)Staff will be provided with training on infection control pratices, including all current Covid 19 Precautions and screening of visitors.

2. A maintenance team from corporate will come and replace all soap and paper towel dispensors in all bathrooms. A monthly health and safety audit will be completed to ensure all dispensors are full and in good working order.

3. All facility Staff will be trained on infection control and safe handling of contaminated. All soiled linens will be moved throughout the facility in a contained bag or hamper.

4. Effective 5/5/2022 All staff were trained on proper medication disposal. Chemical medication destroyer was ordered and will be available for medication disposal. Destruction chemical bottles will be kept in a locked closet and disposed of when full.

5. Resident 5's service plan was updated as was the smoking assessment. Staff were immediately inserviced on the changes to the service plan and signed an inservice acknowledging the changes. All residents who smoke will be assessed quarterly at the time of their service plan review to ensure all residents who smoke are doing so in a safe manner.

Administrator will review and ensure systems being followed at least weekly and monthly during audits.

Administrator and/or Designee as well as Maintenance Director will be responsible for ensuring corrections are completed and maintained.  

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. This placed residents at serious risk of harm or injury and constituted an immediate threat to residents' health and safety. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in December 2020, with diagnoses including chronic obstructive pulmonary disease and major depressive disorder.

Interviews, observations and review of Resident 5's clinical record revealed the following:

During the acuity interview on 11/01/22, the facility stated there were three residents who smoked cigarettes in the Manzanita 2 House. Resident 5 was reported to smoke cigarettes and used continuous flow oxygen, via nasal cannula.

Resident 5's service plan and evaluation dated 09/04/22, stated the resident was alert, oriented, able to make decisions and had been evaluated to be safe and independent with smoking cigarettes but had a history of non-compliance related to oxygen use while smoking.

The service plan stated staff held Resident 5's cigarettes in the medication room and provided cigarettes per the resident's request and directed staff to observe for potential concerns related to "being non compliant with smoking" and immediately report concerns to the Administrator.

During an interview on 11/02/22, Staff 8 (Universal Worker/MT) stated the staff held Resident 5's cigarettes in the med room and usually gave him/her eight cigarettes per day at his/her request. Staff were to observe to ensure the oxygen was turned off and the nasal cannula was removed from the resident's face prior to the resident leaving the building to smoke.

During an interview on 11/02/22, Resident 5 was alert and oriented and stated s/he was aware of the risks and safety precautions related to smoking with oxygen.

On 11/03/22 at 12:40 pm, Resident 5 was observed sitting in his/her wheelchair outside with another resident in the facility's designated smoking area. Resident 5's oxygen tank, placed on the back of the wheelchair, was observed with the flow dial in the on position at 3 Liters per minute. Resident 5 had a partially burned cigarette, no longer lit, in hand and the other resident in the smoking area was actively smoking a lit cigarette. Resident 5 stated s/he had removed the nasal cannula but must have forgotten to turn the tank off.

The surveyor immediately intervened and had staff turn the oxygen tank off. Staff 8 stated they must have missed the residents exiting the building to smoke.

The facility's failure to ensure Resident 5's oxygen tank had been turned off prior to the resident being in close proximity of lit cigarettes placed residents' safety in immediate jeopardy of potential harm or injury related to serious fire hazards. The facility provided an immediate plan of correction to the survey team on 11/03/22 at 4:00 pm, and the immediate jeopardy was abated.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 15 (Regional Director of Operations) on 11/03/22, they acknowledged the findings.

C160

OAR 411-054-0025 (4) REASONABLE PRECAUTIONS

1. Resident's service plan was immediately updated and approved by the survey team for staff to remove the oxygen tank and nasal cannula from the wheelchair each time the resident would like to go out and smoke. Staff will continue to keep cigarettes locked and provide them to resident as requested. Staff in-service was held immediately to inform and update of the changes.

2. Med-Tech is designee on each shift and will ensure service plan is being followed. Staff have been instructed to notify RN/Administrator if there is a deviation from service plan.

3. Administrator/RN/RDO will audit, review and monitor that processes are being followed on a routine basis.

4. The Administrator, Licensed Nurse or Designee will be responsible to ensure the system has been corrected and is monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was clean, in good repair, and nutritious meals were being provided in accordance with the United States Department of Agriculture (USDA) guidelines and Food Sanitation Rules, OAR 333-150-0000. Findings include, but are not limited to:

The kitchen was toured on 04/26/22. The following areas were identified as needing cleaning or repair:

Sage 1 house:

* The refrigerator had dried spills and food matter on the shelves;

* The floors had missing baseboard pieces and exposed wood on the entry gates;

* Multiple cabinets were missing the doors and trim; and

* The floors, cabinet shelves and drawers had food debris and crumbs throughout.

Sage 2 house:

* The kitchen sink faucet was loose and required repair;

* Outlet near the coffee pot was missing the cover plate;

* Multiple pots and pans had dried-on food and build-up;

* The floors had missing baseboard pieces and exposed wood on the entry gates;

* Multiple cabinets were missing the doors and trim; and

* The floors and cabinet shelves, drawers had food debris and crumbs throughout.

Manzanita 1 house:

* Multiple food items in the refrigerator were not labeled and dated. Food was not shelved to allow for air circulation;

* The refrigerator had dried spills and food matter on the shelves;

* The trash can lid had dried spills and food debris;

* Multiple cabinets were missing the doors and trim; and

* The floors and cabinet shelves, drawers had food debris and crumbs throughout.

Manzanita 2 house:

* Microwave had dried splatters and food debris inside;

* The kitchen walls had holes that required repair, some patched areas did not have paint;

* Multiple cabinets were missing the doors and trim; and

* The floors and cabinet shelves, drawers had food debris and crumbs throughout.

In all three houses with residents:

* Raw meats and poultry were being thawed on the top shelves of refrigerators and without any tray or pan underneath to catch potential spills;

* Multiple pots and pans had dried-on food and build-up ; and

* The meals being provided to residents were not equal in nutritional value with the prescribed menu the facility was given to follow from their Registered Dietician.

During an interview on 04/26/22, Staff 1 (Administrator) was asked about the facility menu posted in the houses and provided to surveyors. Staff 1 stated the menus were provided by a system called "Grove Menu's". A print out was provided of the menu for 04/24/22 through 04/30/22 and was signed by a Registered Dietician (R.D.)  The food provided by the facility was not the same, in items listed or nutritional value, as the food on the Grove Menu. Staff 1 explained "care staff" are supposed to fill out a form and submit it to the Regional office when menu substitutions were made. The facility did not have any completed forms to provide as evidence this had been done. Staff 1 explained food substitutions had to be made "towards the end of the month" related to the increased costs of food and limited budget.

The need to ensure the kitchens were clean, in good repair, and that the facility was providing nutritious meals daily was discussed with Staff 1 (Administrator) on 04/26/22. She acknowledged the findings.

OAR 411-054-0030 (1) (a) Resident Services, Meals, Food Sanitation Rule

1. A deep clean of all kitchens will be completed to include all appliances, drawers, cupboards, interior and exterior.

2.Effective 5/5/2022 all cleaning schedule check lists were reviewed and updated to reflect daily, weekly and monthly cleaning and sanitizing. All staff were provided training on updated cleaning and sanitizing schedules.

