Print Inspection: KW8H

The findings of the re-licensure survey, conducted 6/15/22 through 6/17/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:           Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:          Resident Care Coordinator

RN:         Registered Nurse

TAR:         Treatment Administration

Record

tid:          three times a day

The findings of the first revisit to the relicensure survey of 06/17/22, conducted 09/21/22, 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 re-visit to the re-licensure survey of 06/17/22, conducted 01/24/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean, maintained in good repair, and the dish machine was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 06/16/22 at 9:00 am, the main kitchen was observed to need cleaning and repair in the following areas:

a. The dish washing station was noted with:

* A large trash can with dried-on food;

* The dish machine, electrical box, walls, floor, shelving, and pipes under the dish machine and sinks had an accumulation of black matter, debris and food matter;

* Dish racks were stored directly on the floor; and

* The dish machine utilized a high temperature rinse cycle to sanitize dishes. The cycle was observed three times. It did not reach manufacturer required temperature. There was no evidence the dish machine temperature was being monitored.

The surveyor toured the dish washing station with Staff 5 (Lead Cook) and Staff 3 (Regional Director of Operations). Staff 3 ran the dish machine and confirmed the wash cycle was not at the required manufacturer's suggested temperature. The dish machine vendor was called for immediate repair. Disposable dishes were used for the remaining meals and cookware was washed and sanitized in the three compartment sinks.

b. The following was observed in the main areas of the kitchen:

* Entrance door to the kitchen had chipped paint, gouges, dirt, and debris;

* Floors throughout the kitchen and storage areas were damaged, had thick black matter build-up and food debris in corners, under equipment, and around edges/inside of floor drains;

* Carts, Drawers and cupboards, inside and out, walls, and ceilings throughout the kitchen, had multiple spills, smears, splatters, and debris;

* Drawers, cupboards, and counter tops were damaged;

* The heater vents and ceiling grate had a layer of dust and dirt;

* Grease build-up and food debris was observed on counters, shelves, cupboards, drawers, stove, grill, and underneath appliances;

* Pipes behind multiple appliances had grease, dirt, and debris on them;

* Dried-on food was visible on the sides and underneath the oven;

* Trash can sides and lid had an accumulation of dried food matter;

* Dried-on food matter, dust and debris was on the stand mixer;

* Stove hood vents had a layer of grease and dust;

* Spills, splatters, and debris were noted on the dry storage racks and floor.

c. The following items were observed to be improperly stored:

* A rack of backing sheets, covered in dust, spills, and splatters stored next to the mop sink and bucket;

* The ice scoop stored directly on top of the ice machine;

* A rack in a utility closet with pitchers, serving platters, and cutlery stored with cleaning equipment; and

* Bread stored on a rack with chemical de-greaser and mop heads.

d. Staff 5 was observed during meal preparation on 06/16/22 to not change gloves or practice hand hygiene between tasks.  

There was no documented evidence the temperatures of the refrigerators were being monitored.

In an interview with Staff 5, she indicated she was new to the position and was not aware of a cleaning schedule or monitoring of temperatures of the dishmachine and the refrigerators.

At 9:40 am, the surveyor and Staff 3 (Regional Director of Operations) toured the kitchen. Staff 3 acknowledged the above areas needed to be cleaned and repaired.

On 06/17/22 8:15 am, the surveyor observed the dish machine utilizing a chemical sanitizer and operating at the required manufacturer's suggested temperature.

