Print Inspection: GZZ2

The findings of the re-licensure survey, conducted 05/20/24 through 05/22/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

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

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 05/20/24 through 05/22/24, 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.

1.Executive Director and Program Manager for memory care to provide oversight including training, supervision and over all conduct.

2.Daily review and present oversight by the Program Director.

3.Daily and as needed.

4.Executive Director and Program Director

Based on observation, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 1 sampled resident (#1) when receiving meal service. Findings include, but are not limited to:

Resident 1 was admitted in 10/2020 with diagnoses including dementia.

The service plan, dated 03/25/24, was reviewed and noted staff were to assist Resident 1 "with eating [his/her] meals as due to decline in cognition [s/he] forgetting how to feed [him/herself]."

During a meal observation on 05/22/24 at 9:20 am, Resident 1 sat in his/her wheelchair at a dining room table alone. Staff 16 (CG) brought Resident 1's breakfast over and sat it on the table in front of the resident. Resident 1 asked, "What is this?" and Staff 16 replied, "It's your breakfast". Resident 1 asked loudly, "What is this?" to which the Staff 16 replied, "It's your breakfast" and walked away from the table. Resident 1 continued to yell, "What is this?" at which point Staff 2 (Program Director) came over to Resident 1 and stated, "these are scrambled eggs, these are hashbrowns and the bowl is oatmeal" to which Resident 1 replied, "OK" and began to eat his/her breakfast.

The need to ensure residents were treated with dignity and respect was reviewed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

1.Staff will present resident 1 with her meals. While delivering her meal, staff will explain to resident 1 what items are on her plate using a clock reference to explain the placement of each item. Staff will stay present during meal consumption reminding resident 1 what food item she is eating prior to each bite.

2.Personal preferences will be captured in the service plan as well as reviewed with staff. Staff will sign and acknowledge each resident's service, capturing the knowledge of which residents need feed assistance.

3.At each meal service.

Human Resources will be responsible for staff.

The Executive Director or Program Director will be responsible upon admission.

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to:

Observations during the survey from 05/20/24 to 05/23/24, showed a lack of scheduled and unscheduled activities provided for residents living in the memory care community.

An activity calendar was provided which noted scheduled activities for each day of the week. The activities scheduled according to the calendar for 05/21/24 included the following:

* Daily Chronicle and Coffee at 8:30 am. Daily Chronicle handouts were observed laying on tables in the dining room.

* This Day in History at 10:00 am. Observations at 10:00 am were made and the activity did not take place.

* Board games at 10:45 am. Observations were made at 10:45 am and there were no board games offered or played.

* Pretty Pages at 1:30 pm. Observations were made from 1:30 pm to 1:40 pm and there was no activity offered during this time.

Throughout the survey the TV was observed to be on in the common area with two to four residents watching TV at any given time.

Residents were often observed sitting in the dining room at tables, some napping, others just sitting. Residents who were in their apartments were not approached for activity invitations during observations.

The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

1.Activity profile sheets need to be completed for each resident capturing individual preferences. Activity calendar will be printed daily and implemented by LifeStyle Assistant and care staff.

2.Review of calendar of events daily.

3.Daily

4.Program Director of Memory Care

2. Resident 2 was admitted to the facility in 03/2023 with the diagnosis of dementia.

During the acuity interview conducted 05/20/24, staff reported Resident 2 was a smoker and required supervision from staff.

There was no documented evidence a smoking evaluation had been completed for Resident 2 on admission or quarterly thereafter to address the resident's ability to smoke without causing burns or injury to themselves or others, or damage to property. Resident 2's smoking status with instructions for staff was not addressed in the service plan.

Staff 4 (Resident Services Director) completed an evaluation on 05/20/24, during survey, which confirmed Resident 2 required assistance from staff for safety and would need supervision while smoking.

