Print Inspection: IUMK

The findings of the initial survey, conducted 09/12/22 through 09/14/22, 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, 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

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 first re-visit to the re-licensure survey of 09/14/22, conducted 02/27/23 through 03/03/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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 which represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following area:

C 280 - Resident Health Services- OAR 411-054-0045 (1)(a-f)(A)(C-F)

The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety and the situation was abated.

The findings of the second re-visit to the re-licensure survey of 09/14/22, conducted 07/10/23 through 07/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.

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

The findings of the third re-visit to the re-licensure survey of 09/14/22, conducted 10/17/23 through 10/18/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.

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

The findings of the fourth revisit to the re-licensure survey of 09/14/22, conducted 12/05/23, 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 develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 02/27/23 through 03/03/23, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

On 03/03/23, Staff 22 (Interim Executive Director) was interviewed about the facility's quality improvement program. She stated the facility did not have a Quality Improvement (QI) Program policy. She acknowledged the facility did not have a quality improvement plan in place.

Refer to the deficiencies in the report.

C156 OAR 411-054-0025 (9) Facility Administration: Quality Improvement

1. Immediate actions were taken to correct the rule violation by implimenting Quality Improvement program.

2. The system will be corrected so the violation will not happen again. The ED or Designee will be responsible for scheduling monthly QA Meetings with the management team to go ober monthly findings that have been identified through evaluating services, staff performance, resident outcomes and resident satisfaction.

3. The ED will be responsible to ensure the corrections are completed and monitored monthly.

2. Resident 4 was admitted to the memory care community in July 2022, with a diagnosis of dementia.

During the acuity interview, Resident 4 was identified as having a physical altercation with another resident on 08/15/22. A review of the residents record indicated:

*There was no documented evidence the facility reported the altercation to the local SPD office; and

*There was no documented evidence the incident was investigated by the facility, or that measures were taken to protect residents and prevent reoccurrence of abuse.

On 09/14/22 the need to report all resident to resident altercations to the local SPD office and promptly investigate the incidents was discussed with Staff 1 (ED). The surveyor informed Staff 1 the altercation must be reported to SPD prior to the survey team's exit. Staff 1 completed the reporting and presented documentation to the survey team.

Based on interview and record review, it was determined the facility failed to promptly investigate injuries of unknown cause to rule out abuse, and failed to document all required areas of an investigation for 2 of 2 sampled residents (#s 1 and 4) who had incidents of suspected abuse and/or injuries of unknown cause. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance.

a. A Resident Incident Report form dated 08/15/22 documented a resident-to-resident physical altercation in the hallway witnessed by a visitor. There was no documentation the incident had been investigated to include Administrator's review or reported to the local SPD office.

b. Staff documented in a progress note, dated 08/24/22, Resident 1 was using profanity directed at another resident whom s/he was accusing of using his/her cup. There was no documentation the incident of suspected verbal abuse had been investigated or reported to the local SPD office.  

c. Resident 1 had an unwitnessed fall on 09/07/22 and was sent to the hospital with a bump on his/her head. There was no documented evidence of an investigation to rule out abuse, or notification to the local SPD office.

The need to thoroughly investigate incidents of suspected abuse and/or neglect, unwitnessed falls, and injuries of unknown cause immediately, and the need to report to SPD if unable to reasonably rule out abuse and neglect was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Staff 1 was asked to report the incidents to the local SPD office. Confirmation of report was provided prior to survey exit.

C231  OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-other action

1.  Immediate actions taken to correct the rule violation include thoroughly investigating and self-reporting incidents to APS for Resident #1 and #4. Reports were confirmed as sent to APS for each incident prior to Survey exit. Resident specific interventions have been put in place to reduce risk for these incidents to happen again. Service plan has been updated with the interventions for staff to know how to assist the Residents and redirect as needed.

2. The system will be corrected so the violation will not happen again: The MA on shift is responsible for initiating the Resident incident report on the shift the incident occurred. The MA will notify the Manager on Duty immediately if abuse and neglect can not be immediately ruled out. All incidents will be fully investigated and proper reporting will be completed if needed in a timely manner. Abuse reporting and investigating guide for providers for Oregon has been reviewed with the department management team and will be reviewed with Staff at the next all Staff meeting. Additional training will be completed to ensure all staff are aware of the current policy, know where to find blank incident reports and how to fill them out as well as knowing what criteria in the IR triggers immediate notification of the Administrator and self-reporting of abuse/neglect. All MA and MOD staff will take the Oregon Care Partners training "Elder Abuse Prevention, Investigation and Reporting" course for additional education. Continuous quality improvement audits on abuse and neglect reporting and investigation will be completed to ensure all incidents are investigated timely, and are reported to APS if we cannot rule out abuse and neglect.

3. This area needing correction will be reviewed on a daily and monthly basis. All incidents will be reviewed and followed up on appropriately during weekday stand up meetings. The system will be reviewed on a monthly basis during continuous quality improvement reviews.  

4. The Executive Director and Residents Care Coordinator will be responsible to ensure the corrections are completed and monitored.

3. Resident 5 was admitted to the facility in 04/2021 with diagnoses including dementia, Diabetes (type 2) and depression.

Review of Resident 5's progress notes, dated 01/15/23 through 02/27/23, and incident reports, identified a physical altercation between Resident 5 and another resident. Resident 5's clinical records noted the following:

* On 02/12/23 - "While another resident was using the restroom [Resident 5] opened the door and got very upset". "[He/she] then slapped [him/her] in the face very hard"

There was no documented evidence the facility reported this incident to the local SPD office.

In an interview on 03/01/23, Staff 22 (Interim Executive Director) stated no self-reporting to SPD had been completed for the incident. Staff 1 was informed the incident must be reported prior to survey team's exit from the building.

On 03/01/22, Staff 22 presented the surveyor documentation of self reporting the incident, and acknowledged the need to report any future altercations.

Based on interview and record review, it was determined the facility failed to conduct investigations of injuries of unknown cause to rule out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, and failed to have documented evidence of an administrator review and follow-up action by the facility, for 3 of 3 sampled residents (#s 2, 5, and 7). This is a repeat citation. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in March 2022 with diagnoses including dementia.

Interview and record review revealed the following deficiencies:

* On 01/25/23, Resident 2 was involved in a resident-to-resident altercation. There was no documented evidence of an administrator review, or that the altercation had been reported. On 03/02/23, survey reported the incident to the local SPD office;

* On 02/01/23, a progress note indicated Resident 2 had a skin tear on their inner left thigh. There was no documented evidence of an investigation, as to how the resident sustained the injury, or that the injury of unknown cause had been reported. On 03/02/23, survey reported the incident to the local SPD office; and

* On 02/03/23, Resident 2 was involved in a resident-to-resident altercation. There was no documented evidence of an administrator review of the altercation, or the altercation had been reported. On 03/02/23, survey reported the incident to the local SPD office.

On 03/03/23, the need to ensure all allegations of abuse and neglect were reviewed in a timely manner by the facility administrator and reported to the local SPD office was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

2. Resident 7 was admitted to the facility in November 2022 with diagnoses including dementia.

Interview and record review revealed the following:

*Resident 7's service plan, dated 1/17/23, indicated the she/he needed assistance with transfers and ADL care.

* On 02/22/23, a temporary service plan indicated Resident 7 had redness to lower coccyx and was to be monitored for increase in redness and opening skin. There was no documented evidence the facility administrator had conducted an investigation to rule out abuse and neglect. On 03/09/23, survey reported the incident to the local SPD office.

On 03/03/23, the need to ensure all allegations of abuse and neglect were reviewed in a timely manner by the facility administrator and reported to the local SPD office was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C231 OAR 411-054-028 (1-3) Reporting and Investigating-abuse-other-action.

1. Immediate actions taken to correct the rule violation include throughly investigating and self-reporting incidents to APS for Residents 2, 5, 7.

2. This system will be corrected so that the violation will not happen again. The Med Tech on shift is responsible for initiating the incident report for the shift, the day the incident occurred. The Med Tech will notify the Manager on Duty if abuse or neglect cannot be ruled out. All incidents will be fully investigated and reported as needed in a timely manner.

3. All incidents will be discussed and reviewed in daily stand up. All incidents will be reviewed and monitored during monthly QA meetings and audits.

4. The Executive Director and/or the Registered Nurse will be responsible for ensuring the corrections are completed and monitored.

Based on observation and interview, the facility failed to conduct a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to:

During the survey, conducted 09/12/22 through 09/14/22, observations were made in the MCC's common areas. Staff members were observed interacting with residents in one-on-one activities, such as a game or puzzle. However, there were no organized group activities observed.

The survey team was presented with an activity calendar on 09/12/22. No specific times were listed, and none of the scheduled activities were observed during the survey. The activities schedule included the following:

*09/12/22:  Daily brain teaser

                    Chocolate milkshake day

                    Grandparents day

*09/13/22:  Daily brain teaser

                    Positive thinking day

*09/14/22:  Daily brain teaser

In an interview 09/13/22 Staff 1 (ED) confirmed the facility had not been conducting group activities.

On 09/14/22 the need to conduct a daily program of social and recreational activities that were based on individual and group interests was discussed with Staff 1. She acknowledged the findings.

C242 OAR 411-054-0030 (1)(c-d) Resident Services: Activities

1. Immediate actions taken to correct the rule violation include active recruiting for a Life Enrichment Director (posting is on Indeed.com and Zip Recruiter). Until hiring for this position, an activity calendar will be updated to reflect daily planned/timed group activities that the department heads will oversee and assist with. The activities will be tailored to Resident preferences and abilities to participate. Staff will continue to also offer spontaneous and scheduled activities, including 1:1 activities.  