C240

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

1. Actions taken to correct rule violation will include:

a. Dishwashing Station

oThe large trash can will be cleaned and free from dried-on food

oThe dish machine, electrical box, walls, floor, shelving, and pipes under the dish machine and sinks will be cleaned of accumulation of black matter, debris, and food matter

oDish machine will run at high temperature rinse cycle to sanitize dishes and maintain required manufacturer suggested temperature and use a chemical sanitizer.

b. Main Kitchen Areas

oChipped paint, gouges, dirt, and debris at entrance door to kitchen will be cleaned and repaired.

oFloor throughout kitchen and storage area will be repaired of any damage, thick black matter build up and food debris in corners, under equipment, and around edges / inside of floor drains will be cleaned.

oCarts, drawers, and cupboards inside and out, walls, and ceiling through out the kitchen will be cleaned from spills, smears, splatters, and debris.

oDrawers, cupboards, and counter tops will be repaired / replaced due to damage.

oHeater vents and ceiling grate will be cleaned and free of dust / dirt.

oCounters, shelves, cupboards, drawers, stove, grill, and underneath appliances will be cleaned and free of grease build up and food debris.

oPipes behind multiple appliances will be cleaned and free of grease, dirt, and debris.

oDried food on the sides and underneath of the oven will be cleaned.

oAccumulation of dried food matter on sides and lid of trash can will be cleaned.

oStand-mixer with dried-on food matter, dust and debris will be cleaned.

oHood vents on the stove will be cleaned and free of grease and dust.

oSpills, splatters, and debris will be cleaned off dry storage racks and floor.

c. Items Stored Improperly o

Baking sheets will be cleaned and be free of dust, spills and spatters and be stored in appropriate place.

oThe ice scoop will not be stored directly on top of the ice machine.

oThe rack with pitchers, serving platters, and cutlery will not be stored with cleaning equipment in utility closet.

oBread rack will not be stored with chemical de-greaser and mop heads.

d. Gloves and Hand Hygiene

oStaff #5 will be provided with training related to the use of gloves and hand hygiene.

oStaff #5 will be provided with training related to the cleaning schedules and monitoring of temperatures of the dish machine and the refrigerators.

2. The system will be corrected so this violation will not happen again by creating daily, weekly, monthly, and quarterly cleaning schedules for the dishwashing station and main kitchen area.

3. The cleaning schedule will be reviewed daily, weekly, and quarterly with environmental audits.

4. The Administrator or designee will be responsible for reviewing / monitoring the weekly schedule to ensure the correction remain in compliance.

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

A kitchen inspection was conducted on 09/21/22 and revealed the following:

* Cupboard surfaces and shelves were damaged creating an uncleanable surface;

* Black substance and food particles on the wall and floor under triple wash sink;

* Multiple food items in the refrigerator were not dated;

* Top of the dish washer had dried white crusty substance and food crumbs; and

* Food debris in the cupboards under the food preparation area.

A tour of the kitchen was conducted on 09/21/22 with Staff 11 (ED).  Staff 11 acknowledged the areas of kitchen needing cleaning.

The need to ensure the facility prepared food in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 11 on 09/21/22. She acknowledged the findings.

C240 - OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule -

1.)The following actions have been taken to correct this violation, per each example listed: Facility is actively working on correcting the following: Updating cupboard surfaces and shelves, cleaning the wall and floor under triple wash sink, ensuring all food has open dates, cleaning dishwasher, and cleaning cupboards in food prep area. Facility has cleaned and painted underneath the sink and has hung a vinyl cover over the lower cabinets to keep debris out. Facility is working on obtaining bids to remodel the kitchen cupboards. Facility administrator has implemented a daily check of food to ensure it is dated upon opening.

2.)This system is being corrected to eliminate future violations, as follows:

a.Facility administrator and dietary manager will conduct weekly walk-throughs of the kitchen area to ensure that it is in good repair and clean.

b.Facility administrator will spot-check food items once daily (during working days) to ensure all open food has open dates and is disposed of after expiration.

c.Facility administrator will oversee daily, weekly, & monthly cleaning tasks to ensure cleanliness and good repair of the kitchen.

d.Dietary manager will bring all cleaning checklists to monthly QA meeting to review and discuss with IDT, ensuring all necessary items are brought to the team's attention.

3.)This system will be evaluated as follows:

a.Facility administrator and dietary manager (or designee) will conduct at least once weekly walk-throughs of the kitchen.

b.Facility kitchen staff will complete scheduled cleanings as follows: daily, weekly, and monthly. All cleaning checklists will be turned into administrator at least once monthly.

c.Facility IDT will review all kitchen cleaning and repair items at once monthly QA meeting.