The need to ensure a smoking evaluation was completed on admission and quarterly thereafter, and was addressed in the resident's service plan was discussed with Staff 1 (ED). She acknowledged the findings. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure smoking evaluations were completed initially and quarterly thereafter for 1 of 1 sampled resident (# 2), and move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 3's move-in evaluation, dated 04/06/24, lacked information regarding the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences & traditions;

* Ability to use call system;

* Housework and laundry;

* Skin condition;

* Nutrition habits, fluid preferences & weight if indicated;

* Fall risk or history;

* Emergency evacuation ability;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* Smoking, ability to smoke safely; and

* Alcohol and drug use - not prescribed by a physician must be evaluated and addressed.

The need to ensure the initial move-in evaluation included all of the required elements was discussed with Staff 4 (Resident Services Director) on 05/21/24 at 11:20 am and with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

Move in evaluation will include all 22 ADL's plus residents preferences and accommodations.      

2. Detailed evaluations will be completed by PD, ED or RSD.

3. Upon admission.

4. PD, ED and RSD.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, were readily available to staff, provided clear direction for staff, were consistently implemented by staff, were updated quarterly, and written updates to the service plan were initialed and dated for 3 of 3 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 10/27/23 service plan, 01/25/24 through 05/20/24 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas:

* Ability to understand;

* Fall history with interventions;

* Behaviors with instructions for staff;  

* Bowel and bladder continence;

* Assistance for ADLs;

* Use of a walker versus cane; and

* Sleep patterns.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, were consistently implemented, and updated quarterly and with significant changes of condition was discussed with Staff 1 (ED) on 05/22/24. She acknowledged the findings.

2. Resident 4 was admitted to the facility in 10/2023 with diagnoses including dementia and blindness.

Observations of the resident, interviews with staff,  and review of the resident's 10/27/23 service plan, 02/02/24 through 05/20/24 temporary service plans, progress notes, physician communications, and incident investigations were completed.

Resident 4's record revealed a two week hospitalization in 04/2024 where a new diagnoses of diabetes and urinary retention resulted in orders for insulin administration daily and a Foley catheter. Resident 4 was reported and observed during survey to need two person transfer assistance, a wheelchair for mobility with assistance, full assist with ADL care and meal assistance.

a. The resident's service plan was not reflective, lacked resident-specific instructions for staff, and/or was not consistently implemented by staff in the following areas:

* Behaviors with interventions;

* Frequent medication refusals with interventions;

* Psychoactive medications to include non-pharmacological interventions;

* Interventions to accommodate visual loss;

* Glasses;

* Two-person transfer assist;

* Use of wheelchair with assist for mobility;

* One to two person full assist for all ADL activities;

* Eating assistance, interventions to enhance independence with meals/fluids;

* Foley catheter instructions for care and monitoring;

* How the resident expressed pain, including non drug interventions;

* Emergency evacuation ability;

* Diabetes diagnosis with delegation for insulin injections daily; and

* Controlled carbohydrate diet.

b. The service plan had multiple hand written entries lacking date or initials of who made the changes.

The need to ensure resident service plans were reflective of current care needs, provided clear instructions to staff, were consistently implemented, updated quarterly and with significant changes of condition,  and written changes to the service plan were dated and initialed was discussed with Staff 1 (ED) on 05/22/24. She acknowledged the findings.

3. Resident 1 was admitted in 10/2020 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's most recent service plan, dated 03/25/24 revealed the following:

a. Resident 1's service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Toileting;

* Hearing ability;

* Wandering/Elopement;

* Behaviors with interventions; and

* Use of side rails.

b. During acuity interview the survey team was advised service plans accessible to staff could be found in the resident chart. Resident 1's chart was reviewed and a current service plan could not be located. In an interview with Staff 4 (Resident Service Director) on 05/21/24 she stated the most recent service plan, dated 03/25/24, with updates from the significant change of condition related to weight loss, had not yet been placed in the chart as it needed to be signed.

The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were readily available to staff was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24 at 12:30 pm. They acknowledged the findings.