3. The cleaning schedule check lists will be reviewed daily, then weekly to identify any challenges or concerns and completion of duties

4.The Administrator or designee will be responsible to ensure the corrections are completed/monitored

5. Effective 5/5/2022, Safe food handling and storage was reviewed with staff. All staff are to ensure that all meats are stored on the bottom shelf with a pan or bowl under them to catch any potential leaks, drips or spills. All items in the refridgerators will be dated with an open date and fridges will be checked daily for anything needing disposed of. All fridges will be kept clean per the cleaning schedule.

6. All items needing repair will be repaired by our corporate maintenance team. Outside vendors will be hired for any repairs not able to be completed by the company maintenance. This includes all missing cupboard doors, baseboards, gaps in the flooring, kitchen faucet, outlet cover plates, trim, and any exposed wood or patches that need to be fixed/finished.

7. Effective 5/5/2022 all staff have been re-trained on how to properly document menu substitutions. Our corporate office is currently re-evaluating grocery budgets to address the rising cost of groceries, to ensure our resident continue to receive nutricious meals

Based on observation and interview, it was determined the facility failed to ensure house kitchens were clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observations of the kitchen in Manzanita 1 on 11/01/22 showed the following:

* Black and brown spills and debris within cabinets and drawers;

* Missing laminate on the cabinet and pantry shelves;

* Loose eggs in a refrigerator drawer without any indication of a date of expiration;

* Vegetable drawer was densely packed with produce without room for air circulation;

* A build up of drips, spills and splatters were noted on multiple surfaces in the kitchen; and

* A broken kitchen screen with a an opening to the outside and multiple dead insects noted in the window track.

Observations of the kitchen in Sage 2 on 11/02/22 showed the following:

* Spills and debris in the cupboards and drawers;

* Peeling and bubbling shelf surfaces with exposed, untreated wood/fiber board in the cupboards, along the window sill and on the wall near the gate;

* Spills and debris were noted in the refrigerator and freezer; and

* Dark accumulation was noted along the baseboards and edges of the floor in the pantry/dry storage area, food debris was on the floor and lower shelves, red splatter was noted on the door and lower shelf, an open package of crackers and a pan with half a cake was uncovered on upper shelves.

Observations of the kitchen in Manzanita 2 on 11/02/22 and 11/03/22, showed a large number of loose eggs without any indication of an expiration date, were stored within a crisper drawer of the refrigerator. Additionally, the vegetable drawer was overly stuffed with produce and did not provide adequate air circulation.

The need to ensure all house kitchens were kept clean and in good repair and foods were stored properly was discussed with Staff 1 (Administrator), Staff 15 (Regional Director of Operations) and Staff 20 (Maintenance) on 11/02/22 and 11/03/22. The staff acknowledged the findings.

C240

OAR 411-054-0030 (1)(a) RESIDENT SERVICES: MEALS, FOOD SANITATION RULE

1. Manzanita 1-

(a) Deep clean scheduled for the week of 11/14/22 for the kitchen to address the: spills and debris in cabinets/drawers; drips, spills and splatters on multiple surfaces

(b) Cabinet shelving will be cleaned and lined with contact paper

[c] Kitchen window screen has been replaced and window track has been cleaned

(d) Eggs are now being stored in the cardboard crate that identifies the date of expiration

[e] Vegetables will be distributed out between the two vegatable drawers with the eggs being stored in the cardboard egg crates and not loosely in the one vegetable drawer, this allows for more storage

Manzanita 2-

(a) Eggs are now being stored in the cardboard crate that identifies the date of expiration

Sage 2-

(a) Deep clean scheduled for the week of 11/14/22 for the kitchen to address the: spills/debris in cupboards/drawers and refrigerator/freezer; Baseboards/edges of floors in pantry/dry storage area; overall thorough deep clean

(b) All cupboards and drawers are being cleaned and lined with contact paper to address the peeling and bubbling shelf surfaces with exposed, untreated wood/fiber board in cupboards.  

2. Deep cleaning schedule check lists were reviewed and updated to reflect daily, weekly and monthly cleaning tasks. Staff are being provided routine training and coaching on all cleaning schedules

3. Administrator, Assistant Administrator or RDO will audit routinely, but no less than weekly to ensure cleanliness and proper storage is being maintained.

4. The Administrator or Designee will be responsible to ensure the system has been corrected and is monitored.

Based on observation and interview, it was determined the facility failed to provide an activity program based on individual and group interests. Findings include, but are not limited to:

During the re-licensure survey, 04/25/22 through 04/27/22, there was a lack of unscheduled and scheduled activities that occurred for residents.

Staff were Universal Workers and responsible for caregiving, medications administration, housekeeping, laundry, meal preparation and service in addition to providing activities.

No activities were observed to be provided:

*04/25/22 from approximately 12:00 pm to 4:30 pm; and

*04/26/22 from approximately 8:00 am to 4:00 pm;

Interviews with residents and a visitor revealed the following regarding activities:

*"Not much...sit around";

*"they don't do activities anymore, and

*"Have not seen activities happen".

The lack of an activity program based on individual and group interests was discussed with Staff 1 (Administrator) on 04/26/22. She acknowledged the lack of an activity program.

OAR 411-054-0030 (1) (c-d) Resident Services: Activities

1. Actions taken to correct the rule violation include;

a. Facility will hire a full time activities director for the campus within 30 days.

b. Having one full time activites coordinators that  provides indivdual and group activities that meet the physical, mental, and psychosocial needs of residents.

c. Providing in-servicing to staff on creating unscheduled activities, and how to follow schedule/directions for after hours activities.

2. System will be corrected by following the activities calendars consistently, review of activities during weekly leadership meeting, ensuring staffing and supplies are avalible to meet the activity programining needs.

3.The area will be evaluated weekly, and then monthly with the creation of the new calendar for the campus

4. Administrator and Activities Director will be responsible for corrections being complete and monitoring.

Based on observation and interview, it was determined the facility failed to consistently provide an activity program based on individual and group interests. This is a repeat citation. Findings include, but are not limited to:

During the revisit to the re-licensure survey, 11/01/22 through 11/03/22, there was a lack of scheduled and unscheduled activities observed for residents in all three houses.  

Staff were Universal Workers and responsible for caregiving, medication administrations, housekeeping, laundry, meal preparation and service in addition to providing activities when the activity staff was not present.

In interview on 11/02/22, Staff 15 (Regional Director of Operations) indicated a new activity director started a few days prior to survey. The activity staff person spent an hour in the morning and an hour in the afternoon in each house, per day, during her five-day work week.

Observations of Sage 2, Manzanita 1 and Manzanita 2 between 11/01/22 and 11/03/22 from 9:30 am to 5:00 pm showed the following:

* The activity staff was absent 11/01/22 and 11/02/22 due to illness.

* No activities were observed in Sage 2 on 11/02/22.

* No activities were observed in Manzanita 2 during afternoon observations on 11/01/22.

* No activities were observed in Manzanita 2 on 11/02/22.

