Print Inspection: U32E

The findings of the re-licensure survey, conducted 08/29/22 through 08/31/22, 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, 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 re-licensure survey of  08/31/22, conducted 08/07/23 through 08/09/23, 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, Home and Community Based Services Regulations OARs 411 Division 004 and 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 second re-visit to the re-licensure survey of 08/31/22, conducted 01/08/24 through 01/10/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004, and 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 08/31/22, conducted 04/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure incidents were promptly investigated to rule out abuse and neglect and failed to report incidents of possible neglect for 1 of 1 sampled resident (#2) whose incidents were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the MCC on 08/23/22 with diagnoses including dementia and diabetes.

Progress notes dated 08/23/22 through 08/29/22 and MAR dated 08/23/22 through 08/29/22 for Resident 2, were reviewed and revealed the following:

Resident 2 had a physician's order to administer sliding scale Humalog insulin (for diabetes management). The following medication error was noted:

* On 08/24/22 at 7:00 am, Resident 2 received two units instead of zero units according to a CBG of 112.

An interview with Staff 2 (MCC Administrator) on 09/01/22 at 11:06 am confirmed the facility was unaware of the insulin error prior to the relicensure survey and no investigation or SPD report was completed.

There was no documented evidence the facility had investigated the medication error.

The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 09/01/22 at 2:37 pm.  

The need to promptly investigate and report medication errors that could have a negative effect on the resident, was discussed with Staff 1 (ED) and Staff 2 on 09/01/22. They acknowledge the findings.

1. The action taken to correct the rule violation for resident 4 was documented, investigated and promptly reported to Adult Protective Services (APS) by licensed administrator upon discovery. Full Medication Administration Record (MAR) audit to be completed on all residents.

2. Any incidents of suspected abuse or neglect including but not limited to critical med errors will be documented, investigated and promptly reported to APS. Licensed Nurse and Licensed Administrator to review Medication Dashboard for any critical meds that may have been missed, held, or had an incorrect dose administered. Full MAR audit on all residents.

3. Medication Dashboard for critical meds to be reviewed weekly. MAR audit to be completed 1x/month by the 5th of each month for the prior months MAR's.

4. Licensed Administrator and Licensed Nurse will be responsible to see that the corrections are completed/monitored.

2. Resident 5 was admitted to the facility in 07/2021 with a diagnosis of dementia.

The resident's record was reviewed, including the most current service plan, dated 07/14/23, progress notes dated 05/07/23 through 08/01/23, incident reports, and interim service plans (ISPs), and staff were interviewed.

During the acuity interview on 08/07/23, Resident 5 was identified to have had a fall with injury. Record review and staff interviews revealed the following incidents:      * 05/05/23 -Fall with bruising above right eyebrow;

* 05/11/23  - Bruise to right anterior thigh;

* 05/18/23 - Fall with resultant sacral back pain;

* 06/20/23 - Skin tear to the back of the right thigh; and

* 06/21/23 - Fall with multiple contusions to the head/face.

There was no documented evidence the falls with injury and skin injuries of unknown origin had been investigated to rule out abuse and/or neglect or were reported to the local SPD office.

The need to investigate falls with injury and  injuries of unknown cause, and report them to the local SPD office when needed, was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. The facility reported the incidents to the local SPD office as requested by the survey team. Confirmations of the reports were received.

Based on interview and record review, it was determined the facility failed to ensure falls, skin issues, and/or resident-to-resident incidents were investigated, investigated to reasonably rule out abuse and/or neglect, and/or were reported to the local SPD office as needed for 2 of 2 sampled residents (#s 5 and 7) who experienced incidents. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 01/2022 with a diagnosis of dementia.

The resident's record was reviewed, including the most current service plan, dated 04/28/23, progress notes dated 05/07/23 through 08/01/23, incident reports, and interim service plans (ISPs), and staff were interviewed.