2. The system will be corrected so this violation will not happen again by ensuring there is an organized program in place of social and recreational activities that are based on individual and group interests. Until an activity director can be hired, the MOD for each day, including weekends, will oversee and ensure that the planned and spontaneous activities for the day are held. Caregiving staff will be identified per the employee schedule for designation of activities. A life enrichment director will be hired and trained to take over and drive the activities program.

3. The activities calendar will be reviewed daily at Iuditas' standup meetings. The identified MOD for the day will report on the activities planned for the day. The ED or designee will review the calendar weekly (per a recurring meeting on their calendars) and confer with the BOM to ensure that petty cash and/or any needed supplies are available in advance of the coming activities. The BOM will audit current Resident Assessment/Interest profiles to personalize the activity program and fit the needs and preferences of the current Resident population overall. 100% of Residents care plans will be audited and updated with each Residents personalized activity preferences, interests and abilities. This area will be updated with quarterly service plan updates, with significant changes of condition, and as needed.

4. The ED, BOM and daily MOD will be responsible to ensure the corrections above are completed and monitored.     

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to:

a. During the revisit survey the activity program was observed in the memory care community.  The activity calendar was posted, and included the following schedule for 02/27/23:

* 9:00 - Exercise Video;

* 10:30 - Snacktivity;

* 11:00 - Card Games;

* 1:30 - Puzzle Mania;

* 2:30 - Snacktivity;

* 3:00 - Kick Balloon; and

* 4:00 - Stories for Daze.

On 02/27/23 observations were made in the MCC's common area from 9:15 am through 4:30 pm. None of the scheduled activities were conducted. Residents were observed wandering the unit, sitting or talking quietly, or watching television.

On 02/28/23, Staff 11 (MT) stated, activities do not happen often, and residents complained about not having anything to do.

On 03/03/23, the need to provide an activities program based on individual and group interests was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings.

C242 OAR 411-054-0030 (1)(c-d) Resident Services: Activities

1. Immediate actions taken to correct the rule violation by reviewing the Activity Calendar every day in stand up and making sure all supplies are out and ready for scheduled activities.

2. This system will be corrected so this violation will not happen again by ensuring there is an organized program in place of social and recreational activities that are based on individual and group interests.

3. The activities calendar will be reviewed daily during stand up meetings.

4. Each resident's care plan will be updated at move-in, within 30 days of admission, quarterly, or with change of condition documentating the resident's personal activity perferances, interests, and abilities.

5. The Executive Director will be responsible for ensuring the corrections are completed and monitored daily.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations were completed quarterly for 2 of 3 sampled residents (#s 1 and 2) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia.

Review of Resident 1's clinical records showed the most recent evaluation was completed 06/02/22. There was no documented evidence a quarterly evaluation had been completed after 06/02/22.

The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

2. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance.

Resident 2's most recent quarterly evaluation was completed on 04/21/22. There was no evidence an evaluation had been completed after 04/21/22.

The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C252 OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation

1. Immediate actions taken to correct the rule violation include updating the quarterly evaluations for Residents #1 & #2 to reflect all required components per OAR's. These evaluations will be updated at least quarterly, and with any significant change of condition moving forward.

2. The system will be corrected to prevent this violation from happening again by ensuring the resident evaluation will be reviewed and updated by the clinical staff prior to move in, within 30 days and quarterly thereafter. Iuditas has also hired a move-in coordinator responsible for making sure that the appropriate move-in policy is followed, and that all initial move-in evaluations are completed and reflective of all required components. The ED will be responsible for the final approval, after which the RCC or designee will track and update evaluations in a timely manner for the initial, 30 day, then quarterly thereafter.

3. This area needing correction will need to be reviewed and audited prior to any new Resident move in, and the system will be reviewed on a quarterly basis to ensure compliance with OAR's.

4. Administrator, Nurse or designee will be responsible to ensure the corrections are completed and Monitored.

3. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia.

Review of Resident 1's clinical records indicated the following:

*Resident 1's service plan dated 06/02/22, stated the resident was receiving hospice services and was at risk for aspiration. The service plan instructed staff to provide the resident thickened liquids, as needed. The service plan did not provide clear direction to staff related to how staff would identify when the resident might need thickened liquids or what consistency of thickening would be required; and

* Resident 1's current service plan was completed 06/02/22. There was no documented evidence the service plan had been reviewed and/or updated quarterly.

The need to ensure service plans provided clear direction to staff and were reviewed and/or updated quarterly was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

2. Resident 3 was admitted to the memory care community in July 2022, with diagnoses including dementia and depression.

Review of the resident's clinical records indicated the following deficiencies:

Resident 3's current service plan was completed on 04/30/22. There was no documented evidence the service plan had been reviewed or updated quarterly.

On 09/13/22 the need to ensure service plans were reviewed and updated quarterly was discussed with Staff 1 (ED). She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current health status and care needs, provided clear direction to staff regarding the delivery of services, were completed quarterly, and/or were reviewed and updated when residents experienced a change of condition for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance.

a. Observations of the resident, interviews with staff, and review of the resident's 04/21/22 service plan, showed the service plan was not reflective of the resident's current care needs and did not give clear direction to staff in the following areas:

* Level of assistance for multiple ADLs;

* Behaviors and interventions; and

* Use of bedrails; and

* Weight loss.

b. There was no evidence Resident 2's service plan had been reviewed or updated when the resident showed a significant change of condition on 06/15/22 related to weight loss.

c. Resident 2's service plan was completed 04/21/22. There was no documented evidence the service plan had been reviewed and/or updated quarterly.

The need for service plans to be reflective of residents' current status with clear instructions to staff, updated as needed for significant changes of condition, and completed quarterly was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C260  OAR 411-054-0036 (1-4) Service Plan: General

1. Immediate actions taken to correct the rule violation include updating Residents #1, #2 & #3 service plans to reflect all required components. Resident #1's SP has been updated to reflect their level of assistance for multiple ADL's, Behaviors and interventions to minimize and support them, Use of bedrails, and recent weight loss including interventions to maintain current weight and clarification on diet texture. A comprehensive RN assessment will be completed to evaluate Resident #2 for recent significant change of condition related to weight loss. Resident specific Interventions to support weight/nutritional status will be added to the service plan per nursing assessment. The plan to monitor weight will be added to the service plan and changes will be made to support Resident #2's weight loss needs as needed. Resident #3's Service plan will be audited and updated to reflect current needs and preferences, and all Residents will have at least a quarterly service plan review and update moving forward.

2. To ensure this violation will not happen again, 100% of Resident service plans will be audited and updated to reflect person-centered directions for care and preferences. Families/Responsible parties will be contacted and provided with copies of the service plans. 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 Resident Service plans will be reviewed and updated to reflect any changes or personalization via "Temporary service plan". All updates to the service plan are placed in the 24 hr book for all staff to review and sign off on.The ED will be responsible for ensuring implementation of new changes and verifying that staff have read and signed each new service plan. Staff will be observed providing care to ensure that the information was followed. Software will track dates of service plans and needed updates to ensure these take place within the required timeframe. The Service plan update schedule will be discussed at stand-up meetings daily. Bi-Weekly staff meetings involving caregivers and med techs will be held to keep the service plan schedule in compliance, and give staff opportunity to give input on care.  

3. The area needing correction will be evaluated at least quarterly and with any significant changes of condition.

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

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status, provided clear instructions to staff and were followed for 3 of 4 sampled residents (#s 2, 5 and 7) whose service plans were reviewed.  This is a repeat citation. Findings include, but are not limited to

1. Resident 5 was admitted to the facility in 04/2021 with diagnoses including dementia, Diabetes (type 2) and depression.

In an interview on 02/27/23, Staff 24 (Business Office Manager/Assistant ED) stated Resident 5 had exhibited aggressive behaviors, been involved in a resident to resident altercation, and was often resistant to care.

Review of Resident 5's service plan, dated  01/25/23 and temporary service plans determined the service plan was not reflective, or did not provide clear instructions to staff in the following areas:

* Depression;

* Resistance to care; and

* Combative/aggressive behaviors.

On 03/03/23 the need to ensure service plans were reflective of residents' current status, and provided clear instructions to staff was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings.

2. Resident 2 was admitted to the facility in March 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff from 02/27/23 to 03/03/23, review of the service plan, dated 01/26/23, evaluation dated 01/26/23, progress notes, incident reports, and temporary service plans from 01/15/23 to 02/27/23, 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:

* Depression;

* Anxiety;

* Agitation;

* Communication; and

* Judgement.

On 03/03/23, the need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

3. Resident 7 was admitted to the facility in November 2022 with diagnoses including Dementia.

Observations of the resident, interviews with staff from 02/27/23 to 03/03/23, review of the service plan, dated 01/17/23, evaluation dated 01/17/23, progress notes, incident reports, and temporary service plans from 01/15/23 to 02/27/23, 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:

*Resistance to care;

*Judgement;

*Use of side rails; and

*Hospice services provided.

On 03/03/23, the need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C260 OAR 411-054-0036 (1-4) Service Plan:

1. Immediate actions taken to correct the rule violation include updating resident service plans to reflect their level of assistance for multiple ADL's, behaviorsm and interventions to minimize and support them.

2. To ensure this violation will not happen again, Registered Nurse will review all Resident Service Plans, update as needed to reflect person centered directions for care and preferances.

3. The area needing correction will be evaluated quarterly and with any significant change in condition.

4. The Executive Director and Registered Nurse will be responsible for ensuring that the corrections are completed and 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 regarding care and services for 1 of 3 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbances, HIV infection, and depression.