* A card game was observed in Manzanita 1 during afternoon observations on 11/02/22.

* The TV was on throughout the day and evening in all three houses.

* A craft activity was observed in Sage 2 and Manzanita 2 on 11/03/22, led by the activity staff member.

The activity calendar posted in all three houses listed the following daily activities:

* Morning Motivation, pledge of allegiance, storyline and this day in history.

* Additional rotating activities included chair exercises, sit and sip, sing along, balloon fun, baking fun, turkey themed crafts and movie night.

The calendar did not include any times or locations the activities would take place. The activities listed for 11/01/22, 11/02/22 and 11/03/22 did not occur.

Interviews with residents and staff between 11/01/22 and 11/03/22 revealed the following:

* " ...used to go on walks all the time, rarely happen now;"

* "Not much...sit around;"

* "What you see is what you get, TV;"

* "Would be great if there was actually something to do;"

* "I don't have time to do activities with the residents;"

* "The residents don't want to do anything any way;"

* "Haven't heard about anything going on;"

* " ...activities ....HA!"

The lack of an activity program based on individual and group interests was discussed with Staff 1 (Administrator) and Staff 15 on 11/02/22 and 11/03/22. They acknowledged the findings.

C242

OAR 411-054-0030 (1)(c-d) RESIDENT SERVICES: ACTIVITIES

1.

(a) Activity Director on-site 40 hours per week

(b) Activity Director is creating the activity calendar for the upcoming month that will be reflective of locations and times of activities

[c] Administrator did an immediate in-service training with all staff to address the expectation with activities if and when the Activity Director is not on-site

(d) All staff training is scheduled for the week of 11/28/22 and the expectation of activities will be re-addressed at this meeting

2. Activity Director will ensure that activity schedules are up and supplies are available to meet the scheduled activity program needs. Administrator, Assistant Administrator or Activity Director will ensure that all houses have supplies available for unscheduled activities.

3. The Administrator, Assistant Administrator or Activity Director will review weekly, then monthly to ensure resident activities are being offered daily

4. The Administrator, Activity Director or Designee will be responsible to ensure the system has been corrected and is monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure smoking evaluations were reflective of the current status for 1 of 2 sampled residents (#5) whose smoking evaluations were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 12/2020 and utilized oxygen via a nasal cannula.

In an interview with Staff 4 and 5 (Universal Workers) on 04/25/22, they explained Resident 5 smoked independently and was given eight cigarettes a day. They reported Resident 5 used oxygen at all times.

On 04/25/22 at approximately 4:30 pm, Resident 5 was observed seated in a wheelchair outside with a group of residents smoking. Resident 5 had oxygen on via a nasal cannula at 3 liters per minuet from a canister attached to the back of the wheelchair. Resident 5 was questioned about removing the oxygen to smoke. S/he removed the tubing and held it in his/her lap next to the lit cigarette. Staff were immediately notified to assist Resident 5 with turning off the oxygen. Staff indicated Resident 5 often smoked with the oxygen on.

The above observation was reported to Staff 1 (Administrator). Resident 5's 03/11/22 smoking evaluation was reviewed and found to be inaccurate, indicating Resident 5 smoked safely and followed facility protocol.

On 04/26/22 at approximately 8:00 am, Resident 5 was again observed seated in a wheelchair outside with a group of residents smoking. Resident 5 had oxygen on via a nasal cannula at 3 liters per minuet from a canister attached to the back of the wheelchair. Staff were immediately notified.

An immediate plan to prevent any further incidents of unsafe and dangerous smoking was requested from Staff 1.

All cigarettes and lighters were removed from Resident 5, a new smoking evaluation was completed, and a service plan update was created.

The need to ensure the accuracy of evaluations to develop service plans was reviewed with Staff 1. She acknowledged the findings.

OAR 411-054-0034 (2-4) Resident move-in and Eval: Res Evaluation

1. (a)Effective 4/26/2022Resident #5's evaluation was be updated to include the following components; new smoking evaluation, safety plan, and a service plan update was created.

1. (b)An instant inservice was provided for the staff to ensure resident's smoking materials were locked in the med cart, and her oxygen is to be removed before the resident is given her smoking materials.

2. All resident evaluations will be reviewed to ensure all required componets are reflective of his / her needs.

3. Upon admission of new resident, quarterly and / or with a signifcant change of condition.

4. The Administrator or designee will be responsible to ensure the system has been corrected/monitored.

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 to staff for 2 of 4 sampled residents (#s 4 and 5). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia and edema.

Observations of the resident, interviews with staff from 04/25/22 to 04/26/22, review of the service plan, dated 03/01/22, progress notes, incident reports and Home Health documentation showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Sleeping pattern;

* Blood thinner use;

* Skin condition;

* Falls and safety interventions; and

* Hearing Aid use.

2. Resident 5 was admitted to the facility in 12/2020 with diagnoses including insulin dependent diabetes and was identified to smoke.

Observations of Resident 5, interviews with staff and the resident from 04/25/22 to 04/26/22, review of the service plan, dated 03/11/22, progress notes, and smoking evaluation showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Catheter care; and

* Smoking safety and oxygen use.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

1. Actions taken to correct the rule violation will include;

a. Resident #4 service plan will be updated to include Sleeping Pattern, use of blood thinners, skin conditions, falls and safety interventions, and Hearing aide use. .

b. Resident #5 service plan updated to include catheter care(specifically bag placement), Smoking safety and oxygen use.

2. The system will be corrected so this violation does not happen again by ensuring that the service plan is created to reflect the Residents current status prior to  Move in, within 30 days, every 90 days thereafter or with any significant change of condition per company policy and Oregon State Rule.

All updates to the service plan should be initialed and dated. Leadership to provide observations to ensure service plans are being followed.

All Resident Service plans should be reviewed and updated to reflect any changes or personalization via "Temporary service plan". Clinical staff, care staff, Administrator and Resident participate with this process to ensure accuracy, as well as family upon approval/request by the Resident. All updates to the service plan are placed in the 24 hr. book for all staff to review and sign off on.

3. The area needing correction will be evaluated Quarterly. Changes to service plans will be reviewed daily by management team.

4. Administrartor and registered nurse will be responsible to ensure corrections are completed and maintained.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed.  Findings include, but are not limited to:

Residents 1, 3, 4, and 5's most recent service plans lacked documentation of a service planning team that consisted of the resident, the resident's legal representative, if applicable, or any person of the resident's choice.

On 04/26/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0036 (5) Service Plan: Service Planning Team

1. Resident's 1, 3,4, and 5 service plan will be reviewed by administrator and nursing services and any recommended updates added. A service planning meeting will be scheduled if possible. When not possible Administrator will ensure a phone meeting can be scheduled. If neither of the above options are available Administrator will mail a copy of the service plan to the resident's representative. The administrator will ensure all documentation is completed stating how the Service planning meeting occurred.  Re Updated service plans will be placed in the 24 hour book for staff review.

2. System will be corrected by ensuring service plans are updated by the service planning team quarterly and reviewed by the facility RN and administrator prior to placing in the 24 hour binder for all staff review.