During the acuity interview on 08/07/23, Resident 7 was identified to have been involved in multiple resident-to-resident altercations. Record review and staff interviews revealed the following:

* 05/26/23 - the resident was involved in an altercation with another resident which caused the other resident "to slip out of wheelchair and fall.";

* 06/06/23 - the resident hit another resident on the left arm and the other resident hit him/her back with his/her "ski poles.";

* 07/17/23 - the resident yelled at and verbally threatened another resident, then bumped into the other resident "almost causing the other resident to fall over."; and

*07/20/23 - the resident slapped and spit "3 times on the face" of another resident.

There was no documented evidence the resident-to-resident altercations on 05/26/23, 06/06/23, or 07/17/23 had been reported to the local SPD office.

There was no documented evidence the resident-to-resident altercation on 07/17/23 had been investigated to reasonably rule out abuse and/or neglect.

The need to investigate all resident-to-resident incidents and report them to the local SPD office when needed was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. The facility reported the incidents to the local SPD office as requested by the survey team. Confirmations of the reports were provided prior to survey exit.

1. Staff will be inserviced on notification, documentation, and investigation related to falls, skin issues, and/or resident to resident incidents. All allegegations will be reported to the local SPD office.

2. ED and/or designee will monitor resident chart notes for documentation and/or incidents related to falls, skin issues, and/or resident to resident incidents. Incidents investigated thoroughly and timely by Administor and/or designee and reported to local SPD office.

3. This will be evaulated daily by the Adminstrator and/or designee.

4. Administrator and/or designee.

Based on interview and record review, it was determined the facility failed to ensure incidents of suspected abuse were promptly investigated and reported to the local SPD office for 1 of 1 sampled resident (#4) and an unsampled resident whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:

During the re-visit survey, care staff reported concerns regarding the treatment and care of residents in the memory care facility, as follows:

1. During an interview on 01/10/24, a medication aide discussed an incident which occurred in December 2023, when a caregiver was observed asking for assistance to provide incontinence care to Resident #4. During the incontinence care, the medication aide reported asking the caregiver if the resident would be taken to dinner following completion of incontinence care. The caregiver reportedly stated, "[s/he] doesn't deserve dinner." The medication aide was asked if this incident (and similar concerns) had been reported to administration or adult protective services. The medication aide confirmed the incident had been reported to Staff 22 (Resident Care Director/MCC Administrator) in December 2023 and other administrative staff had responded, stating the caregiver's actions were "cultural."

2. On 01/09/24 a caregiver reported s/he had heard another caregiver say to a third caregiver, regarding a resident, "Tell [him/her] to stop doing that or [s/he's] not going to get any dinner."

On 01/11/24, the incidents reported were discussed with Staff 37 (ED). Staff 37 confirmed there was no documentation of the incidents and no investigation or SPD report was completed.

Staff 37 was directed to self-report the incidents to the local SPD office following a follow-up interview with the medication aide who witnessed the incidents. Confirmation of the report was received on 01/11/24 at 4:30 pm.

The need to promptly investigate and report incidents of abuse and neglect was discussed with Staff 37 (ED) on 01/11/24. She acknowledge the findings.

1. Investigation into abuse/neglect allegation of resident #4, and subsequent widescope investigation into all care staff knowledge of abuse and nelgect observation, prevention, and reporting requirements was completed by Milestone regional and senior leadership staff. Employment of involved staff member was terminated.

2. Atrium staff were in-serviced on Abuse and Neglect signs and symptoms, prevention, investigation, and reporting requirements.  Atrium staff were educated on level of reporting methods beyond required State reporting including Milestone hotline with contact information provided at community.

3. Abuse and Neglect education will continue to be provided for all new hires, and quarterly as education for all staff.

4. The atirum administrator with direct oversight from the dedicated Regional Operations Specialist during this plan of correction period and the Milestone regional team thereafter.    