1. Detailed person centered information will be gathered upon admission and as changes occur which will be implemented in each individual service plan

2. Upon admission, in 30 days (Re-Eval) and quarterly. Change of Conditions and admissions.

3. Admission, 30-day, 90-day and PRN for change of condition.

4. RSD/RSC     

2. Resident 2 was admitted to the facility in 03/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 12/26/23, temporary service plans and progress notes dated 02/16/24 to 05/20/24 were completed.

The resident experienced multiple short-term changes lacking determination of actions or interventions as indicated, communicated to staff on all shifts, with resident-specific directions, and documented progress at least weekly until resolution in the following areas:

* 02/25/24 "Sore on shin;"

* 04/29/24 Congestion, coughing, diagnosis of bronchitis with antibiotic treatment;

* 05/07/24 Non-injury fall; and

* 05/09/24 Increased confusion, incontinence and four person assist with transfers.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, determination of actions or interventions as indicated, were communicated to staff on all shifts, with resident-specific directions was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.  

3. Resident 4 was admitted to the facility in 10/2023 with diagnoses including dementia and blindness.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/27/23, temporary service plans and progress notes dated 02/15/24 to 05/20/24 were completed.

The resident experienced short-term changes related to falls which lacked determination of actions or interventions as indicated, communicated to staff on all shifts with resident-specific directions, and documented progress at least weekly until resolution in the following areas:

* 02/02/24 Fall with head strike; and

* 03/18/24 Non-injury fall.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, determination of actions or interventions as indicated, communicated to staff on all shifts, with resident-specific directions was discussed with Staff 1 (ED) on 05/22/24. She acknowledged the findings.

Based on observations, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions to staff, and/or monitor progress of the conditions to resolution for 3 of 3 sampled residents (#s 1, 2 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 10/2020 with diagnoses including dementia.

The resident's clinical record, including progress notes, dated 01/26/24 to 05/14/24, temporary service plans, and incident reports, were reviewed and interviews were conducted. The following was identified:

a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, or documented weekly progress through resolution for the following short-term changes of condition:

* 02/14/24 progress note documented increased behaviors of "yelling throughout day"; and

* 03/13/24 progress note documented "resident has a cough that is present and appears to be worsening".

b. There was no documented evidence short-term changes of condition were monitored, with progress documented at least weekly through resolution for the following:

* 04/18/24 progress note stated "resident was found onto[sic] floor this morning by NOC MedTech."

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24 at 12:30 pm. They acknowledged the findings.

1. RN oversight and assessment on all changes of conditions. Residents 1, 2 and 4 the last two weeks were reviewed to rule out any short term change of conditions. Any change of condition identified will further be evaluated and reviewed with staff.

2. RN will conduct all significant and short term changes of conditions. Providing oversight, documentation and follow through.

3. RSD or designee will audit the 24 hour book 5 days a week to ensure all short term COC's and TSP's  are placed on alert. Clinical services team will review documentation weekly to ensure information is documented. Documentation will be reviewed monthly and clinical review meetings until deficient practice is complete. RSC or designee will alert RN of any short term COC's that is not resolving to trigger a comprehensive COC. Any short term COC will be in a 24hr book. RSC/PD will check daily to ensure proper resolution.

4. RN      

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed including documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (# 4) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 03/2023 with diagnoses including dementia.

During the acuity interview on 05/20/24 Resident 4 was identified as being legally blind.

The resident's 10/27/23 service plan indicated the resident needed minimal assist with bathing and dressing, was independent after set up with grooming and hygiene tasks, and was continent of bowel and bladder with stand by assist using a walker.

The resident was hospitalized March 31, 2024 through April 15, 2024, returning with  new diagnoses of diabetes and urinary retention, requiring insulin injections and an indwelling catheter.

Observations during survey found the resident received full assist with bed mobility, catheter care, total assist with ADLs, and two person transfer assistance to and from the wheelchair. Staff assisted with wheelchair mobility and staff were observed providing total meal assist for food and fluid intake at lunch on 05/20/24.