3. System will be reviewed weekly via the morning manager meeting and quarterly.

4. Administrator and registered nurse will ensure correctiosn are completed and monitored.

2. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia.

Resident 4's 03/01/22 service plan, 01/28/22 through 04/25/22 Observation Notes, home health nursing notes, and Nursing Assessment form were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and lacked resident specific directions to staff in the following areas:

* Falls with injuries;

* Hospitalization;

* Medication changes; and

* Wounds.

Resident 4 experienced the following significant changes without documented evidence of an evaluation, referral to the facility nurse, and update of the service plan:

*Open wound to the lower left leg; and

*Compression fracture to the back.

The need to ensure changes of condition were evaluated, referred to the RN, if significant, had documentation to reflect at least weekly monitoring to resolution, and provided clear, resident specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/26/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated, interventions were determined, documented, communicated to staff, and the determined actions were resident-specific and residents were monitored consistent with their evaluated needs for 3 of 4 sampled residents (#s 1, 3, and 4) who had changes of condition or who required monitoring. Findings include, but are not limited to:

Resident 1 was admitted in 2020 with diagnoses which included TBI (traumatic brain injury) and Schizoaffective disorder.

Review of the medical record revealed Resident 1's weight dropped from 145 pounds on 09/07/21, to 127 pounds on 01/18/22, a loss of 18 pounds (12%) in four months.

The current service plan, dated 02/21/22, did not include any reference to weight loss or interventions. In an interview on 04/26/22, Staff 3 (House Manager/ Universal Worker) stated there had not been any service plan updates related to weight loss.

The "care instructions" page of the service plan instructed staff to documented the percentage of the residents meal finished, however, review of the 04/2022 "Recorded Care Report" showed approximately half of the meals were marked "not recorded".

On 04/26/22, Staff 2 RN acknowledged the weight loss had not been evaluated, and no resident specific interventions were developed.

The need to ensure changes of condition were evaluated, had documentation to reflect monitoring at least weekly to resolution, and to provided clear resident specific directions to staff, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/26/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 12/2021 with diagnoses including a history of substance abuse and addiction.

On 04/19/22, review of the resident record indicated Resident 3 ran out of their routine Morphine (45 mg twice daily) and were sent to the ER to treat withdrawal symptoms.

On 04/26/22, Staff 7 (Universal Worker) reported the resident returned to the facility on 04/19/22 from the severe withdrawal symptoms after being treated at the hospital.

There was no documented evidence the facility monitored the resident's return from the hospital after experiencing severe withdrawal symptoms.

The need to ensure the facility was monitoring changes of condition to resolution was reviewed with Staff 1 (Administrator) on 04/26/22. She acknowledged the findings.

OAR 411-054-0040 (1-2) Change of condition and Monitoring

1.Resident #1 Has had significant weight loss (12% in 90 days) Facility RN and Admin will complete A change of condition to reflect the weight loss and provide intervention as needed. This resident was trying to lose weight but did not have a physician note stating the weight loss was planned. Admin and RN will ensure all planned weight loss is documented and resident physicians are aware and request for physician oversight.

Effective 4/26/2022 Resident #2 significant change of condition was completed due to compression fracture to spine by the facility RN. Administrator will ensure all concerns about change in condition are monitored daily and significant changes reported to the facility RN. All records with outside agency will be kept in the outside agency binder and reviewed bi weekly by the facility RN.

Resident 3 went to the ER for signs and symptoms of withdrawl. Upon return Staff failed to intiate monitoring for continuation of symptoms. Effective 5/5/2022 all staff were re-trained on incident report steps and procedures, which include filling out the report, notifying the RN, Admin and any family, and the Physician, initiating Alert charting, and initiating a temporary plan of care for the incident. Management and Faciltiy RN will check daily to ensure the proper steps are being followed after incidents are reported.

2. Staff will receive in-servicing specific to monitoring for short term change of condition and signifcant change of condition, appropriate documentation related to the change, and when to notify the nurse.

The community will implement a 24 hour

communication system.

The "24 hour binder" will be set up to include

a) Shift to Shift Communication Log

b) Alert charting log

c)Temporary Service Plan

d) Signifcant Change of Condition Log

e) Weekly Skin Monitoring Log

Staff will start Short Term Monitoring / Communication System for any resident identified to have a change of condition including but not limited to, return from hospital, signs or symptoms of urinary tract infection, new or missed medication etc.. Staff will initiate the alert log, including resident name, change identified, start a temporary service plan, and complete proper notifications to ensure they monitor resident and identify when to report concerns to nursing or physician. The staff will be aware of what to report to nurse and/or physician per the temporary service plan  which corresponds with the resident change of condition. The Temporary Service Plan will have specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report, who to report to and staff signature lines to sign once they have read and understood the Temporary Service Plan.

Staff will monitor the residents status until the resident condition resolves and they are back to their baseline.

24 hour book / process will be reviewed daily during shift change meetings as a means to identify  potential significant change that needs to be assessed by the Registered Nurse.

3. The system will be reviewed daily to ensure compliance is maintained.

4. The Administrator or designee and Registered Nurse will be respsonsible to ensure the corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 2 sampled residents (#s 1 and 4) who experienced significant changes in condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia.

During the acuity interview, Resident 4 was identified to receive home health services for wound care and have a compression fracture from a fall.

There was no documented evidence of an RN assessment of Resident 4's open wound or compression fracture. There was no update to the service plan providing interventions and instructions to staff for Resident 4 significant changes.

In an interview with Staff 2 (RN) on 04/26/22, she acknowledged the significant changes had not been assessed.

On 04/26/22, the need to ensure the facility RN completed an assessment for significant changes of condition, including developing interventions for the changes, was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Resident 1 was admitted in 2020 with diagnoses which included TBI (traumatic brain injury) and Schizoaffective disorder.

Review of the medical record revealed Resident 1's weight dropped from 145 lb on 09/07/21, down to 127 lbs on 01/18/22, a loss of 18 lbs (12%) in four months.  The unexplained weight loss constituted a significant change of condition requiring assessment by an RN.

There was no documented evidence of an RN assessment of Resident 1's weight loss. There was no update to the service plan providing interventions and instructions for staff after Resident 1's significant change.

In an interview with Staff 2 (RN) on 04/26/22, she acknowledged the significant change of condition had not been assessed.

On 04/26/22, the need to ensure the facility RN completed an assessment for significant changes of condition, including developing individualized interventions, was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0045 (1) (a-f) (A) (C-F) Resident Health Services

1.Effective 4/26/2022 A Change of Condition was completed by the facility RN for Resident # 4 due to compression fracture to spine.  Rn will ensure all changes in condition are monitored daily and complete change of condition assessment for significant chnages. All short term changes will be monitored until resolved or new baseline is established.

Effective 5/1/2022 significant change in condition for weightloss was completed by the facility RN. As above the facility RN will ensure changes are monitored daily and change of condition will be completed when neecessary.  

2. Staff will receive in-servicing specific to monitoring for short term change of condition and signifcant change of condition, appropriate documentation related to the change, and when to notify the nurse.