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. Findings include, but are not limited to:

Observations of the kitchen, food storage, prep and service areas were made on 08/29/22 and 08/30/22. The following was observed:

a. Food Storage

* The door leading into the walk-in cooler had built-up debris present;

* The fan inside the walk-in cooler was dusty;

* The racks inside the walk-in cooler had debris present throughout;

* The walk-in freezer had frozen food on the floor;

* The dry storage floor was in need of deep cleaning; and

* The reach in refrigerator had food debris on the outside of the door and inside on the bottom shelf.

b. Food Service

* Staff did not use alcohol wipes after taking the temperature of the food, they wiped it with a cloth out of a sanitation bucket;

* Staff were observed to unwrap frozen chicken fried steaks, push the garbage down into the receptacle, take a chicken fried steak out of a metal container located in the steam table, cut up the steak then placed the food on a plate, this was done wearing the same pair of gloves; and

* Observations were made of staff touching a garbage can with her bare hands, getting tongs and then serving fruit with the tongs in bowls without washing her hands after touching the garbage can.

c. Sanitation and Equipment

* The attached cutting board on the cold food storage unit had gouges and knife score marks present;

* All four drawers had built up debris inside and outside in the back of the kitchen's food prep area;

* The sugar and potato bins had debris on the inside and outside;

* The flour and oatmeal bins had debris on the outside;

* There was debris on the standing mixer, the guard and the table it was sitting on;

* The oven, stove and hood were in need of deep cleaning;

* The shelf directly above the food storage area in the steam table had food debris under it;

* The lower shelf to the left of the stove had debris on it:

* There was brownish black matter in the drain to the left of the stove;

* There were multiple areas in the janitorial closet in need of cleaning and repair;

* Observations of staff who were washing dishes touched the dirty dishes, sprayed them with water, then took clean plates out of the clean warewasher rack and put them away without washing her hands;

* The warewashing machine did not get up to sanitizing temperature and the strips to test the chemicals did not work for the machine;

* There was black matter in the drain under the warewashing machine;

* The walls throughout the area were in need of cleaning and repair;

* The windowsill had dust and debris on it and there was blue tape on the window;

* The vent on the ice machine had built up dust present;

* Garbage cans were not covered;

* There was brownish black matter throughout the kitchen's tile baseboards;

* Kitchen doors (e.g. office, exits, janitorial closet, dry storage) were in need of cleaning, painting and repair; and

* There were multiple cutting boards that were gouged, had knife scores and were stained.

d. Memory Care Kitchenette

* The toaster had built-up food debris visible;

* The floor was sticky throughout the kitchenette;

* There were multiple drawers throughout kitchenette that were sticky and had food debris on the outside and inside;

* Window sills had brown and black matter on them;

* The mixer, blender and microwave had built-up food debris on and inside of them;

* The stove, oven and hood were in need of cleaning;

* The cupboard labeled "clothing protectors" had a broken handle;

* The drawer under the "napkin" drawer was in need of repair; and

* Not all garbage receptacles had a lid.

The areas in need of cleaning and repair and infection control practices were reviewed with Staff 1 (ED), Staff 2 (MCC Administrator) and Staff 6 (Director of Culinary Services) on 08/29/22 and 08/30/22. They acknowledged the findings.

1. The action taken to correct the following rule violations are as follows:

a. Food Storage:

* Areas were promptly cleaned including the removal of built-up debris in various food storage areas including the walk-in freezer, walk-in fridge, reach-in fridge, and dry storage area.

* The walk-in cooler fan and racks were cleared of dust or built-up food debris.

* Frozen food was removed from the walk-in freezer floor.

b. Food Service:

* All kitchen staff were immediately trained on glove use and disposal, hand-washing, and cross contamination.

* Kitchen staff were provided with alcohol swabs for cleaning thermometers.

c. Sanitation and Equipment:

* Cutting board for cold food storage to be repaired and gouges removed

* Kitchen food prep including drawers were cleansed of debris inside and outside.

* Sugar and Potato bins were cleansed of debris inside and outside

* Flour and oatmeal bins were washed on outside

* Oven, Stove and Hood were deep cleaned.