During interviews with Staff 13 (CG) and Staff 17 (MT) on 05/20/24 and 05/21/24 staff reported that since Resident 4 had returned from the hospital s/he had a Foley catheter, needed full assist with all ADLs, was a two person transfer, could no longer ambulate and received insulin injections for diabetes.

On 05/15/24 the facility RN completed an assessment for the change of condition, although did not include the significant decline in mobility and ADL functioning abilities or the new diagnosis of insulin dependent diabetes with delegation of blood glucose testing and insulin injections daily.

The need to ensure an RN assessment was completed for significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) on 5/22/24 at 9:40 am. She acknowledged the lack RN assessment which included all of Resident 4's significant changes of conditions and lack of  interventions updated to reflect the changes.

1. RN will complete a change of condition for resident number #4. RSD will modify and capture changes in the Service plan. Capturing new diagnosis diabetes, requiring insulin injections, urinary retention requirement of catheter.

2. RN will complete all assessment for all change of conditions including decline in #4s mobility and new diagnosis of insulin dependent diabetes.  

3. As needs arise RN will complete assessments for changes of conditions.  

4. RN.      

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment during meal service. Findings include, but are not limited to:

Observations of  meal service were completed between 05/20/24 and 05/22/24 revealed the following:

* Multiple care staff served food and provided occasional direct feeding assistance to residents without donning a protective barrier over potentially contaminated clothing.

* Multiple care staff were observed serving meals and beverages, retrieving items in the MCC's kitchenette, touching residents, or coughing and touching their faces wearing the same pair of gloves without doffing the gloves and performing hand hygiene prior to or between tasks.

In an interview with Staff 1 (ED) and Staff 17 (MT) on 05/22/24 at approximately 8:45 am, Staff 17 reported she had told staff to wear clean aprons during meal service, although stated most had not listened.  Staff 1 stated the facility expected caregivers to wear clean aprons and perform hand hygiene frequently when they assisted residents.

The need to establish and maintain infection prevention and control protocols during the meal service to provide and a safe and sanitary environment was discussed with Staff 1 on 05/22/24. She acknowledged the findings.

Provide staff infection control training through oregon care partners and reliass upon hire and ongoing PPE education.

2. Oversight and training by infection control specialist and Program Director.

3. Training upon hire and quarterly.

4. Infection Control Specialist.

2. Resident 4 was admitted to the facility in 10/2023 with diagnoses including dementia, hypertension and recent diagnosis of diabetes.

Review of the MAR, dated 05/01/24 through 05/20/24, and current physician's orders revealed the following medications/treatments were not completed as ordered:

* Metoprolol 25 mg twice daily for high blood pressure was not administered as ordered from 05/02/24 through 05/12/24 due to "waiting for delivery from pharmacy";

* Multivitamin one a day for supplement was not administered from 05/05/24 through 05/10/24 due to "waiting for delivery from pharmacy"; and

*There was no documentation that staff checked Resident 4's CBG's on 05/16/24 through 05/20/24, prior to the administration of insulin as ordered.  

The need to ensure that physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2020 with diagnoses including type 2 diabetes and dementia.

Review of the MAR, dated 05/01/24 through 05/20/24, and current physician's orders, dated 01/31/24, noted the following:

* Check blood sugar three times weekly, fasting draw.

During an interview on 05/21/24 at 10:50 am, Staff 17 (MT) stated blood sugar checks had not been completed on 05/11/24, 05/14/24 and 05/18/24 as she had "not been delegated" for the task.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

1. Ensure that any and all information regarding missing medication is handled immediately for residents # 1 and #4. All med techs to be delegated on blood sugar checks and insulin administration.

2. Daily clinical meetings with written review of MARS/TARS for missed medications.

3. Daily.

4. PD, RSD, RSC, ED, RN     

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication and treatment refusals. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 03/2023 with diagnoses including dementia.

The resident's 01/01/24 through 02/05/24 MARs and signed physician orders were reviewed.