The Resident will be entered into the 24-hour report document.  If warrranted the resident will be place on the alert log with all supporting components being completed, including Provider notifications as needed.

The Registered Nurse will utilize the significant change of condition log to direct who requires a weekly nursing assessment until the resident is back at their baseline health status or a new baseline is established. The Registered Nurse will update the Service Plan based on the nursing assessment to ensure staff are notified of the Residents current needs and preferences. The Registered Nurse will coordinate care with the Residents Provider related to any on-going changes or care needs based off of weekly assessments.

3. The system will be reviewed daily to ensure compliance is maintained

4. The Administrator or designee and Registered Nurse will be respsonsible to ensure the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure clinical information from on-site health care providers was reviewed and clarified as necessary, the service plan updated, and new interventions communicated to facility staff to implement, for 1 of 2 sampled residents (# 4) who received outside services. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia and congestive heart failure with edema.

Resident 4 began receiving home health nursing services for a wound to the lower left leg 03/20/22.

Home health provided wound care twice weekly from 03/20/22 to 04/24/22.

There was no evidence the home health documentation was reviewed by staff. Recommendations were not implemented or added to Resident 4's service plan.

In an interview with Staff 2 (RN) on 04/26/22, she was not aware of the wound to Resident 4's leg.

The need to ensure care was coordinated with outside provides and recommendations reviewed and implemented was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Svc

1. Actions that will be taken to correct the rule violation include;

    a.Resident #4 record including service plan and MAR will be updated to reflect services provided by home health provider, staff interventions to support resident wound care needs, and when to notify outside provider.

2. The system will be corrected so the violation will not happen again by;

    a. Ensuring all documentation received by on or off site services are process through triple check system. All documents should be processed as orders through the triple check process to ensure staff are informed of new interventions, that the service plan is adjusted if necessary and that any interventions are implemented per outside provider recommendation.

b.This process triggers staff to immediately review any document for any changes to Residents services or medications, initiate TCP(Temporary Care PLan) to update the service plan with recommendations received, and place Resident on alert for monitoring.

c.For onsite providers specifically, community is utilizing an outside provider form to coordinate care. All outside providers will be educated to fill out this form located at the sign in book as well as in the med room with every visit to inform who visited, reason for visit and if any concerns noted and any recommended changes to service plan.  

    d. Facility will post education sheet to outside providers notifing why it is so important for them to leave documentation of coordination of care.

3. The area needing correction will need to be evaluated daily during morning leadership meeting with 24 hr. book review. System will be reviewed monthly through Continuous quality improvement program.

4. Administrator, Registered Nurse, and Designee will be responsible to see that the corrections are completed and monitored.

2. Resident 4 was admitted in 03/2022 with diagnoses including dementia and congestive heart failure.

Resident 4's April 1st through 24th, 2022 MARs revealed Resident 4 was administered the following medications without signed orders:

* Lasix 20 mg daily; and

* Potassium Chloride ER 10 meg daily.

Electronically signed orders were obtained from the pharmacy on 04/27/22.

3. Resident 5 had diagnoses including insulin dependent diabetes.

Resident 5 had physician's orders for weekly weights with directions to re-weigh with three pound or more difference and to notify the RN or Administrator.

April 1st through April 25th, 2022 MARs revealed Resident 5 was not re-weighed and the RN and Administrator were not notified as directed when weight varied by three pounds or more.

The need to ensure signed physicians' orders were in residents charts and followed was reviewed with Staff 1 (Administrator). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 4 and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted in 2020 with diagnoses which included TBI (traumatic brain injury) and Schizoaffective disorder.

Resident 4's April 1 through 24th 2022 MARs revealed the following medications were ordered, but not administered on the following dates:

* Advair Diskus Inhaler on 04/23, 04/24, and 04/25;

* Breo Ellipta Inhaler on 04/6, 04/11,  04/22 and 04/24;

* Flonase Allergy Relief on 04/15;

* Ipratropium on 04/6 and 04/11; and

* Zofran on 04/3, 04/9, and 04/10.

The need to ensure all medications were administered as prescribed by the physician was reviewed with Staff 1 (Administrator) on 04/26/22. She acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

1. Actions taken to correct the rule violation for each resident include;

    a. Ensuring resident #1 receives medications as ordred, and comprehensive chart audit for medication/order reconciliation to ensure signed, current physician orders are in place, and carried out accurately as prescribed.

    b. Comprehensive 3 way cart to MAR to PO review to be completed for all Residents in the community to ensure accurate medication and treatment delivery system is in place for all Residents.

2. The system will be corrected so this violation does not happen again by the following measures:

    a. All order will be processed through triple check to ensure they are entered correctly into the MAR and have final review from Nursing to ensure appropriate directions for staff to follow are in place.

    b. Medication delivery system will be followed by Med Techs to ensure all medications are being given and treatments are carried out per MD order and parameters for follow up or notifying MD are being followed.

   c. All staff were inserviced on 5/5/2022 about the importance of re-weighing residents with a +/-3lb and notifying the facility RN and Admin.

    d. Weekly MAR audits will take place to ensure orders and parameters are being followed accurately. Weekly medication administration report to be pulled from electronic health record system to verify that there are staff signatures for 100% of orders in MAR.

3. The area needing corrected will be evaluated daily when processing new orders via triple check system, weekly with MAR audits and monthly with Medication System Continued Quality Improvement process.

4. Administrator, Registered Nurse, or Designee will be responsible to see that the corrections are completed and monitored

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:

On 04/25/22, Staff 1 (Administrator) was asked to provide documentation of her Residential Care Facility Administrator license. Staff 1 revealed her license had expired.

The requirement to have a current Residential Care Facility Administrator was discussed with Staff 1 on 04/26/22. She acknowledged the findings.

OAR 411-054-0065 (3-4) Administrator: Administrator Requirements

1. Current Administrator will complete her required CEU's and renew her Admin Liscense.

2. Administrator will complete the 20 hours of  yearly required CEU's, and renew the liscense before expiration.

3.The administrators' Regional Director of Operations will review the Administrators CEU progress quarterly to ensure completion.

4. The regional Director Of Operations and the Administrator will monitor the completion of CEU's to ensule the liscense can be renewed when it is due.  

Based on observation, interview, and record review, it was determined the facility failed to have a 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. Findings include, but are not limited to:

The facility was licensed as a Residential Care Facility (RCF). The RCF was divided into four separate buildings. Residents occupied three buildings:

* Manzanita 1 had a census of 10 residents, one of which used a wheelchair and needed ADL assistance;

* Manzanita 2 had a census of 14 residents, three identified as needing full assistance with ADL care, multiple residents were identified to need interventions and cueing related to cognitive decline and behaviors.

* Sage 2 had a census of 10 residents, one identified as needing full assistance with ADL care, and one identified to needing constant supervision related to cognitive decline.

Review of the facility schedule showed the facility routinely scheduled only one Universal Worker in Manzanita 1 and one Universal Worker in Sage 2 to care for ten residents each. Two Universal Workers were scheduled for the day shift in Manzanita 2 and one Universal Worker was scheduled for the Swing and overnight shifts to care for 14 residents.