During an interview on 7/12/23 at 8:35 am, Resident 8 was observed with a dressing on his/her  right wrist. During an interview with Staff 16 (CG) she indicated that due to Resident's 8 diagnosis of HIV infection, they try to cover any area of his skin that could be a potential exposure.

Resident 8's service plan dated 04/12/23, and behavioral plan dated 05/09/23, lacked clear direction regarding the delivery of services including a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas:

* Assistance with dressing, bathing, personal hygiene, and shopping;

* Depression/suicide talk interventions;

* Written communication ability; and

* Infection prevention related to compromised skin integrity.

In an Interview with Staff 32 (Executive Director), Staff 34 (Consultant RN) and Staff 39 (RN) on 07/11/23, the need to ensure service plans provided clear caregiving direction which included a written description of who shall provide services and what, when, how and how often the services shall be provided was discussed, and they acknowledged the findings.

3. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia.

Clinical records were reviewed during survey and indicated the following:

On 07/26/22, the facility received an order for a COVID-19 rapid test for Resident 1. A progress note dated 07/27/22 indicated Resident 1 had episodes of gastrointestinal symptoms and nausea. There was no documented evidence the facility tested the resident for COVID-19 or evaluated and monitored Resident 1 for possible symptoms of COVID-19.

The need to ensure changes of condition were evaluated and monitored through condition resolution was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

2. Resident 4 was admitted to the memory care community in July 2022, with a diagnosis of dementia.

During the acuity interview, Resident 4 was identified as having a physical altercation with another resident on 08/15/22.  

There was no documented evidence the facility evaluated the resident following the altercation, monitored the resident for injuries or adverse effects, or developed interventions to prevent further altercations.

On 09/14/22 the need to document resident to resident altercations, monitor residents involved for adverse effects, and provide clear instructions to staff was discussed with Staff 1 (ED). She acknowledged the findings.

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

1. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance.

Resident 2's clinical record was reviewed. Multiple changes of condition were identified with the following deficiencies:

a. No actions or intervention developed, no communication to staff on each shift, or evidence of monitoring for the following changes of condition:

* Significant weight loss of 5.76% between 05/15/22 and 06/15/22;

* Change in behavior, with resident-to-resident physical altercation 08/15/22; and

* Resident-to-resident verbal altercation 08/24/22.

b. Lack of monitoring at least weekly to resolution for:

* Urinary tract infection 06/14/22;

* Urinary tract infection 08/25/22;

* New medication Cephalexin (antibiotic) 08/25/22;

* Four missed doses of antibiotic discovered 09/1/22; and

* Bruise noted on lower left buttock/upper hip area 09/9/22.

The need to determine and document what actions and interventions were needed for the resident when s/he experienced short-term changes of condition, communicate them to staff, and monitor them at least weekly through resolution was discussed with Staff 1 (ED) 09/14/22. She acknowledged the findings.

C270  OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. Immediate actions taken to correct this rule violation include completing a comprehensive RN assessment related to recent significant changes of condition for Residents # 2, and 4. A comprehensive Physician Order audit will be completed for Resident #1 to ensure accuracy of current orders and follow up to any order change is in place. To ensure all Physician orders are followed in the future refer to C300 for POC.

Resident #2: Comprehensive RN assessment to be completed to include causative factors and personalized interventions to support recent significant weight loss, multiple UTI's, missed medications and skin issues. Also focused on behavioral concerns to identify non-pharmacological interventions that would be beneficial to attempt with ongoing behaviors, as well as identify any causative factors that may be triggering undesired behaviors for Resident #2. Changes in behavior (physical alt 8/15/22 and verbal alt 8/24/22) were reported to PCP and Resident has been seen by their PCP for these areas of concern. Physician made no changes and requested continued monitoring. On 9/21/22 PCP approved use of scheduled THC/CBD gummies per family request as an alternative to a new  psychoactive medication. This treatment was initiated, and a TSP for adverse effects, desired effect of the gummies, and effective non-pharm interventions to attempt with any future undesired behaviors was

initiated. No incidences of Resident to Resident altercations (verbal or physical) since this was initiated, and their behavior has been more stable from morning to evening hours.

Resident #4: RN to complete a comprehensive assessment and behavioral review to reduce risk of future altercations. Potential causative factors as well as triggers will be identified as part of the RN assessment, and Resident specific non pharm interventions will be initiated to reduce risk of negative behaviors or altercations in the future. Changes will be made to the Service plan based off findings in RN assessment.

2. The system will be corrected so this violation will not happen again the community will follow their 24 hr communication system. The "24 hr binder" is set up to include:

 a. Shift to Shift Communication LOG

 b. Alert charting log

 c. TSP's and updated Service Plans for staff review

 d. Significant change of condition LOG

Staff will follow the Short Term Monitoring and Communication System for any Resident identified to have an acute change of condition such as UTI, missed med, resident to resident altercation, return from hospital, fall for example. When a change of condition is identified, Staff add the Residents name to the alert log to ensure they monitor the Resident and identify when to report concerns to Nursing or MD. The Staff will be aware of what to report to Nurse/MD per the temporary service plan (TSP) that has been put in place, which correlates with the Residents change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the ISP.

Staff should monitor Resident status until Resident condition resolves and they are back at their baseline.

To monitor weight changes, weights are taken monthly (or per doctor orders) and sent to the nurse consultant for review. Significant or unexplained weight gain/loss of 5% or more over 30 days, 7.5% over 90 days or 10% over 180 days  will trigger an RN assessment to determine the underlying cause. The Nurse will direct staff to any intervention or monitoring plans via a TSP for staff instructions.

3. The area needing correction will be evaluated daily during stand up with the 24 hr review.  The Community will audit to ensure clinical systems are in compliance with company policy and Oregon Administrative Rules.

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

2. Resident 5 was admitted to the facility in 04/2021 with diagnoses including dementia, Diabetes (type 2), and depression.

Resident 5's progress notes, dated 01/15/23 through 02/27/23, service plan dated 2/20/21, temporary service plans, and incident reports indicated the resident had experienced the following:

On 02/12/23, Resident 5 had a witnessed resident-to-resident altercation, in which [he/she] "slapped the other resident hard in the face".

In an interview on 02/28/23 Staff 20 (CG) stated "[Resident 5] does have aggressive behaviors sometimes, but we just try to anticipate the problem, and redirect [him/her]".

The resident's records lacked documented evidence the negative behavior was evaluated, with needed actions and interventions determined.

On 03/03/23 the need to evaluate changes of condition and determine interventions needed was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support).  They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed, when residents experienced changes of condition for 2 of 4 sampled residents (#s 2 and 5) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance.

Resident 2's clinical record was reviewed for changes of condition and revealed the following:

* On 01/31/23, Resident 2 and three un-sampled residents were involved in a verbal altercation and Resident 2 attempted to punch an unsampled resident. Staff were able to step between to prevent the unsampled resident from being struck.

There was no documented evidence the facility determined and documented what resident specific actions or interventions were needed to minimize further occurrences.

On 03/03/23, the need to determine and document what actions and interventions were needed  when a resident experienced a short-term change of condition was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C270 OAR 411-054-0040 (1-2) Change in Condition and Monitoring:

1. Actions taken to correct this rule violation include completeing a comprehensive RN assessment related to significant change od condition for resident #2 & 5.

2. The system will be corrected so that this violation does not happen again the communication binder is set up to include the following:

a. shift to shift Communication Log

b. Alert Charting Log

c. TSP's and updated Service Plans for staff review

d. Significant change of condition log

3. The Registered Nurse will review the 24-hr communication binder daily and complete a comprehensive RN assessment for significant change of condition.

4. The area needing correction will be evaluated during daily stand up with the 2-hour review. The community will audit to ensure clinical systems are in compliance.

5. The ED and RN 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 document what action or interventions were needed or document weekly progress for 1 of 3 sampled residents (# 8) who experienced short-term changes of condition. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbance.

The resident's progress notes, dated 06/16/23 through 07/07/23 and temporary service plans were reviewed and noted the following:

*On 06/16/23, Resident 8 was noted to be found on the floor. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident;

*06/19/23, Resident 8 was involved in a resident to resident altercation. There was no documented evidence the facility determined and documented what actions or interventions were needed to help minimize future occurrences;

*06/28/23, Resident 8 was involved in a staff to resident altercation. An investigation was completed, Adult Protective Services was notified, a temporary service plan was created however, there was no documented evidence of weekly progress noted through resolution; and

*On 06/29/23, Resident 8 was involved in a resident to resident altercation. There was no documented evidence the facility determined and documented what actions or interventions were needed to help minimize future occurrences.

During an interview on 07/11/23 at 12:12 pm, Staff 34 (Consultant RN) stated he believed there was a temporary service plan completed related to the resident to resident altercation however, was unable to find documentation that it had been completed.

Determining actions and interventions for short term changes of condition and monitoring changes weekly through resolution was discussed with Staff 32 (Executive Director), Staff 34 (Consultant RN) and Staff 39 (RN) on 07/11/23 at 12:12 pm. Staff acknowledged the findings.

Based on interview, and record review, it was determined the facility failed to ensure an RN assessment was performed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 1 of 2 sampled residents (#2) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in March 2022 with diagnoses including Alzheimer's disease with behavioral disturbance, hypertension, and bilateral leg edema.

Review of the resident's monthly weight records from 3/15/22 through 9/14/22 showed the following:

The resident experienced a 9.5 lb weight loss from 05/15/22 to 06/15/22, which constituted a 5.76% weight loss in one month. The resident weighed 171.4 on 05/15/22 and 161.9 on 06/15/22.

There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

A current weight was requested by the surveyor on 09/14/22; the resident weighed 177.0.

On 09/14/22 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (ED). She acknowledged the findings.