4.)The facility administrator and dietary manager (or designee) will be responsible for corrections and overseeing ongoing compliance.

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

Resident 3 was admitted to the facility on 05/26/22. The following required elements were not addressed in the initial evaluation:

* List of medications and PRNs used;

* Visits to Health care practitioners in the last year;

* Vital signs if indicated by diagnoses, health problems, or medications;

* Presence of depression, thought disorders or behavioral or mood problems;

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

* Eating, dental status, and assistive devices; and

* Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.

On 06/16/21, the need to ensure the initial move-in evaluation addressed all required elements was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations). They acknowledged the findings.

C252

OAR 411-054-0034 (1-6) Resident Move-In and Evaluation: Res Evaluation

1. Immediate actions to correct the rule violation include comprehensive review and update to Resident #3 evaluation to reflect the following required elements.

oList of medications and PRN's used;

oVisits to Health care practitioners in the last year;

oVital signs if indicated by diagnoses, health problems, or medications;

oPresence of depression, thought disorders or behavioral or mood problems;

oPersonality, including how the person copes with change or challenging situations;

oEating, dental status, and assistive devices; and

oPain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.

2. To ensure they system will be corrected so this violation will not happen again, evaluations including all required factors will be competed per company policy and Oregon State Rule prior to move in, updated within 30 days, quarterly thereafter and with any significant change of condition. The document should be signed to indicate who completed the evaluation.

3. The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of evaluation will be reviewed in daily clinical stand-up meeting prior to each new move in to ensure all components are reflective and all areas are complete with appropriate information.

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

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 2 of 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 11/2019 with diagnoses including dementia.

Observations of the resident, interviews with staff from 06/15/22 to 06/17/22, review of the service plan, dated 05/19/22, evaluation dated 05/19/22, progress notes, incident reports, and temporary service plans from 03/01/22 to 06/15/22, 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:

* Falls and safety interventions; and

* Behavior interventions.

2. Resident 2 was admitted to the facility in 03/2016 with diagnoses including dementia and was receiving Hospice services for end of life care.

Observations of Resident 2, interviews with staff from 06/15/22 to 06/17/22, review of the service plan, dated 06/01/22, progress notes, and temporary service plans from 03/01/22 to 06/15/22, 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:

* Two staff for transfer assistance;

* The use of an alternating pressure air mattress; and

* The need for routine re-positioning.

The need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/16/22 and 06/17/22. They acknowledged the findings.

C260

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

1. Immediate actions taken to correct the rule violation was to update Resident #1 and #2 service plans.

Resident #1 service plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects falls and safety interventions, and behavior interventions.

Resident #2 service plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects two staff for transfer assistance, the use of an alternating pressure air mattress, and the need for routine re-positioning.

2. The system will be corrected so this violation does not happen again by ensuring the service plan is updated with any acute or significant change of condition, as well with pre-scheduled updates (initial, 30-day and ongoing quarterly updates) to reflect the residents' current status per Oregon State Rule.

Clinical services and Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative.

3. This will be evaluated at time of move-in, 30-day review, quarterly and as needed if a change of condition occurs.

4. The Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 1, 2 and 3 were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team.

On 06/16/22 and 06/17/22, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations). They acknowledged the findings.

C262

OAR 411-054-0036 95) Service Plan: Service Planning Team

1. Immediate actions taken to correct the rule violation include: Resident #1, #2, and #3 service plan have been updated with evidence that the resident and / or the residents' legal representative / person of residents' choice, the facility Administrator or designee, and at least one other staff person familiar with their provided services participated.

2. To ensure the system will be corrected so this violation will not happen again; the service plans will be developed by a service planning team.

Monthly service plan review schedule has been set up to ensure timely reviews take place consistently. An invitation will be extended to family / person of residents' choice to attend service plan meeting. All those in attendance will review and sign the service plan. Those not able to attend will be sent a copy of the service plan for review and signature. Signature page will then be attached to service plan.