The facility utilized Universal Workers who were responsible for caregiving, medication administration, housekeeping, laundry, activities, meal preparation and service.

Record review, observations, and interviews conducted between 04/25/22 and 04/27/22 revealed:

* During interviews, several staff confirmed the facility was short staffed and they we not able to complete all duties;

* EMTs were called to assist with lifting residents who had fallen;

* Multiple times throughout the survey, a resident was observed to smoke unsafely and staff were not available to monitor;

* During interviews, multiple residents verbalized the need for additional staff;

* No activities were offered or provided between 04/25/22 and 04/27/22 and residents and staff confirmed a lack of activities in interviews;

* On 04/25/22 an overflow of laundry was observed in all houses; and

* Multiple areas in all houses were in need of cleaning.

The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents and to compensate for staff duties beyond caregiving was shared with Staff 1 (Administrator) on 04/26/22. No further information was provided.  

Refer to C 240, C 242, C 510, and C 513.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

1. Action taken to correct the rule violation includes; increasing scheduled staffing to meet the scheuled and unscheduled needs of residents based on acutiy and worker responsiblities.

Shift

Day         1 staff  1 short shift

Evening1 staff  1 short shift

Noc         1 staff

A full time activities director will be hired for the campus.

2. System will be corrected so that the violation will not happen again by montly review of the community acuity report and adjustment of staffing plan as needed to meet the scheuled and unscheduled needs of residents.

3. Corrections will be evaluated monthly and as needed with changes in resident acuity.

4. Administrator, and Registered Nurse will be responsible to corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and dementia care training had been completed prior to staff providing direct care to residents for 2 of 3 newly hired staff (#s 6 and 9). Findings include, but are not limited to:

Review of the facility's training records on 04/26/22 indicated the following:

Staff 6 (Universal Worker), hired 10/27/21, and Staff 9 (Universal Worker), hired 02/04/22, lacked documented evidence they had completed the required six hour pre-service dementia training prior to providing direct care to residents and lacked documented evidence of completing the following pre-service orientation topics:

* Resident rights and values of community-based care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures; and

* Food handler's certificates.

Staff 1 (Administrator) stated Staff 6 and 9 "have not completed" their training, had been informed and would be completing it by the end of the month. No records were provided to review.

The training program requirements were discussed with Staff 1 (Administrator) on 04/26/22. She acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

1.Staff #6 and #9 will complete preservice dementia training by  6/1/2022, or they will be pulled off the schedule. Preservice orientation will also be completed by 6/1/2022, community corporate office provided a record breakdown of training. An audit of training records will be conducted, any staff missing preservice dementia training or preservice orientation will be removed from the schedule and required to complete training before being placed back on the schedule .

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program.

3. Staff training records will need to be evaluated on a monthly basis.

4. The Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 9, and 12) had demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

An Interview with Staff 1 (Administrator) and a review of the facility's training records on 04/26/22 indicated the following:

Records were requested for the training and competency of staff in the required areas within 30 days of hire. Staff 1 stated she did not have these records, but provided a copy of the new training checklist the facility would be using "going forward".

There was no documented evidence provided that Staff 6 (Universal Worker), hired 10/27/21, and Staff 9 (Universal Worker), hired 02/04/22, had demonstrated competency within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid and Abdominal Thrust.

There was no documented evidence provided Staff 12 (Universal Worker/MA), hired 10/01/21, had demonstrated competency within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.   

The need to ensure staff had documented evidence of competency demonstration in all assigned duties, within 30 days of their hire date, was discussed with Staff 1. No additional information was provided.

OAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff

1.(a) An audit of staff trainng records will be completed and any staff without the required demonstrated competencies within 30 days of hire including Role of service plans in providing individualized care;providing assistance with ADL's; changes associated with normal aging;identification, documentation and reporting of changes of condition; conditions that require assessment, treatment and observation and reporting, and General food safety, serving and sanitation will be provided the training.  

(b) An audit of staff training records will be completed and any staff without the required First Aid and Abdominal Thrust training will be provided the training.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program.

3. Staff training records will need to be evaluated on a monthly basis.

4. Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours of dementia related training, was completed for 3 of 3 long-term staff (#s 3, 4 and 14) whose training records were reviewed. Findings include, but are not limited to:

The annual in-service training records for the year 2021 were requested on 04/25/22. On 04/26/22, Staff 1 (Administrator) provided training records from 01/2022 through 03/2022 and stated she was not able to locate the prior months training records. A review of the records provided revealed the following:

* Staff 3, 4 and 14 (Universal Workers) failed to have documented evidence of completing 12 hours of required in-service training, including six hours of dementia related training.

The need to ensure the facility had a tracking system of annual required training and maintaining of records was discussed with Staff 1. No additional information was provided.

OAR 411-054-0070 (6-7) Annual Training and Other Requirements

1. Action taken to correc the rule violation inclues;

    a. Staff #3, 4, and 14, will complete the minimum required 12 hours of annual in-service training

2. System will be corrected so that violation will not happen again by;

    a. Comprehenisve training record audit of all trainings and competencies completed and documneted on a training log for review

    b. Any missing competencies and training will be completed for currently employed staff.

    c. Staff will utilize a combination of Oregon Care Partners Programing, medi tech meetings, and monthly staff meetings to meet the annual in-servicing requirements

    d. Staff will submit certificates of completion or evidence of participation at facility provided trainings for documentation.

3. Area needing correction will be evaluated weekly and monthly via review of newly hired staff and training log review.

4. Administrator and/or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in according to the Oregon Fire Code. Findings include, but are not limited to:

On 04/26/22, fire drill and fire and life safety training records for the previous six months were requested. Review of the documentation provided identified the following:

* There was no documented evidence of the number of occupants evacuated during fire drills, that residents were being evacuated, or had participated in the evacuation drills.

The requirements regarding fire drills were reviewed with Staff 1 (Administrator) on 04/26/22. She acknowledged the findings.

OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and Instruction

1. Fire Drills will be conducted and recorded at a minimum of every other month at different times of the day, evening and night shift. Fire and Life Safety Training will be provided on alternating months.

The fire drill document will include the following components: Date and time of day, location of simulated fire origin, the escape route used, problems encountered and comments relating to residents who residted or failed to participate in the drills, evacuation time period needed, staff members on duty and participating, number of occupants evacuated.

2. Fire Drills and Fire and Life Safety Training will be competed with all current staff to ensure awareness and understanding of emergency procedures including,

but not limited to evacuation routes, fire extinguisher use, locating and reading the fire panel, etc. Staff will be provided with a written fire drill protocol for reference. The fire drill documents and fire and life safety instruction documents will be filed in the Fire Drill/Fire and life safety binder in order of month.

3. The system will be evaluated monthly to ensure all requirements have been met and documented.

4. The Maintenance Director and Administrator or designee will be responsible to ensure the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Review of fire and life safety records provided for 09/2021 through 03/2022, and staff interviews revealed the facility lacked documented evidence of the following:

* Staff providing fire evacuation assistance to residents knew the designated point of safety;

* Evidence residents were being instructed on fire and life safety procedures within 24 hours of admission;

* A written record of training for residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and

* Documentation the facility had identified residents who were unwilling to participate in fire drills and show that immediate changes had been made to ensure the evacuation standard for those residents had been met.