C280 OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

1. Immediate actions taken to correct the rule violation for each example/resident include completing an RN assessment of current weight to evaluate for recent and any current weight loss. Interventions to maintain or gain weight if weight loss is identified to be unintentional will be added to the SP and monitored to ensure effectiveness. Changes will be made as needed. Weight will continue to be monitored on a monthly basis and sent to the nurse consultant for review and reassessment. The Nurse will direct staff to any intervention plans that will be put in a TSP along with instructions regarding when to notify nursing or PCP of concerns related to ongoing weight loss.

2. The system be corrected so this violation will not happen again by following current policy for significant changes of condition. Staff will be re-educated on this policy, definition of and examples of a significant change of condition, and when/how to utilize the 24/7 phone and video call access to the on-call RN provided through Ally Senior Management Co. When a significant change is identified, the Nurse/designee will add Resident name and area of concern to the Significant change of condition LOG. The RN will perform a comprehensive change of condition assessment within 48 hrs to identify interventions required to support the resident, review effectiveness of current interventions put in place, and follow up with their provider on any noted concerns or recommendations. A weekly RN assessment will continue until Residents health status returns to baseline, or a new baseline can be established.To monitor weight changes, weights will be taken monthly (or per doctor orders) and sent to the nurse consultant for review. Significant or unexplained weight gain/loss of 5% or more over 30 days, 7.5% over 90 days or 10% over 180 days will trigger an RN assessment to determine the underlying cause. The Nurse will direct staff to any intervention or monitoring plans via a TSP for staff instructions.

3. This area needing correction will need to be evaluated on a Monthly basis and as needed per individual Resident orders for monitoring.

4. The ED, Nurse or Designee will be responsible to ensure these corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents including an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. Resident health and care needs were placed at risk. This is a repeat citation. Findings include, but are not limited to:

During the survey on 02/27/23 through 03/03/23, it was disclosed the Facility had been without an Oregon licensed nurse since 02/15/23, who was regularly scheduled to be onsite or available for phone consultation.

In an interview on 03/02/23, Staff 22 (Interim Executive Director) and Staff 23 (Regional Support), confirmed the facility had been without a regularly scheduled RN since 02/15/23. The Surveyors requested an immediate plan of correction to acquire an Oregon licensed nurse to be scheduled onsite or available for phone consultation.

The facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents including an Oregon licensed nurse who was regularly scheduled for onsite duties placed resident health and care needs at risk.

On 03/03/23, Staff 22 provided the surveyors with a plan of correction noting the facility retained a regularly scheduled onsite Oregon licensed nurse and the situation was abated.

C280 OAR 411-054-0045 (1) (A)(C-F) Resident Health Services

1. Immediate action taken to correct the rule violation for failure to provide health services and have systems in place respond to the 24-hour care need of residents including having an Oregon Licensed Registered Nurse who is regularly scheduled for onsite visits.

2. The system is being corrected by having an Oregon Licensed Registered Nurse on site 40 hours per week and available 24/7 via phone, video call to the on-call Registered Nurse.

3. This area needing correction will be evaluated daily during stand up to ensure nursing coverage.

4. The Executive Director will be responsible for ensuring these corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist. Findings include, but are not limited to:

In an interview on 09/13/22 Staff 1 (ED) stated the facility did not have a designated Infection Control Specialist.

On 09/14/22 the need to designate an Infection Control Specialist, who has completed all required training was reviewed with Staff 1. She acknowledged the findings.

C295  OAR 411-054-0050 (1-5) Infection Prevention & Control

1. Immediate actions taken to correct the rule violation include the community registering their RCC as well as the ED for the IFS class. The RCC will act as the communities infection control specialist, and the ED will act as back up.

2. The system will be corrected so this violation does not happen again by adding the required training for "infection control specialist" to the RCC training/ orientation record as well as to the ED's. The community will maintain a designee for this position to be responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The annual training record will also reflect the need for this training to be completed on a bi annual basis per OAR's.

3. This area needing correction will need to be evaluated on an annual basis with annual inservice/ training review.

4. The ED, BOM or designee will be responsible to see that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:

a. During the initial licensure survey, conducted 09/12/22 through 09/14/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 303: Systems: Medication and Treatment Orders;

C 310: Systems: Medication Administration;

b. During a review of staff training records, 09/14/22, four newly hired MT's lacked documentation medication administration competency training had been completed.

Refer to Z155

Failure to ensure a safe medication system and to ensure adequate professional oversight, based on deficiencies related to medication administration was discussed during the exit meeting on 09/14/22.

C300 SS=F OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

Please refer to Z155, C303 and C310 for the plan of correction for this citation.      

2. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia.

Clinical records were reviewed during survey and indicated the following:

On 07/26/22, the facility received a faxed order for a " COVID rapid test, to be tested by facility" from Resident 1's physician. There was no documented evidence the facility carried out the order to complete a COVID-19 rapid test as the physician had prescribed.

The need to ensure the facility carried out all physician orders as prescribed was discussed with Staff 1 (ED) on 09/14/22. 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 2 of 3 sampled residents (#s 1 and 2) whose clinical documentation was reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility 03/2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance.

Review of Resident 2's MAR, dated 08/01/22 through 09/12/22 and physician orders identified the following deficiencies:

a. On 08/23/22 an order was received for Cephalexin (antibiotic) 500 mg Capsule, one capsule by mouth three times daily for 5 days. A fax to the physician from the facility on 09/01/22 at 12:35 pm stated: "Resident was taking ABX [antibiotic] Cephalexin for UTI. Resident's last dose was due 8/28, however resident has two capsules left in AM card and two capsules left in mid-day card. This fax is to inform PCP of med error."

b. A fax from Resident 2's physician on 09/01/22 at 3:32 pm ordered "please continue antibiotics to completion" in response to the fax from the facility documenting four missed doses of Cephalexin (see above). There was no documented evidence this medication was administered.

The need to ensure that physician orders were carried out as prescribed was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C303  OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

1. To correct the rule violation for each example, a comprehensive MAR to cart to Physician order audit will be completed for Residents #1 and #2. The goal of the 3 way audit will be to ensure all medications and treatments are being given per MD order, and identify med errors including missed doses, to correct and evaluate Resident status timely.

2. The system will be corrected so this violation will not happen again by providing re-training/ education for med techs on following the current medication delivery process per company Policy. Staff will be trained on the process to follow and ensure all medications are available and being given per MD order. A missed med report will be reviewed by RCC or designee daily as part of clinical review. The community has initiated use of a new electronic health record, "ALIS", and will be providing training for all clinical staff who oversee and administer medications to run medication reports on a daily basis that will identify any medication that is unavailable, miss med or refusals. The triple check system will be reviewed as part of the medication delivery process training, and when followed accurately, will ensure all provider orders, including orders to test for COVID are processed and carried out per order in a timely manner.

3. The area needing correction will be evaluated each working day in the daily stand up meeting. The Medication/ Treatment processing and delivery system will be reviewed quarterly with the CQI process to ensure a safe system is in place.

4. The ED, RCC 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 medication orders were carried out as prescribed for 1 of 2 sampled residents (# 11) whose orders were reviewed. Resident 11 experienced medical complications potentially as a result of not receiving blood pressure medications as prescribed. Findings include, but are not limited to:

Resident 11 was admitted to the facility in March of 2023 with diagnoses including hypertension, subarachnoid hematoma (2022), and neurocognitive deficit.  

Review of Resident 11's current physician orders and MARs and progress notes  from 06/01/23 through 10/17/23 revealed the following:

* Amlodipine 5 mg was ordered one time daily for hypertension. There was no documented evidence the Amlodipine was administered on 23 occasions from 06/01/23 through 06/28/23.

* Losartan 25 mg was ordered one time daily for hypertension.  There was no documented evidence the Losartin was administered on 23 occasions from 06/01/23 through 06/28/23.

The exceptions report indicated the medications were not administered as ordered due to "med unavailable," med on back order," or "med ordered."

On 06/28/23 the resident's blood pressure at 08:00 am was documented to be 185/111. A progress note dated 06/28/23 at 2:22 pm stated the resident appeared "drowsy, pale and clammy."  Emergency services were called, and the resident was transported and admitted to the hospital, returning to the facility on 07/01/23 with a diagnosis of syncope (loss of consciousness). The discharge orders included Amlodipine and Losartin to be discontinued.

On 07/04/23 Resident 11's blood pressure at 08:35 am was documented as 188/115. The resident was sent by emergency services to the emergency department for hypertension and returned the same day. The Amlodipine and Losartan were ordered to start again, and Metoprolol 50 mg twice daily was ordered for hypertension.

On 07/06/23 a signed order from the resident's cardiologist physician discontinued the Amlodipine and Losartan and ordered the Metoprolol to continue at 50 mg a day.

On 10/10/23 the facility received signed orders for Losartan 50 mg a day and Amlodipine 5 mg a day from Resident 11's physician. The medications were not transcribed to the MAR upon receipt. Staff 32 (Executive Director) reported the medications had not been brought to the facility by the resident's power of attorney. The medications were not administered as ordered from 10/10/23 through 10/17/23.

The additional following medications were not administered as ordered between June 1, 2023 and October 17, 2023 and were documented as not available:

* Nutrisource Fiber packet twice daily (for bowel care): 13 occasions in June, five occasions in July, five occasions in August, five occasions in September and 21 occasions between October 1 through October 17, 2023.

* Polyethylene Glycol powder, one packet daily (for bowel care): 10 days in June, 28 days in July, four days in August, 10 days in September and 6 days October 1 through October 17, 2023.

* Tamsulosin HCL .08 mg daily (for benign prostatic hyperplasia): Three days in June, nine days in July, eight days in August and two days in September.