3. The area will need to be evaluated at resident move in, 30-day review and quarterly update and / or as needed if significant change of condition occurs.

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

Based on interview and record review, it was determined the facility failed to document monitoring of residents consistent with their evaluated needs for 1 of 1 sampled resident (#1) who experienced falls. Findings include but are not limited to:

Resident 1 was admitted to the facility in 11/2019 and evaluated as a fall risk.

Resident 1's facility Resident Service Notes and Incident Report and Investigations from 03/2022 through 06/13/22 revealed falls on 04/21/22, 06/02/22 and 06/04/22.

There was no documented evidence the incidents of falling had been reviewed per Residents 1's evaluated fall risk. Interventions identified in facility Incident Reports and Investigations were not reviewed for effectiveness.

The need to monitor residents per their evaluated needs was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/16/22 and 06/17/22. They acknowledged the findings.

C270

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

1. Immediate actions taken to correct the rule violation include the following:

Resident #1 has had a comprehensive nursing assessment and appropriate follow up completed related to fall risk and fall interventions. Reports and investigations have been reviewed for effectiveness.

2. To ensure the system will be corrected so this violation will not happen again, a 24-hour communication system is in place to include:

a. Shift to Shift Communication Log

b. Alert Charting Log / Audit Log

c. Significant Change of Condition Log

d. Weekly Skin Monitoring Log

Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as UTI, missed medication, return from the hospital, or fall for an example.

When change of condition is identified, staff add the resident name to alert log to ensure they monitor resident and identify when to report concerns to nursing or physician.

The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with resident of 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 TSP.

Staff should monitor resident status until resident condition resolves, and they are back to their baseline. 24-hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessment by the RN.

3. The area needed correction will be evaluated daily during stand up with 24-hour audit system compliance. Facility will also complete Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule.

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

Based on interview and record review, it was determined the facility failed to document monitoring of residents consistent with their evaluated needs and service plan for 1 of 1 sampled resident (#4) who experienced falls. Findings include but are not limited to:

Resident 4 was admitted to the facility in 08/2022 and evaluated as a fall risk.

Resident 4's facility Resident Service Notes and Incident Report and Investigations from 08/20/22 through 09/19/22 revealed Resident 4 had 10 non-injury falls.

There was no documented evidence the incidents of falling had been reviewed per Residents 4's evaluated fall risk. Interventions identified in facility Incident Reports and Investigations were not reviewed for effectiveness.

The need to monitor residents per their evaluated needs was discussed with Staff 11 (ED), Staff 1 (Administrator) and Staff 2 (RN) on 09/21/22. They acknowledged the findings.

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

1.)The following actions have been taken to correct this violation, per each example/resident listed: Facility is doing a thorough chart review of resident #4 recent falls, interventions, and the effectiveness of interventions. Facility will document findings and create new interventions via interim service plan to ensure the safety of the resident.

2.)This system is being corrected as follows:

a.Facility RN is providing training to direct care staff related to completing incident reports, ensuring that incident reports are thorough and tell the entire story of the incident.

b.Facility will conduct on-going risk for falls evaluation to determine if current interventions are effective, and to ensure appropriate interventions are implemented.

c.Facility will ensure that all incident reports are reviewed daily (during workdays) as part of the 24hr process, to ensure timely follow-up and implementation of interventions.

d.All findings from incident report investigation and fall evaluation(s) will be made a part of the residents' permanent record via interim service plan, in a timely manner.

3.)This system will be evaluated as follows:

a.Facility RN will provide training and/or in-service to direct staff at least once monthly.

b.Fall risk evaluations will be conducted at least quarterly, and as needed based on severity of falls/injury falls.

c.Facility will review all incident reports, daily (5 days per week) during clinical drilldown to ensure timely follow-up.

d.All findings related to falls will be reviewed and documented via interim service plan and upon completion of service plan review/update: Upon admission, at admission, within 30 days of admission, quarterly thereafter, and with any changes of condition.