The resident had a signed physician's order which included directions for staff to notify the physician after "refusal of three or more doses of any medication/ treatment."

Medications/treatments documented as refused multiple times between 05/01/24 and 05/20/24 included:

* Aquaphor lip repair ointment for moisture;

* Carboxymethyl 0/5% Ophthalmic Solution for dry eyes;

* Compression stocking and moisturizing treatment for edema;

* Wound care to left shin; and

* Daily weights.

There was no documented evidence the physician was notified after three refusals for the above medications/treatments.

The need to notify the practitioner of resident medication/treatment refusals was discussed with Staff 1 (ED) on 05/22/24. She acknowledged the findings.

1.Orders will be faxed to pharmacy to update resident #2's profile with proper documentation provided for each staff member on steps to be taken.

2. All staff were re-trained on residents rights on 6/14/24. All staff have been trained on the refusal process for all residents. Orders will be sent to PCP to ensure proper documentation of refusals are marked as such for notifications.

3. MAR will be monitored weekly.  

4. PD, ED, MT, RN, RSD

Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 10/2023 with diagnoses including behavioral disorder associated with dementia.

A review of the resident's 05/01/24 through 05/20/24 MAR and 01/31/24 physician orders showed the following:

Olanzapine 2.5 mg every four hours as needed for agitation or delirium. The Olanzapine PRN dose was administered on 05/08/24 and 05/20/24 .

The MAR did not contain resident-specific parameters for staff describing how the resident expressed agitation or delirium, and there was no documented evidence that non-pharmacological interventions had been tried first with ineffective results.

The need to ensure medications given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented as ineffective prior to the administration for psychotropic medications was discussed with Staff 1 (ED) on 05/22/24. She acknowledged the findings.

1. Parameters for resident #4 on their expressions of agitation and delirium. Train staff on interventions that may be beneficial prior to administering pharmaceutical medications. RSD will capture interventions in resident #4's service plan.

2.Provide training to staff of alternative interventions prior to giving psychotropic medications. Documenting successful resolutions.

3. Each occurrence.

4. Med Tech  

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, document other less restrictive alternatives were evaluated prior to the use of the device, instruct caregivers on the correct use and precautions related to the use of the device, include the use of the supportive device in the service plan, and evaluated on a quarterly basis for 1 of 1 sampled residents (#1) who used a supportive device with restraining qualities. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/2020 with diagnoses including dementia.

Review of Resident 1's service plan dated, 03/25/24, revealed there was no documentation of the use of supportive devices with restraining qualities included in the resident's service plan.

On 05/20/24 at 3:40 pm siderail assessment documentation was requested from Staff 17 (MT). Staff 17 reported the facility lacked documented evidence of a siderail assessment having been completed.  

On 05/22/24, a hospital bed was observed to have bi-lateral, quarter-length siderails in the resident's unit. The siderails on the bed were in the up position and securely fastened to the bed.

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and documentation of their use was included in the resident service plan was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

1.RSD will update Resident #1's service capturing the need of assistive devices.

2. Side rail assessments will be provided prior to moving. RN, PT and OT eval will be provided prior to utilizing devices. Documentation will be captured in the resident service plan.

3. Quarterly/ Upon Admission.

4. RN, PT, OT    

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 15, 16 and 19) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records reviewed on 05/21/24 at 8:30 am with Staff 5 (Business Office Director) identified the following:

Staff 15 (MT) was hired 02/19/24, Staff 16 (CG) was hired 03/28/24, and Staff 19 (CG) was hired 02/07/24. There was no evidence Staff 15, 16 and 19 completed First Aid/abdominal thrust training within 30 days of hire.

The need to ensure staff demonstrated competency in all required training areas within 30 days of hire was discussed with Staff 5 (Business Office Director) on 05/21/24, and Staff 1 (Executive Director) on 05/22/24. They acknowledged the findings.

.Train staff upon hire to teach/demonstrate abdominal thrust.