The need to ensure resident fire and life safety training within 24 hours of admission and annually, and to identify and make plans for resident's who refused to participate in drills was discussed with Staff 1 (Administrator) on 04/26/22. She acknowledged the findings.

OAR 411-054-0090 (1(e-h))-(2-5) Fire and Life Safety: General

1. General Fire and Life Safety training will be provided and documented for current residents, and at a minimum annually.

2. General Fire and Life Safety training will be provided for all new residents within 24 hours of admission and at a minimum annually.Training to include the following: alternative exit route used during fire drills. Additionally, documentation of partcipation in fire drills and training to assess ongoing evacuation capabilities of both residents and staff and interventions and resolution related to resident evaucation concerns identified during fire drills.

3. This system will evaluated at a minimun of monthly to ensure all requirements have been met and documented.

4. The Maintenance Director and Administrator or designee will be responsible to ensure the corrections are completed/monitored.

Based on observation, 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 150, C 160, C 40, C 242, C 510 and C 513.

C455

OAR 411-054-0105 (2-4) INSPECTIONS AND INVESTIGATION: INSP INTERVAL

REFER TO C150, C160, C240, C242, C510 & C513

Based on observation and interview, it was determined the facility failed to ensure exterior grounds were orderly, free of litter and refuse, and pathways were maintained in good repair. Findings include, but are not limited to:

The facility grounds were toured during the survey and the following was observed in all four houses of the facility:

* Long weeds and grass, trash, branches and twigs, large piles of dead leaves in the yards and patio areas;

* Multiple missing and damaged window screens;

* Door mats covered in dirt, debris and dead leaves in front of entrance doors;

* Broken appliances and boxes of trash in patio areas;

* One of the facility dumpsters was overflowing with garbage, causing the lid to remain open;

* Cigarette butts littered the patios and walkway areas;

* Broken chairs, tables and patio furniture in the yards and patio areas;

* Patio furniture had stains and burn holes in the fabric and some of the chairs required repair;

* Manzanita 1 house had handrails on the patio ramps with broken areas, rough areas and unpainted railings, areas of the soffit were peeling away allowing birds to enter and had missing pieces of siding along the back of the building; and

* Manzanita 2 house had a pathway in the back yard where the tree roots were lifting the sidewalk and resulted in several uneven areas of approximately 2-3 inches, creating a tripping hazard.

The building exterior was toured with Staff 1 (Administrator) on 04/27/22.  She acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

1. The corporate office is sending a maintenance team to fix all of the stated issues, and plan to hire and utilize local vendors and corporate maintenance to keep up on facility Maintenance issues.

2. Once all of the concerns have been addressed The Admin and the RDO (Regional Director of Opporations) will complete a monthly audit of maintenance needs and report back to thr Corporate head of Maintenance any needs or concerns until a local maintenance man can be hired.

3. Once a local Maintenance person is hired the RDO will meet with them weekly to ensure all maintenance needs are being addressed.

4. The corporate head of maintenance will be in charge of maintenance oversight. Locally the RDO and Admin will report to our corporate Head until a local maintenance person is hired.

Based on observation and interview, it was determined the facility failed to ensure exterior grounds were orderly, free of litter and refuse, and pathways were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

The facility grounds were toured between 11/01/22 and 11/02/22 and the following was observed:

Manzanita 1:

* Trash was noted on the ground near the back deck and along the concrete pathway;

* A small table was noted with a broken wicker top, a chair with the fabric seat ripped away from the frame was near the broken concrete pathway; and

* Siding facing the back deck was rippled and pulling away from the building.

Manzanita 2:

* A broken wheelchair, a broken air conditioning unit and paint cans were located on the patio residents used; and

* Drop offs at pathway edges greater than two inches were noted in the resident outdoor area.

The need to keep the facility exterior and pathways in good repair was discussed with Staff 1 (Administrator) and Staff 20 (Maintenance) on 11/02/22 and 11/03/22.  The staff acknowledged the findings.

C510

OAR 411-054-0200 (3) GENERAL BUILDING EXTERIOR

1. Manzanita 1-

(a) Maintenance Director completes walk-throughs on a daily when on-site of the grounds to ensure there is no debris/trash on the grounds

(b) Small table with broken wicker top was thrown away during survey

[c] Chair with fabric seat ripped away was thrown away during survey

(d) Pending quote and time estimate from Sutterfield Siding Company for repair of siding facing the back deck that is rippled/pulling away from building

Manzanita 2-

(a) Drop-offs in the backyard around the flower bed has been re-built up with bark dust

Sage 1- (empty facility)

(a) The broken wheelchair, air conditioner and paint cans located in the patio area have been thrown away

(This item was listed on the SOD as being in Manzanita 2)

2. Maintenance Director will observe and monitor grounds daily when on-site for trash/debris, all areas of drop-offs for potential settling due to moisture and fill with bark dust as needed, proper disposal of broken/malfunctioning furniture/equipment; Maintenance Director will coordinate siding repair with outside provider

3. Maintenance Director will observe and monitor daily when on-site; Administrator will audit no less than monthly to ensure facility exterior and pathways are in good repair

4. The Administrator and Maintenance Director will be responsible to ensure the system has been corrected and is monitored.

Based on observation and interview, it was determined the facility failed to ensure all materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident was clean and in good repair. Findings include, but are not limited to:

The facility was comprised of four separate "houses". The observed findings from a tour conducted on 04/25/22 in each house are listed below:

1. Sage 1 house was not currently housing residents and was being used by Administrative staff:

* Ceiling light fixtures were missing covers and some were filled with debris;

* The floor in the common areas were missing pieces of laminate, creating gaps and crevices;

* Multiple broken PTAC heating/cooling units;

* Holes in the drywall;

* Laundry piled on top of the washer machine;

* Window screens piled against the washing machine; and

* Floors and walls with dust, debris and stains.

2. Sage 2 house was housing ten residents:

* PTAC units in the common areas were not fully functioning for heating/cooling;

* The toilet in the bathroom across from room 6 was loose and not properly secured to the floor;

* A sink in the common dining area had poor water pressure;

* The laminate flooring had gaps, gouges and missing pieces;

* Multiple light bulbs were burned out throughout the facility; and

* Walls, baseboards and floors had gaps and were scraped, gouged and had dust and debris.

3. Manzanita 1 house was housing ten residents:

* Multiple windows were missing screens and there was evidence of insects inside the windows;

* The PTAC unit in the common area dining room was not fully functioning for cooling;

* Hallway carpets were stained with black marks;

* Multiple light bulbs were burned out in resident rooms and common areas; and

* Walls, baseboards and floors had gaps, were scraped, gouged and had dust and debris.

4. Manzanita 2 house was housing fourteen residents:

* There was no soap and paper towels in the dispensers in resident and common area bathrooms;

* The common area fireplace was missing the metal bars to cover the top, exposing the parts inside the fireplace;

* Multiple areas on the walls had been patched but were not painted;

* The flooring in the common area bathroom (across room 10) was lifting and had gaps and the shower floors had build-up of grime and black material; and

* Walls, baseboards and floors had gaps, were scraped, gouged and had dust and debris.