4.)Facility RN and facility administrator will be responsible for corrections and ongoing oversight to ensure compliance.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month, and document all required components on fire drill records. Findings include, but are not limited to:

Fire drill and fire safety instruction records were requested for 01/2022 through 06/2022.

Review of the records revealed fire drills were not conducted every other month and records lacked the following components:

* Location of simulated fire origin;

* The escape route used;

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

* Evacuation time period needed; and

* Number of occupants evacuated.

Fire drill documentation and requirements were discussed with Staff 4 (Administrative Assistant) and Staff 3 (Regional Director of Operations) on 06/16/22 and 06/17/22. They acknowledged the findings.

C420

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

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

a. Facility will conduct unannounced fire drills every other month at different times of the day, evening, and night.

b. Fire and life safety instruction to staff will be provided on alternate months.

c. Written fire drill records will be kept that include but not limited to;

oLocation of simulated fire origin;

oThe escape route used;

oProblems encountered and comments relating to residents who resisted or failed to participate in the drills;

oEvacuation time period needed; and

oNumber of occupants evacuated.

2. The system will be corrected so this violation does not happen again by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in servicing administration or designee conducting fire and life safety drills and education on process and documentation required.

3. The area needing correction will be evaluated monthly.

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

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

Refer to C240, C270, Z142 and Z162.

C 455 SS=F OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval -

Please refer to C240, C270, Z142, and Z162.

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

During a tour of the facility on 06/15/22, the following was observed:

* All easy chairs in the common television room had staining to the fabric seats and arms;

* Multiple dark stains on the carpet in room 132;

* Baseboard moldings by the television room was missing an approximate 2 inch section which created a sharp edge; and

* Corner of the hallway wall scraped and gouged.

On 06/16/22, the need to ensure all materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator). She acknowledged the findings.

C513

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

1. Actions taken to correct this rule violation include:

a. cleaning or replacing all easy chairs in the common television room due to staining to the fabric on seats and arms.

b. room #12 carpet will be cleaned or replaced due to multiple dark stains.

c. baseboard molding will be replaced by the television room

d. gouged and scraped corner of the hallway near the television room will be patched and repaired.

2. The system will be corrected so this violation will not happen again by; staff will be provided with in servicing on reporting damaged, broken facilities or equipment, utilization of maintenance request log as means of communication regarding repair needs that are not urgent, and Maintenance Director will response to repair needs timely.

3. The area needing corrected will need to be evaluated on a monthly basis as per of the environmental audit.

4. The Administrator, Maintenance Director 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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

C240, C420 and C513.

Z142

OAR 411-057-0140(2) Administration Compliance

Refer to C240, C420 and C513 per plan of correction

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

Refer to C240.

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

Please refer to C240

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 9, and 10)  completed all required pre-service dementia training and demonstrated competence in job duties within 30-days of hire. Findings include, but are not limited to:

A review of staff training records were reviewed on 06/16/22.

1. Staff 8 (CG), hired 02/01/22, Staff 9 (MA), hired 02/16/22, and Staff 10 (CG), hired 05/03/22, lacked documented evidence of completing the required pre-service dementia training prior to working with residents, including:

* 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;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

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

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

2. Staff 8, hired 02/01/22, Staff 9, hired 02/16/22, and Staff 10, hired 05/03/22, lacked documented evidence of demonstrating satisfactory performance in:

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

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

* Providing assistance with ADLs.

The facility's failure to ensure staff completed all required training was discussed with Staff 1 (Administrator), Staff 4 (Administrative Assistant), and Staff 3 (Regional Director of Operations) on 06/16/22 and 06/17/27. They acknowledged the findings.

Z155

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

1. Immediate actions taken to correct the rule violation include:

a. staff #8, #9, and #10 will receive the required training in:

oHow to provide personal care to a resident with dementia, including an orientation to the resident and the residents' service plan.

oThe use of supportive devices with restraining qualities in memory care communities; and

oProviding assistance with ADL's.