* Quetiapine 50 mg twice daily (for agitation): Eight occasions in July, one in August, seven in September and six times October 1 through 17, 2023.

* Metoprolol 50 mg daily (for hypertension): Three days in July, one day in August and five days in September.

During an interview with Staff 32, she reported that Resident 11's medications came from an outside pharmacy and were set up to be delivered to the resident's power of attorney. She stated the facility had difficulty getting the medications to the facility, which had caused medications to be missed.

On 10/18/23 Staff 32 reported the delivery address for Resident 11's medications was changed to the facility address. She stated that, if needed, facility staff would pick up filled prescriptions from the pharmacy or pay to have a limited supply delivered from the facility's contracted pharmacy.

The facility failed to ensure blood pressure medications were administered as prescribed, contributing to medical complications, including hospitalization and an emergency room visit.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 32, Staff 33 (Assistant ED), and Staff 40 (Consultant RN) on 10/18/23. They acknowledged the findings.

C303 - Systems: Treatment Orders

Executive Director impelmented immediate chages to medication prescriptions, and doctor's orders for Resident #11

(See attached medication plan for resident #11).

Executive Director/RN, and Med Tech's will follow up daily on medications the community is awaiting delivery from the pharmacy or new/renewed prescriptions from the Doctor. RN/Med Tech's will call the pharmacy and/or Doctor's office daily and document in the electronic system the status of the medications.  

Iudtias MC will use in-house pharmacy Pharmecia as a back up as needed to fill prescriptions if unable to receive it timely from the residents preferred pharmacy.  Iuditas MC will pay for the medication to be delievered when appropriate.  

RN/Med Tech's will review the medication exception report daily and follow up on any missed medication, and document in the communities electronic system the status of the medications.

2. Resident 3 was admitted to the memory care community in July 2021, with diagnoses including dementia and depression.

Review of Resident 3's MAR, dated 08/01/22 through 09/12/22 indicated the following deficiencies:

The MAR lacked reason for use of the following medications:

*quetiapine (an antipsychotic); and

*flutic/salmet (for difficult breathing).

On 09/14/22 the need to ensure an accurate MAR was kept for all medications prescribed by a legally recognized practitioner and administered by the facility was discussed with Staff 1 (ED). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident-specific parameters and/or reason for use for all routine and PRN medications and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. The resident's 08/01/22 through 09/12/22 MAR was reviewed, and the following deficiencies were identified:

a. Cephalexin (antibiotic) was documented on the MAR as being administered by staff 14 times 8/23/28 through 8/28/22 per a 15-dose order: take 1 capsule by mouth three times daily for 5 days. A fax to the physician on 09/01/22 noted the resident had 4 capsules remaining.

b. There was no reason for use documented on the MAR for the following medications:

* Levothyroxine (for thyroid);

* Cephalexin (antibiotic);

* Clopidogrel (blood thinner);

* Escitalopram (anti-depressant);

* Metroprolol (blood pressure;

* Pravastatin (cholesterol);

* Mirtazapine (depression); and

* Diclofenac Gel (pain).

c. There were no parameters for when to administer one PRN pain medication versus the other for PRN acetaminophen and tramadol;

d. Diclofenac gel lacked instructions as to where staff should apply the gel; and

e. On 08/28/22 at 8 pm, the MAR indicated the resident did not receive Cephalexin and no reason was documented for the missed dose.

The need to ensure MARs were accurate, included parameters for PRN medication and a reason for use for the administration of all medications and treatments the facility was responsible to administer was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C310 OAR 411-054-0055 (2) Systems: Medication Administration

1. Actions taken to correct the rule violation include completing a comprehensive MAR to Cart to Physician order audit for Residents #2 and #3 to ensure MAR's are accurate, and the orders include Resident specific parameters and reason for use. The RN will add any directions to the orders as needed for staff to know when to offer which medication, for what specific reason, and location of treatments such as gels or patches.

2. The system will be corrected so this violation will not happen again by reviewing the triple check process with all staff who administer medications and/or oversee the medication processing and delivery system. Correct use of this process will ensure MAR's are accurate, include resident specific parameters and/or reason for use for all routine and PRN medications and treatments the community is responsible for delivering.

3. This area needing correction will be evaluated on a daily and quarterly basis. Order changes will be reviewed daily through the triple check system, where staff verify all required components are located in the order, including resident specific parameters and reason for use.

4. The Nurse, RCC or designee are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included reasons for use for all medications, and included clear instructions for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 2, 5 and 7) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the memory care community in 04/2021 with diagnoses including dementia, Diabetes (type 2) and depression.

Review of the resident's MARs, dated 02/01/23 through 02/27/23, and physician orders indicated the following medications lacked reasons for use:

* Aspirin;

* Citalopram;

* Januvia;

* Melatonin;

* Mirtazapine;

* Pantoprazole; and

* Valacyclovir.

On 03/03/23, the need to ensure Residents MARs were accurate and included reasons for use for all medications was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings.

2. Resident 2 was admitted to the facility in March 2022.

Review of the Resident's MAR between 02/01/23 through 02/27/23 revealed the following:

a. The following medications lacked reasons for use:

* Escitalopram;

* Levothyroxine;

* Mirtazapine;

* Pravastatin; and

* Dicofenac gel 1%.

b. The following PRN medications for pain were prescribed without guidance to non-licensed staff for which medication to administer first:

* Acetaminophen 650 mg every four hours as needed for pain; and

* Tramadol 50mg once a day as needed.

On 03/03/23, the need to ensure residents' MARs were accurate was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

3. Resident 7 was admitted to the facility in March 2022.

Review of the residents MAR between 02/01/23 through 02/27/23 revealed the following:

PRN Acetaminophen failed to have a documented reason for use.

On 03/03/23, the need to ensure residents' MARs were accurate was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C310 OAR 411-054-0055 (2) Systems: Medication Adminsitration

1. Actions taken to correct the rule violation include completeing an audit of all medication orders and relation to diagnosis, medication reason for use.

2. The system will be corrected so this violation does not happen again by reviewing the triple check process with staff who administer medications and/or oversee medication procesing and delivery. Correct use of this processing and delivery. Correct use and processing to ensure MARs are accurate, include resident specific parameters and or reason for use for all routine and PRN medications and treatments.

3.This area needing correction will be evaluated on a daily and quarterly basis.

4. The Executive Director and Registered Nurse are responsible for seeing that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was thoroughly assessed by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 1) who had a half-length side rail on their bed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in April, 2022 with a diagnosis of dementia.

On 09/13/22 and 09/14/22, a half-length side rail was observed in use on Resident 1's bed.

During an interview on 09/13/22, Staff 21 (CG) stated Resident 1 was bed bound and used the side rail to assist with bed mobility.

Review of the resident's clinical record revealed there was no documented evidence an assessment for use of the side rail had been completed by an RN, Physical Therapist or Occupational therapist.

The need to ensure a supportive device with potentially restraining qualities was thoroughly assessed by an RN, PT or OT was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C 340  OAR 411-054-0060 Restraints and Supportive Devices

1.) Actions taken to correct violations include: Facility RN will complete a supportive device assessment as per regulations, for resident #1. Facility will update resident's service plan to be reflective of the supportive device, staff instructions, and risk vs benefits.

2.) The system will be corrected as follows: Facility will conduct a room-to-room audit to identify any supportive devices and ensure appropriate RN assessment is in place. Facility will review all supportive devices when updating the residents' service plan(s) and facility RN will complete assessment at that time as well.

3.) This correction will be evaluated every time a request for consideration for an assistive device with restraining qualities is made. If a hospital bed arrives for a resident, and assistive devices are not needed then devices (i.e. bed rails) will be removed from the room and stored separately. Ongoing supportive device assessments will be completed, quarterly and with changes of condition when applicable.

4.) Who will be responsible to see that the corrections are completed/monitored? RCC and ED

2. Resident 6 was observed during the survey on 02/27/23 through 03/03/23, and was noted to have side rails attached to his/her bed in the up position.

Review of the resident's clinical record revealed the following:

* No documented evidence Resident 6 requested or approved of side rails being used, and was informed of the risks and benefits of the side rails;

* No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails;

* No documented evidence other less restrictive alternatives had been attempted prior to use; and

* There was not clear instruction to caregivers on the correct use and precautions related to the use of side rails.

On 03/03/23, the lack of an assessment and documentation of requirements for side rail use was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Corporate Support). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 2 of 2 sampled residents (#s 6 and 7) who had side rails on his/her bed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was observed during the survey on 02/27/23 through 03/03/23 and noted to have side rails attached to his/her bed in the up position.

Review of the resident's clinical record revealed the following:

* No documented evidence Resident 7 requested or approved of side rails being used and was informed of the risks and benefits of the side rails;

* No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails;

* No documented evidence other less restrictive alternatives had been attempted prior to use; and

* There was not clear instruction to caregivers on the correct use and precautions related to the use of side rails.

On 03/03/23, the lack of an assessment and documentation of requirements for side rail use was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C340 OAR 411-054-0060 Restraints and Supportive Devices

1. Actions taken to correct violations include Facility Registered Nurse will complete a supportive device assessments as per regulations, for resident #6 & #7. Facility will update resident's service plan to be reflective of the supportive device, staff instructions and risk vs benefits.

2. The system will be corrected as follows: Facility will conduct an audit to identify any supportive devices and ensure an appropriate RN assessment is in place.

3. This correction will be evaluated every time a request for consideration for an assistive device with restraining qualities is made.

4. The Executive Director or Registered Nurse will be responsible for ensuring the corrections are completed and monitored.