2. Upon hire, the business office director will secure certificates in staff files.

3. Upon hire and prior to expiration.

4. BOD.      

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

Staff 1 (ED) and Staff 6 (Maintenance Director) reported in interviews on 05/21/24 and 05/22/24, respectively, that they were unaware separate fire drills and fire and life safety instruction to staff were required for the memory care community, apart from the assisted living community.

The need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternate months, was discussed with Staff 1 on 05/21/24 and Staff 6 on 05/22/24. They acknowledged the findings. No further documentation was provided.

1.Fire drills will be conducted every other month. Education will be in alternate months.

2. The Maintenance Director will conduct fire drills utilizing Westmont Senior Living form.

3. Every other month for fire drills and training on odd months.

4.Maintenance Director    

Based on interview and record review, it was determined the facility failed to re-instruct 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. Findings include, but are not limited to:

On 05/22/24, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 6 (Maintenance Director). Staff 6 reported he did not have documented evidence of annual fire and life safety instruction to residents.

The need to ensure residents were re-instructed 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 was reviewed with Staff 2 (Program Director) and Staff 6 on 05/22/24. They acknowledged the findings.  

.Residents will be educated upon admission within 24 hrs of admit and annually.

2. Documentation of residents' fire education will be kept in the binder in the maintenance office.

3. Admission and annually

4. Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure the interior was free from unpleasant odors. Findings include, but are not limited to:

The interiors of the memory care were toured at 11:50 am on 05/20/24. The following was identified:

Pervasive odors were present throughout the common area living room and dining area that did not dissipate during the survey. In an interview with Staff 1 (ED) on 05/22/24 at 10:00 am, it was determined that furniture in the common area was the likely source of the pervasive odors.

The need to ensure the facility was free from unpleasant odors was discussed with Staff 1 and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

1.Hired a full time housekeeper for the Memory Care Unit. Saturated furniture was removed from the unit.

2. Daily monitoring and nightly deep cleaning of all furniture. Soiled briefs will be discarded immediately after patient care.  

3.Daily and as needed.

4. Program DIrector, Med tech and Caregivers

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1511 Individual Rights Settings: OAR 411-004-0020 (1)(d)

(1) Residential and non-residential HCB settings must have all of the following qualities:

(d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS

443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1518 Individual Door Locks: Key Access:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

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

Technical assistance was provided in the following area related to H 1518:

H 1580 Individual Based Limitations

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

The findings of the first revisit to the re-licensure survey of 05/22/24, conducted 01/07/25 through 01/08/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

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

Refer to C 150, C 200, C 242, C 372, C 420, C 422, C 513.

Refer to POC C150, C200, C242, C372, C420, C422 and C513

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 15, 16 and 19) completed all required orientation, pre-service and competency training within the required timelines, and 3 of 3 sampled long term staff (#s 8, 10, and 20) completed the required Home and Community Based Services (HCBS) training by 03/31/24. Findings include, but are not limited to:

Staff training records reviewed on 05/21/24 at 8:30 am with Staff 5 (Business Office Director) identified the following:

1. There was no documented evidence Staff 15 (CG), Staff 16 (CG), and Staff 19 (MT), hired on 02/19/24, 03/28/24, and 02/07/24, respectively, had completed the following required pre-service orientation topics:

* Department approved infectious disease prevention training; and

* Approved HCBS training course.

2. Staff 15, Staff 16, and Staff 19 lacked documented evidence of required pre-service dementia training.

3. There was no documented evidence that Staff 15, Staff 16, and Staff 19 demonstrated competency in their job duties within 30 days of hire in the following areas:

* The 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; and

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

* General food safety, serving and sanitation.

4. There was no documented evidence Staff 8 (Activities), hired 09/05/22,  Staff 10 (CG), hired 08/30/23, and Staff 20 (Housekeeping), hired 02/24/15, had completed the required HCBS training course prior to 03/31/24.