2. Ongoing, any newly hired staff will receive the required pre-service training prior to beginning their job duties. All new staff will receive Memory Care required training with 30 days of hire, and ongoing in-service training for Memory Care per annual in-service requirements.

3. The areas needing correction will be evaluated prior to any new hire work with residents by using new hire checklist as well as with community continuous quality assurance system reviews.

4. The Administrator m Business Office Manager and / 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 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, C262 and C270.

Z162

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

Refer to C252, C260, C262, and C270 per plan of correction

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 C270.

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

Please refer to C270

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, and 3's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and individualized activity plans developed including:

* Residents' past and current interests;

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate in activities; and

* Identified activities for behavior interventions.

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

On 06/17/22, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Administrator)and Staff 3 (Regional Director of Operations). They acknowledged the findings.

Z164

OAR 411-057-0160 (2d) Activities

1. Immediate actions taken to correct the rule violation include the review and development of residents' #1, #2, and #3 individualized activity plans based off activity evaluation. The activity plans will address the following:

oResidents' past and current interests;

oCurrent abilities and skills;

oEmotional / social needs and patterns;

oPhysical abilities and limitations;

oAdaptions necessary for the resident to participate in activities; and

oIdentified activities for behavior interventions

Activity plans will consistently provide meaningful activities for residents' #1, #2 and #3 and will be developed for 100% of residents to promote or help sustain their physical and emotional well beings. There personalized activity plan will be included in their service plan for staff reference to engage in meaningful planned and spontaneous activities with the residents throughout the day.

2. This system will be corrected so this violation will not happen again by ensuring that at the time of move in, an individualized activity plan will be developed and included on the new admission care plan. The activity plans will be person directed and meaningful with focus to promote or help sustain physical and emotional wellbeing for the residents. It will take into consideration past and current interests, current abilities and skills, emotional / social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate in activities; and identified activities for behavior interventions.

The facility will provide daily structured and nonstructured / spontaneous activities throughout the day. The activities will be selected based on resident preferences and ability to participate.

3. To ensure the activity plan meets the current needs of each resident, it will be reviewed and updated as needed at their quarterly service plan review. In addition, it will be updated as needed when a significant change of condition occurs. Activity Director will review activity options and scheduled appropriate activities on a monthly basis when updating the activity calendar.

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

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

Resident 1 was admitted to the facility in 01/2019, with diagnoses including dementia.

Resident 1's progress notes indicated Resident 1 wandered throughout the facility, would collect community items as well as personal belongings of other residents, and was resistive to care.

During an interview with Staff 7 (MA) on 06/16/22, it was reported Resident 1 was often resistive to care, would collect many items and could be possessive of the items when staff attempted to retrieve them.

The resident's current service plan did not address the wandering, colleting of items, resistance to care, and lacked individualized interventions to assist staff in minimizing the negative impact of these behaviors.  

The need to include an individualized behavior plan for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/16/22 and 06/17/22. They acknowledged the findings.

Z165

OAR 411-057-0160 (e) Behavior

1. Immediate actions taken to correct the rule violations include evaluating Resident #1 for behavioral symptoms and ensuring the service plan is updated to reflect all current and effective interventions identified for staff to utilize to better meet resident needs and minimize behaviors including wandering, collecting others items, and being resistive to care.

All current residents will be evaluated for behavioral symptoms, which negatively impact the resident ro others. Based off of this evaluation, resident specific interventions to reduce, eliminate or de-escalate any  identified behaviors that do negatively impact the resdient and others will be identified and added to the service plan.

2. The system will be corrected so this violation will not happen again by ensuring that an evaluation of behavioral symptoms will take place as part of the evaluation process at the time of move in. An individualized behavior support plan will be developed based on residents evaluated needs, and included on the new admission service plan. This area will be re-evaluated within 30-days, and quarterly thereafter to ensure the behavioral plan remains effective to support the residents current needs and preferences.

3. Each residents' behavioral support plan will be reviewed and updated as needed at their next scheduled service plan review (30-day or 90-day) or as needed wihen a signifcant change of condition occurs.

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