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

In an interview on 09/13/22, Staff 1 (ED) stated the facility had not selected or implemented an ABST to use in developing the facility staffing plan.

On 09/13/22 the need to complete an assessment of each resident and implement an ABST was discussed with Staff 1. She acknowledged the lack of an ABST.

C361 OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool.

1.) Actions to correct this violation include:

a. Facility is completing the Acuity-Based Staffing Tool on The Department's Site,

b. Facility RCC will receive training related to ABST requirements, to ensure the staffing schedule meets requirements.

2.) Acuity-Based Staffing Tool: This system is being corrected to eliminate future violations, as follows:

a. Facility IDT will receive training related to the requirements of the Acuity-Based Staffing Tool,

b. Facility will maintain ABST and update resident care needs in the ABST at time of each resident evaluation &/or with any significant change of condition

c. Facility Administrator will review staffing schedule to ensure that the schedule is reflective of staffing requirements based on the ABST.

3.) Acuity-Based Staffing Tools: This system will be evaluated as follows:

a. Facility will update the ABST with each resident evaluation: initial, 30-days, quarterly, and with significant change of condition,

b. Facility Administrator will review monthly staffing schedule to ensure that schedule is reflective of staffing needed per the ABST at least once monthly.

4.) Facility Administrator and Facility RCC will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 direct care staff (#s 14 and 15) had completed first aid/abdominal thrust training within 30 days of hire. Findings include, but are not limited to:
 

Training records for Staff 14 (CG/MT) hired on 06/27/22, and Staff 15 (CG) hired on 05/17/22, were reviewed during survey. There was no documented evidence Staff 14 and Staff 15 had completed first aid/abdominal thrust training within 30 days of hire.

The need to ensure all direct care staff completed first aid/abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C372 OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1.) Facility will correct each violation per example given as follows:

Employees #14 & 15 will successfully complete first aid and abdoiminal thrust training.

2.) Facility will audit all employees training records to ensure that employees are up-to-date on required training within 30 days of employment. All employee training(s) and upcoming training(s) will be kept on a training grid to ensure completion of required training in a timely manner. Facility B.O.M. will bring the training grid to monthly QA meeting to review with IDT and ensure all trainings are done according to the regulations.

3.) Facility will audit the training grid at least once monthly, and with each new hire. Facility IDT will review training grid status at monthly QA meetings.

4.) Facility Administrator & Facility B.O.M will be responsible for overseeing all employee trainings.

Based on interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 2 of 2 sampled residents (#s 6 and 7) who had side rails on his/her bed. This is a repeat citation. Findings include, but are not limited to:a repeat citation. Findings include, but are not limited to:

Training records for Staff 29 (MT) hired on 01/03/2023, and Staff 27 (RCC) hired on 12/30/2023, were reviewed during survey. There was no documented evidence Staff 29 and Staff 27 had completed First Aid and abdominal thrust training within 30 days of hire.

On 03/02/23, the need to ensure all direct care staff completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 23 (Regional Support). She acknowledged the findings.

C372 OAR 411-054-0070 (6) (9) Training within 30 days: Direct Care Staff

1. Facility will correct each violation per example given: Employee #27 & #29 will complete First Aid and Abdominal Trust Training.

2. Facility will audit all employee training records to ensure that all employees are up to date on required training within 30 days of employment.

3. Facility has implemented a training compliance tracking system.

4. The Executive Director or Designee and Business Office Manager will audit the training compliance tracker weekly and at least once per month at monthly QA meetings.

5. The Excutive Director and the Business Office Manager will be responsible for overseeing all employee training.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and fire and life safety training's to staff on alternate months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of fire and life safety records from 03/01/22 through 09/12/22 identified the following deficiencies:

*There was no documented evidence the facility conducted fire drills every other month, as required; and

*There was no documented evidence the facility conducted fire and life safety training instruction to staff on alternate months.

On 09/14/22, the need to conduct and document fire drills every other month and fire safety training's on alternate months, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings.

C420 OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1.) Facility will audit Fire & Life Safety binder to identify past fire drills and staff education. Facility will ensure that a fire drill is completed every other month, with staff training on the alternative months. Facility will provide an in-service for all staff to receive fire and life safety training, and will document training as required.

2.) Facility maintenance director will turn in all fire and life safety documents (fire-drills and/or education)  to facility administrator during monthly QA meeting. IDT will review fire-drills and staff education during once monthly QA meeting to ensure all required components are present.

3.) All fire-drills and fire and life safety training will be reviewed at minimum on a monthly basis, by IDT during monthly QA meetings. Facility administrator will audit fire and life safety binder once monthly to ensure oversight and compliance.

4.) Facility maintenance director and facility administrator will be responsible for overseeing ongoing compliance.

Based on interview and record review, it was determined the facility failed to conduct fire drills and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Review of facility records from 01/15/23 to 03/01/23 identified the following deficiencies:

* There was no documented evidence a fire drill or fire and life safety instruction had been conducted between 0/15/23 through 03/01/23.

On 03/03/23 the need to conduct regular fire drills, and to provide fire and life safety instruction to staff in accordance with the OFC, was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings.

C420 OAR 411-054-0090 (1-2) Fire and Life Safety

1. Facility will audit Fire & Life Safety binder to identify past fire drills and staff education. Facility will ensure that a fire drill is completed every other month on each shift, with staff training on the alternative months.

2. The Executive Director and Designee will document all Fire and Life Safety trainings and fire drills for review during monthly QA meetings.

3. All fire drills and fire and life safety training will be reviewed at minimum monthly, by the Executive Director and Designee during monthly QA meetings. The Executive Director and Designee will audit fire and life safety to ensure oversight and compliance.

4. The Executive Director will be responsible for overseeing ongoing compliance.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of fire and life safety records from 03/01/22 through 09/12/22 indicated the following deficiencies:

There was no documented evidence the facility provided annual fire safety instruction for residents, as required.

On 06/02/22 the need to provide and document annual fire safety instruction for residents, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings.

C422 OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

1.) Fire & Life Safety Training for Residents: The following actions are being taken to correct each violation per examples given on the S.O.D:

a. All residents will be instructed on 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 re-instructed annually. Residents who do not have the mental capability to understand fire & life instructions and/or training, will have clear evacuation instructions in their service plans, for staff to reference. Facility will conduct an audit on 100% of residents to identify residents who have not received fire and life safety training, and facility will provide education to these residents.

2.) All new residents will be instructed on fire and life safety within 24hrs of move-in, and reinstructed annually thereafter. All resident fire and life safety training will be documented and filed on-site. Facility maintenance director will keep an on-going spreadsheet of residents' admission dates and dates of reinstruction.

3.) Facility maintenance director will be required to bring all resident fire and life safety training to QA meeting each month for IDT to review. Facility maintenance director will review fire and life safety spreadsheet at least once weekly to ensure on-going and timely resident training.

4.) Facility maintenance director and facility administrator will be responsible for overseeing ongoing compliance.

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

Refer to C 140, C 156, C 231, C 242, C 260, C270, C 280, C 310, C 340, C372, C 420, C 545, Z155, Z 163, Z 165, Z 173,

C455 OAR 411-054-0105 (2-4) Inspections and Investigation:

Insp Interval

1. Facility will maintain inspection schedule. Facility will ensure that inspections are completed within scheduled time lines.

2. The Executive Director and Designee will Document all inspections and maintain records for completions.

3. Inspection and investigations wil be monitored by the

Executive Director and Designee during monthly QA meetings. The Executive Director and Designee will audit Inspection binder once monthly to ensure oversight and compliance.

The Executive Director will be responsible for overseeing ongoing compliance.

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

Refer to C260 and C270.

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

On 09/12/22, the surveyor measured water temperatures in two common area bathrooms, two laundry rooms and two resident apartments. These water temperatures were as follows:

South laundry room:  101.2

North laundry room:  100.4

Lobby restroom:  97.6

North restroom:  103.4

Apartment 26:  101.4

Apartment 7:  100.8

On 09/12/22 at 1:10 pm the Surveyor reported the temperatures to Staff 1 (ED). She indicated the water heater would be adjusted before the end of the day.

On 09/14/22 at approximately 10:30 am hot water temperatures were re-checked in three locations in the building. The readings were as follows:

North laundry room:  101.8

Lobby restroom:  102.8

Apartment 34:  103.2

The need to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1. No further information was provided.

C545 OAR 411-054-0200 (9) Plumbing Systems

1.) Water heater has been serviced as of 9/16/22 - thermostat was reset and water temps checked are within range.

2.) Facility will create a temp log that facility maintenance director will use to check water heater temps. Any temperatures outside of range will be reported to facility administrator for correction. Facility maintenance director will bring all temp logs to monthly QA meeting to turn into facility administrator and for IDT to review for quality improvement.

3.) Facility maintenance director will check temps and document at least once weekly. Temp log will be brought to QA meeting once monthly for review.

4.) Facility administrator and facility maintenance director will responsible for overseeing ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit (F). This is a repeat citation. Findings include, but are not limited to:

On 02/27/23 survey recorded the following water temperatures:

* First floor shower room: 88.6 degrees F;

* Resident room 18: 92.4 degrees F; and

* Resident room 23: 95.8 degrees F.

On 02/28/23 at 9:20 am, survey rechecked the water temperatures in the same locations, the temperatures were as follows:

* First floor shower room: 78.4 degrees F;

* Resident room 18: 82.6 degrees F; and

* Resident room 23: 87.2 degrees F.

On 02/28/23 at 1:10 pm the Surveyor reported the temperatures to Staff 22 (Interim Executive Director). She indicated the water heater would be adjusted before the end of the day.