The need to ensure all required training was completed within the specified time frames was discussed with Staff 5 on 05/21/24 and Staff 1 (ED) on 05/22/24. They acknowledged the findings.

1. Staff 15, 16 and 19 will complete pre-service, 30 day competency, annual training,dementia training and HCBS by 7/21/24.

2. BOD will require certificate proof of completion.

3. Upon hire for all new staff and ensure all existing staff obtain certificate by July 21, 2024.

4. BOD

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

Refer to C 252, C 260, C 270, C 280, C 295, C 303, C 305, C 330 and C 340.

Refer to POC. C252, C260, C270, C280, C295, C303, C305, C330, C340

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans, for 3 of 3 sampled residents (#s 1, 2, and 4). Findings include, but are not limited to:

Residents 1, 2 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration was discussed with Staff 1 (ED) on 05/22/24. She acknowledged the findings.

1. Residents #1, #2 and #4  are at risk for dehydration and nutrition plans. RSD will update service plans to reflect individualized status and needs. Facility will provide nutrition and hydration carts to each resident in between meal times.

2.Capture at each service plan. Review monthly weights.

3.Nutrition and Hydration carts will be offered during activity and in between meals.  

4. Program Director and Registered Nurse.   

Based on observation, interview and record review, it was determined the facility failed to ensure residents were evaluated for activities for 2 of 3 sampled residents (#s 2 and 4) and individualized activity plans were developed for each resident based on their activity evaluation for 3 of 3 sampled residents (#s 1, 2 and 4) whose records were reviewed. Findings include, but are not limited to:

Service plans and evaluations were reviewed for Resident 1, 2, and 4. Observations and interviews were completed between 05/20/24 and 05/22/24. The following deficiencies were revealed:

1) An interview with Staff 12 (CG) on 05/21/24 at 9:45 am revealed the facility had a binder titled, "Individualized Activity Plans: The Gardens".

Review of the information revealed Residents 2 and 4 lacked documented evidence an activity evaluation had been completed.

2) Residents 1, 2, and 4 lacked documented evidence of a specific activity plan which detailed what, when, and how often staff should offer and assist the residents with more individualized activities.

The need to ensure the facility evaluated all residents for activities and developed individualized activity plans was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings.

1.Activity profiles will be complete for residents #1, #2 and #4 which will reflect what, when and how often staff should offer and assist the residents with more individualized activities.

2. ED/PD will ensure that all updated activities forms are integrated into residents service plans and any behavioral plans.  

3.Update as needed and quarterly.

4. Lifestyle Director.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 1 and 4) with documented behaviors. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2020 with diagnoses including dementia and depression.

Resident 1's record documented behaviors including yelling, screaming, agitation, verbal and physical aggression.

The resident's service plan, dated 03/25/24, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

2. Resident 4 was admitted to the facility in 10/2023 with diagnoses including dementia.

Resident 4's record documented behaviors including agitation, delirium and repetitive yelling out.

The resident's service plan, dated 10/27/23, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.

On 05/22/24 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED). She acknowledged the findings.

1. Resident #1's and #4's service plans will be updated by RSD to address behaviors and individualized interventions.

2. ED contacted DHS behavioral therapists to coordinate training on behaviors and behavioral plans.

3. PD and RSD will ensure all behavior plans are being followed by weekly audits by designated staff members.

4. PD will look after residents that need behavioral plans to ensure they are in place.

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility grounds of the memory care community were toured on 05/20/24 at 11:50 am. Outdoor furniture was observed in the courtyard, to which residents had free access. The furniture was movable, and not of sufficient weight to prevent injury or elopement.

On 05/22/24 at 10:00 am the outdoor courtyard was toured with Staff 1 (ED). The need to maintain outdoor furniture of sufficient weight was discussed with Staff 1, and she acknowledged the findings.  

Outdoor furniture was removed from the outdoor gazebo area.

2. The Maintenance Director will ensure all outdoor furniture is sufficiently secured.

3. Weekly audit.

4. The Maintenance Director