* Shelf above food storage area in the steam table was washed and all debris removed

* Janitorial closet was cleaned to best of community capability - Restoration company scheduled to clean and make necessary repairs to closet.

* Education to staff provided on clean to dirty process for dish pit.

* Warewashing machine was serviced by contractor

* Black matter that was observed on kitchen tile, baseboards, grout, drain under ware washing machine and drain to left of stove will be cleaned by professional floor cleaning contractor.

* Walls will be cleaned and repaired on a schedule with Maintenance Department.

* Windows immediately dusted and debris removed, as well as blue tape.

* Vent on ice machine was promptly cleaned

* Garbage lids were promptly found and put in place.

* Kitchen doors are on schedule to be cleaned, painted and repaired.

2. To ensure the system is corrected cleaning task lists have been implemented for culinary staff including; task, frequency of completion, and person responsible.

3. This will be evaluated every 2 weeks

4. Director of Culinary Services and Executive Director will be responsible to see that the corrections are monitored/evaluated.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

Resident 2 was admitted to the MCC on 08/23/22 with diagnoses including dementia and depression.

Resident 2's move-in evaluation failed to address:

* Spiritual, cultural preferences and traditions;

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

* History of treatment for mental health issues;

* Effective non-drug interventions for mental health issues; and

* Hearing, vision and speech abilities and use of assistive devices related to communication.

The need to ensure new move-in evaluations included all required components was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. They acknowledged the move-in evaluation did not include all the required elements.

1. The action taken to correct the rule violation for was completed by discovering missing components and adding to service plan. Audit will be performed on all other resident records to ensure that all elements specified in OAR 411-054-0034 section (5) of the rule have been addressed in the evaluation and have been incorporated into the resident's service plan.

2. Community move-in evaluation has been corrected to ensure all components are included in accordance with OAR 411-054-0034.

3. The area needing correction will be evaluated and monitored for each move-in to ensure that the evaluation is complete and accurate.

4. The Licensed Administrator and Executive Director will be responsible to see that the corrections are completed/monitored.

2. Resident 5 was admitted to the MCC in 07/2021 with diagnoses including dementia.

During the acuity interview on 08/07/23 it was reported the resident required two-person assist to transfer and staff assistance with all ADLs. Review of Resident 5's progress notes dated 05/07/23 through 08/07/23 and temporary service plans, interviews with staff, and observations of the resident were completed.

The most recent evaluation, dated 07/14/23, was not reflective of the resident's health status and current needs or condition in the following areas:

* Mobility and ambulation, including devices;

* Dressing, grooming, toileting, and bathing assistance; and

* Mental health issues, including presence of depression, thought disorders, or behavioral or mood problems; history of treatment, and effective non-drug interventions.

On 08/09/23, the need to ensure quarterly evaluations were reflective of the resident's health status, current needs, and conditions was discussed with Staff 21 (Interim Director Memory Care). He acknowledged the findings. No other information was shared.

Based on interview and record review, it was determined the facility failed to address all required elements on the initial evaluation for 1 of 1 sampled resident (#6) and failed to gather data which was relevant to the needs and current condition of the resident for 1 of 1 sampled resident (#5) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 08/2023 with diagnoses including dementia.

Review of the resident's initial evaluation, dated 07/18/23, revealed the following required elements were not addressed:

* Customary routines related to eating;

* Interests, hobbies, social, leisure activities;

* List of current diagnoses;

* Mental health issues, including presence of depression, thought disorders, or behavioral or mood problems, and history of treatment;

* Decision-making abilities;

* Personality, including how they cope with change or challenging situations;

* Ability to understand;

* Dental status;

* Pain, including pharmaceutical and non-pharmaceutical interventions and how they express pain;

* Nutrition habits;

* Fall history; and

* Complex medication regimen.