On 03/01/23 at approximately 10:30 am hot water temperatures were re-checked in the same three locations. The readings were as follows:

* First floor shower room: 116.4  degrees F;

* Resident room 18: 117.6 degrees F; and

* Resident room 23: 115.2 degrees F.

On 03/02/23 at 11:15 a follow-up temperature check was conducted in two different locations. The water temperatures were as follows:

Central restroom:  158.4 degrees F; and

North shower room:  145.2 degrees F.

The surveyor immediately spoke with Staff 22 and Staff 23 (Regional Support), and asked them to re-adjust the water temperatures.

On 03/02/23 at 3:30 pm a final water temperature check was conducted. The water temperatures where within the required range.  

The need to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 22 and Staff 23. They acknowledged the findings.  

C545 OAR 411-054-0200 (9) Plumbing Systems

1. The water heater has been reset and checked as of 3/2/23 with no further issues. Weekly water temps are being recorded.

2. Facility will check water temps and record on the temp log. Any temperatires outside of the range will be reported to Executive Director and Designee for correction. Water Temp Logs will be reviewed during monthly QA Meetings.

3. The Excutive Director and Designee will check temps and record at least once per week. Temp log will be brought to QA meeting monthhly for review.

4. The Excutive Director will be responsible for overseeing ongoing compliance.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the MCC. Findings include, but are not limited to:

The facility was toured on 09/12/22 at 11:15 am. There was no system in place which alerted staff when a resident exited the building into the courtyard area.

In an interview on 09/13/22 Staff 10 (MT) stated the door to the courtyard was locked after 8:00 pm, and unlocked in the morning. He/she stated staff pay attention to the exit door during the day, and periodically check the courtyard throughout each shift.

The need to have a system which alerted staff when residents exited the building was discussed with Staff 1 (ED) on 09/12/22. She acknowledged the findings.

C555 OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

1.) A wireless door sensor chime with 600' range was installed on 9/16/2022 - there are two recieivers that were placed throughout the building that alert staff at anytime that the back patio door is opened.

2.) The facility will conduct weekly spot-checks to ensure alarm is in working order and that staff respond appropriately when alarm engages. Facility will provide an inservice to all staff related to exit door alarms.

3. Facility administrator and maintenance director will do weekly walk-throughs to ensure alarms are in good working order.

4. Administrator and maintenance director will ensure and oversee ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative 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 re-visit survey, conducted on 02/27/23 through 03/03/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations, new citations and identification of harm.

Refer to deficiencies in report.

Z 140 OAR 411-057-0140 Administration Responsibilities

Refer to deficiencies in Report

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

Refer to C 231, C242, C295, C361, C372, C420, C422, C545 and C555.

Z142 OAR 411-057-0140(2) Administration Compliance

Please refer to the following tags: C231, C242, C295, C361, C372, C420, C422, C545, and C555.

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

Refer to C 156, C 231, C 242, C372, C 420 and C 545.

Z142 OAR 411-057-0140 (2) Administration Compliance

Please refer to the following tags: C156, C231, C242, C372, C420, and C545

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 8, 14, 15 and 18) completed all required pre-service training and all direct care staff demonstrated competency in the required topics within 30 days of hire for 6 of 7 direct care staff (#s 11, 12, 13 14, 15 and 18) whose training records were reviewed. Findings include, but are not limited to:

Training records for the following staff were reviewed during survey:

* Staff 8 (Cook) hired on 01/16/22;

* Staff 10 (CG/MT) hired on 04/13/21;

* Staff 11 (CG/MT) hired on 12/10/21;

* Staff 12 (CG/MT) 09/20/21;

* Staff 13 (CG/MT) hired on 02/1/22;

* Staff 14 (CG/MT) Hired on 06/27/22;

* Staff 15 (CG) Hired on 05/17/22; and

* Staff 18 (CG) hired 07/20/22.

1. There was no documented evidence Staff 8, 15 and 18 completed training on the following required pre-service orientation topics:

* Resident rights;

* Abuse reporting;

* Fire safety and emergency procedures; and

* Infectious disease prevention.

Additionally, there was no documented evidence Staff 14 had completed infectious disease prevention training.

2. There was no documented evidence 30 day competency demonstration had been completed for Staff 14, 15 and 18 related to the following topics:

* Role of the service plan;

* Providing assistance with ADLs;:

* Changes associated with normal aging;

* Indentation documentation and reporting changes of condition;

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

* General food safety, serving and sanitation.

Additionally, medication administration competency training was reviewed for Staff 10, 11, 12, 13 and 14 who administered medications. There was no documented evidence Staff 11, 12, 13, and 14  had completed medication administration competency training.

The survey team requested the facility provide documented evidence to show all staff who administered medications had been trained and demonstrated competency of the task prior to those staff continuing to administer medications. The facility provided documentation of training prior to survey exit for all required staff.

The need to ensure staff completed all required pre-service training and all direct care staff demonstrated competency in the required  topics within 30 days of hire was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Z155 OAR 411-057-0155(1-6) Staff Training Requirements

1.) A complete audit of all employee files will be performed and missing training items will be completed. BOM will monitor monthly staff in-services and record topic and attendance for staff present, and follow up with staff who did not attend, to meet the requirements.

2.) Upon hire, new staff will complete all pre-service trainings before working on the floor with residents. Monthly staff meetings will be used for 1 hour of CEU's and attendance and training topics will be documented by BOM.

3.) BOM will track staff's anniversary dates and accumulated CEU's and will work with RCC to ensure staff know their CEU status and have access to online CEUs through Relias and Oregon Care Partners to make up 16 CEUs for that year.

4.) BOM and RCC will be responsible for working with staff to ensure their pre-service orientations are completed upon hire and they maintain 16 CEUs per year based on their hire date.

Based on interview and record review, it was determined the facility failed to ensure newly hired staff completed all required pre-service training and/or demonstrated competency in the required topics within 30 days of hire for 2 of 2 direct care staff (#s 27 and 29) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Staff training records for Staff 29 (MT) hired on 01/03/23 were reviewed on 03/02/23.

a. There was no documented evidence Staff 29 completed training on the following pre-service orientation topics:

*Infectious Disease Prevention;

*Fire safety and emergency procedures; and

*Written job description.

b. There was no documented evidence Staff 29 completed the following pre-service dementia training topics:

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms;

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

* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, identify and address pain, provide food and fluid, prevent wandering and elopement, use a person-centered approach;

* Environmental factors that are important to resident's well-being;

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

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

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

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

c. There was no documented evidence 30 day competency demonstration had been completed for Staff 29 related to the following topics:

* Role of the service plan;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification documentation and reporting changes of condition;

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

* General food safety, serving and sanitation; and

* Other job duties as applicable (Medication pass, treatments).

2. Staff training records for Staff 27 (RCC) hired on 12/30/22 were reviewed on 03/02/23.

a. There was no documented evidence Staff 27 completed training on the following pre-service orientation topics:

*Written job description.

b. There was no documented evidence 30 day competency demonstration had been completed for Staff 27 related to the following topics:

* Role of the service plan;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Indentation documentation and reporting changes of condition;

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

* General food safety, serving and sanitation; and

* Other job duties as applicable (Medication pass, treatments).

On 03/02/23 the need to ensure staff completed all required pre-service orientation and pre-service dementia training, and all direct care staff had documented evidence of demonstrated competency within 30 days of hire was discussed with Staff 23 (Regional Support). She acknowledged the findings.

Z155 OAR 411-057-0155 (1-6) Staff Training Requirements

1. An audit of all employee files will be performed and missing training items will be completed. The Business Office Manage will monitor monthly staff in-services and record topic and attendance for staff present and follow up with stadd who did not attend.

2. All newly hired staff will be complete all pre-service training before working on the floor with residents. Monthly staff meetings will be used for 1 hour of CEUs and attendance and training topics will be documented by the Business Office Manager.

3. The Business Office Manage will track staff's anniversary dates and accumulated CEUs and will work with the supervisor to ensure staff know their CEU status and have access to online CEU's through Relias and Oregon Care Partners to make up 16 CEU's for the year.

4. The Excutive Director and Business Office Manager will be responsible for working with staff to ensure their pre-service orientation is completed upon hire and they maintain 16 CEU's per year based on their hire date.

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 C252, C260, C270, C280, C300, C303, C310 and C340.

Z162 OAR 411-057-0160(2b) Compliance with Rules Health Care

Please refer to the following tags: C252, C260, C270, C280, C300, C303, C310, and C340.1

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

Refer to C 260, C270, C 280, C 310 and C 340.

Z162 OAR 411-057-0160 (2b) Compliance with Rules of Health Care

Please refer to tag # C260, C270, C280, C310, & C340

Based on interview, and record review, it was determined the facility failed to ensure compliance with healthcare related Residential Care and Assisted Living regulations. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260 and C 270.

Based on interview, and record review, it was determined the facility failed to ensure compliance with healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:

Refer to C 303.  

Z162 - Refer to C303

Based on observation, interview and record review, it was determined the facility failed to ensure a nutrition and hydration plan was included in each residents' service plan and was based on the residents' individual preferences and needs for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in April, 2022 with a diagnosis of dementia.

Observations made on 09/13/22 and 09/14/22, showed Resident 1 was dependent on staff for all ADLs and required full assistance from staff for eating and drinking.

The following information was documented in Resident 1's current service plan:

Resident 1 was bed bound, at risk for dehydration and required staffs full assistance for eating and drinking. The service plan lacked clear direction to staff related to the resident's nutrition and hydration preferences.

The need to ensure each resident's service plan included an individualized nutrition and hydration plan, based the residents' preferences, was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

2. Resident 2 was admitted to the facility in March 2022 with a diagnosis of early onset Alzheimer's disease with behavioral disturbance.