On 04/27/22, the need to ensure all materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

1. The corporate office is sending a maintenance team to fix all of the stated issues, and plan to hire and utilize local vendors and corporate maintenance to keep up on facility Maintenance issues.

2. Once all of the concerns have been addressed The Admin and the RDO (Regional Director of Opporations) will complete a monthly audit of maintenance needs and report back to thr Corporate head of Maintenance any needs or concerns until a local maintenance man can be hired.

3. Once a local Maintenance person is hired the RDO will meet with them weekly to ensure all maintenance needs are being addressed.

4. The corporate head of maintenance will be in charge of maintenance oversight. Locally the RDO and Admin will report to our corporate Head until a local maintenance person is hired.

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

The facility was comprised of four separate houses. The environment was toured between 11/01/22 and 11/03/22 and showed the following:

Sage 2:

* The sink in the dining room had extremely poor water pressure and a cracked counter top;

* Laminate flooring in the dining room and kitchen area was pulling apart at the seams and separating creating gaps between the flooring that was accumulating debris;

* Flooring in the laundry room had two large chunks missing and a section that was separating at the seam between doorways;

* Flooring in the back hallway, had a large, deep crack near the transition between the two types of flooring;

* Three bug catching light units, located in the dining room, had copious amounts of dead insects stuck to the inserts;

* The door from the laundry room to the deck had a large piece of missing molding around the window;

* The double patio door leading from the dining room to the deck, had two large sections of missing molding and cracks in the door exposing the inner pieces; and

* The door knob to the back door was extremely loose and wobbly, and the door was difficult to open to the deck area.

Manzanita 2:

* Dark carpet stains in room nine and brown/yellow stains to the lower portion of the bed that was resting on the floor.

Manzanita 1:

* Dark stains to the carpet, of various sizes, in the common areas and hallways.

The need to ensure the resident houses were kept clean and in good repair was discussed with Staff 1 (Administrator), Staff 15 (Regional Director of Operations) and Staff 20 (Maintenance) on 11/02/22 and 11/03/22. The staff acknowledged the findings.

C513

OAR 411-054-0200 (4)(d-i) DOORS, WALLS, ELEVATORS, ODORS

1. Manzanita 1-

(a) Bissell Professional Carpet Cleaner was purchased by RDO on 11/2/22 to address dark stains to the carpet in the common areas and hallways. If stains still present, will consult with Corporate Maintenance Team to replace carpet

Manzanita 2-

(a) Room #9 carpet was cleaned on 11/11/22

(b) Box spring cover has been purchased through Amazon and will be placed on bed upon arrival

Sage 2-

(a) The sink in the dining room with low water pressure and cracked countertop is in process of being removed, cap off water/drain lines into the wall and replace with a desk

(b) Flooring will be replaced in the dining room, kitchen and hallway areas that has areas with gaps, cracks and pulling apart at the seams

[c] Flooring in laundry room is being replaced with laminate planks the week of 11/14/22

(d) The bug catching light units have been added to the NOC shift  cleaning schedule to check weekly and change monthly depending on unit saturation

[e] The laundry room door has been ordered and pending replacement. Waiting on delivery date

(f) The double patio door leading from the dining room to the deck was ordered on 10/13/22 and at that time the wait time for delivery was 8-10 weeks. (The surveyor was provided a copy of the receipt during the survey)

2. Maintenance Director will complete and/or coordinate necessary repairs

3. Administrator and Maintenance Director will audit and review weekly, but no less than monthly to ensure resident houses are kept clean and in good repair

4. The Administrator and Maintenance Director will be responsible to ensure the system has been corrected and is monitored.

Based on observation and interview, it was determined the facility failed to ensure a chemical disinfectant was used for soiled linens when washers did not have a minimum rinse temperature of 140 degrees Fahrenheit, in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

A tour of the facilities laundry rooms on 04/27/22 revealed the following:

The laundry rooms had residential style washers for cleaning laundry and plastic containers with blue powder for staff to use to wash clothing and linens. There was no information on the containers related to the contents of the blue powder.

In an interview on 04/27/22, Staff 1 (Administrator) was asked if a disinfectant was added to soiled linens during the washing process. Staff 1 reported she was not sure of the temperature of the washing machine and a disinfectant was not added for use with washing soiled linens.

The need to ensure a chemical disinfectant was used for cleaning soiled linens unless they were washed in a minimum of 140 degrees Fahrenheit, was discussed with Staff 1 (Administrator) on 04/27/22. She acknowledged the findings.

OAR 411-054-0070 (7)(b-d) Housekeeping and Laundry

1.Actions taken to correct the rule violation include;

a.Residential washers hot water heaters will be adjusted to ensure they reach the appropriate temperature for disinfection. If appropriate temperature cannot be reached chemical disinfectant will be added.

b.      All cleaners will be in labeled containers, to ensure the contents of the container can be identified.  

2.System will be corrected so the violation will not again inclue, staff in-servicing on reporting areas in need of repair via maintenance log.

3.Area needing correction will be evaluated weekly and monthly via maintenance log review and community facilities walk through by administrator and maintenance director.

4.Administrator and Maintenance director will be responsible for correctison and monitoring.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building and that a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors. Findings include, but are not limited to:

1. Observations on 04/25/22 and a tour of all four building in the facility with Staff 1 (Administrator) on 04/27/22 revealed exit doors did not have consistently operational alarms or other acceptable system to alert staff when residents exited the building.

2. The bathrooms (toilet and bathing facilities) in all four houses of the facility did not have a manually operated emergency call system for use by residents and visitors.

The need to ensure exit doors were equipped with working alarming devices to alert staff when residents exited and the need for a call system in bathrooms was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit

Dr Alarm, Phones, TV, or Cable

1. (A)Batteries were replaced and alarms were tested at exit doors to ensure they were operational.

   (B)Corporate maintenance team will install bathroom emergency call system when they are in the building fixing other repairs.   

2.Exit door alarms and bathroom call system checks will be added to staff and administrator daily walk through task sheet to ensure proper functioning of alarms.  Staff will receive in servicing on reporting urgent and non urgent repairs via facility maintenance log or Administrator if urgent.

3. The system will be evaluated daily

4.The Administrator or designee and Maintenance Director to ensure the corrections are completed/monitored.

Based on observation and interview, the facility failed to ensure residents who lived in the facility were provided a key to their units per their evaluated need. Findings include, but are not limited to:

Review of records for Residents 1, 2, 3, 4, and 5 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.

The need to ensure all residents were evaluated for the ability to manage keys to their units and providing keys based on those evaluations was discussed with Staff 1 (Administrator). She acknowledged the findings.

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

1. A key evaluation will be implemented for all residents to determine their ability to manage keys to their rooms.

2. Administrator will ensure key evaluations are completed upon move-in and quarterly with their service planning team meeting.

3. Key evaluations will happen upon move in and quaterly there after.

4. The Adminitrator or designee will be responsible to ensure corrections are completed/monitored.