There was no individualized nutrition plan documented in the service plan based upon the resident's needs and preferences.

The need to develop individualized nutrition plans based on residents' preferences and needs was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Z163 OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

1.) Facility will create an individualized nutrition and hydration plan for resident #1 and resident # 2. Individualized nutrition and hydration plan(s) will be made a part of residents' service plan(s) for all staff to follow.

2.) Facility will conduct an audit to ensure all all residents have an individualized nutrition and hydration plan. Nutrition and hydration plans will be completed/reviewed at admission, within 30 days of admission, quarterly, and/or with change of condition. All direct-care staff will access to each resident's nutrition and hydration plan, via TSP.

3.) Facility administrator, LN, and/or RCC will review all nutrition and hydration plans during each residents evaluation/SP: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition.

4.) Facility administrator, RCC, and LN will oversee ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure a nutrition and hydration plan was included in each residents' service plan and was based on the residents' individual preferences and needs for 2 of 4 sampled residents (#s 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 6 and 7's current service plans were reviewed and lacked an individualized nutrition and/or hydration plan.

On 03/03/23, the need for individualized nutrition and hydration plans was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

Z163 OAR 411-057-0160 (2) (C) (A) (B) Nutrition and Hydration

1. Facility will create an individualized nutrition and hydration plan for resident #6 & #7. Individualized nutrition and hydration plan(s) will be made as part of resident's service plan(s) for all staff to follow.

2. Facility will do an audit to ensure all residents have individualized nutrition and hydration plan. Nutrition and hydration plans will be completed/reviewed at admission. Within 30 days of admission, quarterly and or with change of condition. All direct-care staff will have access to each resident's nutrition and hydration plan.

3. The Executive Director or Designee and RN will review all nutrition and hydration plans during each residents evaluation/SP: at admission, 30 days, quarterly thereafter, and with any change of condition.

4. The ED and RN will oversee ongoing compliance.

2. Resident 8 was admitted to the facility 11/2022 with a diagnosis of dementia with behavioral disturbances and neurocognitive disorder.

On 07/10/23 at 12:10 pm, Resident 8 was observed to eat independently and consumed approximately 100 % of his/her meal.  Resident 8 drank approximately 50% of his/her red drink.

The service plan dated 04/12/23 noted, Resident 8 needed consistent one on one cueing in finishing a meal, and the behavior plan, dated 05/09/23 noted the resident enjoyed cookies, chips and juice.

Resident 8's individualized hydration and nutrition plan, dated 04/18/23 listed the preferences for likes/dislikes as "food" and fluid preferences as "drink."

During an interview on 07/11/23, Staff 16 (CG) stated Resident 8 loved coffee.

The need to ensure each resident's service plan included an individualized nutrition and hydration plan, based the residents' preferences, was discussed with Staff 32 (Executive Director), Staff 34 (RN Consultant) and Staff 39 (RN) on 07/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 2 of 3 sampled residents (#s 8 and 9). This is a repeat citation. Findings include, but are not limited to:

1. Resident 9's was admitted to the facility 09/2021 with diagnoses including dementia.

The current service plan was reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.

The lack of an individualized nutritional plan was discussed with Staff 32 (Executive Director) and Staff 33 (Assistant ED/BOM) on 07/12/23. They acknowledged the findings.

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

Resident 1, 2 and 3's evaluations and service plans were reviewed during survey and revealed the activity evaluation and activity service plan was not completed and/or did not include the following required information:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

The need to ensure an individualized activity plan was developed for each resident based on their activity evaluation was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Z164 OAR 411-057-0160(2d) Activities

1.) Facility will create an individualized activity plan for residents #1, 2, & 3. Activitiy plan will be made apart of residents' service plan and available for all staff to review.

2.) Facility will conduct an audit to identify any residents who do no have an individualized activity plan. All identified residents will have an activity plan created for them, including: Past and current hobbies, current abilities and skills, emotional needs and patterns, physical abilities and limitations, adapatations necessary for the resident(s) to participate, and identification of activities for behavioral interventions.

3.) Facility administrator, LN, and RCC will review/complete all activity plans as follows: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition.

4.) Facility administrator, LN, and RCC will be responsible for ongoing compliance.1

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

Resident 2 was admitted to the facility in 03/2022 with diagnoses including early onset Alzheimer's dementia with behavioral disturbance.

Resident 2's record documented behaviors including directing profanity toward staff and residents, being physically aggressive toward staff, and a resident-to-resident physical altercation on 08/16/22.

The resident's service plan, dated 04/21/22, lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 09/14/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED). She acknowledged the findings.

Z165 OAR 411-057-0160(e) Behavior

1.) Facility will create and implement a behavior plan for resident # 2. Facility will make resident(s) behavior plan a part of the residents permanent service plan. All direct care staff will have access to behavior plan at all times.

2.) Facility will review any residents with ongoing behaviors and ensure a behavior plan is created, with clear staff instructions and interventions. All behavior plans will become a part of the residents permanent record via interim service plan.

3.) Facility administrator, RCC and LN will review/complete all behavior plans as follows: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition. Facility LN and RCC will review any interim service plans written related to behaviors and determine if resident would benefit from a behavioral plan, during daily 24hr process.

4.) Facility Administrator, RCC, & LN will responsible for ensuring ongoing compliance.

2. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's dementia with behavioral disturbance.

Resident 2's service plan, dated 01/26/23, 01/15/23 through 02/27/23 progress notes, and temporary service plans were reviewed, observations were made, and interviews with staff revealed the following:

*Resident 2's record documented behaviors such as yelling towards staff and residents, being physically aggressive toward staff, and resident-to-resident physical altercations on 01/25/23 and 02/03/22. There was no documented evidence the facility evaluated the residents behaviors, or initiated and coordinated outside consultation.  

The need to ensure the facility evaluated residents behaviors, or coordinated with outside providers, was reviewed on 03/03/23 with Staff 22 (Interim Executive Director). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident or others for 2 of 2 sampled residents (#s 2 and 5) who exhibited behaviors. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility 04/2021 with diagnoses including dementia, Diabetes (type 2), and depression.

Review of Resident 5's service plan, dated 01/25/23, progress notes, dated 01/15/23 through 02/27/23, and incident reports revealed s/he had been involved in a resident to resident altercation on 02/12/23. Staff witnessed the resident "slapping another resident hard in the face".

There was no documented evidence the facility had evaluated the residents behaviors, updated the service plan to address the behaviors,  or initiated contact or coordination with outside providers.  

The need to ensure the facility evaluated residents behaviors, updated the service plan, or coordinated with outside providers, was reviewed on 03/03/23 with Staff 22 (Interim Executive Director) and Staff 23 (Corporate Support). The staff acknowledged the findings.

Z165 OAR 411-057-0160 9e) Behavior

1. Facility will create and impliment a behavior plan for resident #2 & #5. Facility will make resident(s) behavior plan part of the residents permanent service plan. All direct care staff will have access to behavior plan at all times.

2. The facility will review any residents with ongoing behaviors and ensure a behavior plan is created with clear staff instructions and interventions. All behavior plans will become part of the resident's permanent record via interim service plan.

3. Facility ED or Designee and RN will review/complete all behavior plans as follows: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition. Facility RN will review any interim service plans written realated to behaviors and determin if resident would benefit from a behavioral plan during daily 24 hour process.

4. ED and RN will be responsible for ensuring ongoing compliance.

Based on observation and interview, 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 09/12/22 at 11:15 am. Outdoor wicker chairs were observed in the courtyard, to which residents had free access. The chairs were easily movable, and not of sufficient weight to prevent injury or elopement.

On 09/14/22 the need to maintain outdoor furniture of sufficient weight, was discussed with Staff 1 (ED). She acknowledged the findings. The furniture was removed prior to the survey teams exit.

Z173 OAR 411-057-0170(6) Secure Outdoor Recreation Area

1.) Facility removed all courtyard furniture that was not weighted or secured, prior to survey exit. Facility will ensure that only weighted or secured furniture is in the courtyard.

2.) Facility administrator and maintenance director will conduct spot-checks to ensure residents, family, and/or staff have not brought any furniture outside in courtyard that may pose a risk to residents. All non-weighted and non-secured furniture will be removed if noted during walk-through.

3.) Facility administrator and maintenance director will conduct weekly walk-through of MCC to ensure all furniture in the courtyard is secured and/or weighted.

4.) Facility administrator and facility maintenance director will ensure ongoing compliance.

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

The facility grounds of the memory care community were toured on 02/27/23 at 10:45 am. Outdoor wicker chairs were observed in the courtyard, to which residents had free access. The chairs were easily movable, and not of sufficient weight to prevent injury or elopement.

On 02/28/23 the surveyor and Staff 22 (Interim Executive Director) observed the courtyard area. Staff 22 acknowledged the chairs were not of sufficient weight, and stated plans to immediately remove the chairs.

On 03/01/23, a follow-up tour of the courtyard was conducted. The wicker chairs had been removed.

On 03/03/23 the need to maintain outdoor furniture of sufficient weight, was discussed with Staff 22 and Staff 23 (Regional Support). They acknowledged the findings.

Z173 OAR 411-057-0170 (6) Secure outdoor Recreation Area

1. Facility had new outdoor furniture but the weights were not on the furniture. Furniture was removed from the area prior to survey exit.

2. Facility Executive Director and Designee will conduct spot checks to ensure residents, family, and/or staff have not removed the weights from the furniture in the area or moved it in a way that may pose a risk to residents. All non-weighted and non-secured furniture will be removed.

3. The facility ED and Designee will conduct weekly walk through of the facility to ensure all furniture in the courtyard is secured and/or weighted.

4. The ED will ensure ongoing compliance.