The need to address all required elements in the initial evaluation was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

1. Resident 5 and 6 will receive chart review to ensure resident updated evaluation and service plan.

2.  VP of Health and wellnesss will conduct EHR review of atrium residents that are due/pass due for their OR evaluation/service plan. Regional nurse will be notified of VP of Health and Wellness audit results. Regional nurse will review audit and collaborate with community RN to ensure OR evaluation/service plans are updated. EHR will be set up to notify clincal team of OR evaluation/service plans due.

3. Administrator will review OR evaluation/service plans due with community nurse during 1:1 weekly meeting.

4. Administrator and/or designee

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 1 of 4 sampled residents (#4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, anxiety and behavioral disturbance.

The resident's 06/27/22 service plan was reviewed, staff were interviewed and Resident 4 was observed during the survey. The service plan was inaccurate or lacked clear caregiving instruction in the following areas:

* Shower days;

* Where the behavioral interventions were located;

* Activities of interest;

* Smoking and where the cigarettes and lighter were kept;

* Anxiety triggers such as seeing fire trucks or police cars outside;

* Interventions relating to toileting;

* Apartment key use; and

* Sleep patterns.

On 08/29/22 and 08/30/22, Resident 4 was observed walking around the facility, stopping only to look out of the windows in the dining room, briefly watching television in a common area and having short conversations with staff and other residents.

On 08/30/22 at 9:37 am, Staff 11 (MT/CG) verified the inaccuracies relating to activities, smoking, behavior interventions, key use and sleep patterns.

The need to ensure the residents service plans were reflective and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/31/22. They acknowledged the findings.

1. Action taken to correct the rule violation on Resident 4. Resident service plans were reviewed and updated to reflect residents' needs and provide clear direction for staff regarding delivery of services to said residents.

2. To ensure accuracy of service plan staff will be interviewed. Nurse and Memory Care Director will review final service plan to ensure accuracy.

3. The area needing correction will be evaluated monthly during Quality Improvement Meetings.

4. Executive Director and Memory Care Director will be responsible to see that the corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff, were consistently implemented, and/or were readily available to staff for 4 of 4 sampled residents (#s 5, 6, 7, and 8) 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 07/2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 07/14/23, and progress notes dated 05/07/23 to 08/07/23 were completed. Staff indicated they provided full assistance with ADLs and and two-person assistance with transfers. The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not implemented in the following areas:

* Wheelchair versus walker use for mobility;

* Escort to meals;

* Puree diet;

* Number and level of staff assistance required and specific steps for ADL completion;

* Behaviors and mood problems; and

* Instructions for determining when the resident would be a one-person versus two-person transfer.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

2. Residents 6 and 8 were admitted to the facility in 08/2023 and 07/2020, respectively, with diagnoses including dementia.

A review of the residents' clinical records revealed their service plans were not readily available to care staff.

The need to have residents' service plans accessible to staff was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

3. Resident 7 was admitted to the facility in 01/2022 with a diagnosis of dementia.

A review of the resident's current service plan, dated 04/28/23, interviews with staff, and observations of the resident were conducted. The resident's service plan was not reflective of the resident's current status and care needs, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* Behavioral interventions;

* Refusals of care;

* Staff assistance with ADLs; and

* Ability to communicate needs.

The need for the service plan to accurately reflect the resident's current status and care needs, to provide clear direction to staff regarding the delivery of services, and to be implemented was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

1. Residents 5,6,7 and 8 will receive chart review to ensure residents updated evaluation and service plan via service plan team.

2.VP of Health and wellnesss will conduct EHR review of atrium residents that are due/pass due for their OR evaluation/service plan. Regional nurse will be notified of VP of Health and Wellness audit results. Regional nurse will review audit and collaborate with community RN to ensure OR evaluation/service plans are updated. EHR will be set up to notify clincal team of OR evaluation/service plans due.

3. Administrator will review OR evaluation/service plans due with community nurse during 1:1 weekly meeting.

4. Administrator and/or designee.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 3 of 3 sampled residents (#s 5, 7, and 8) whose service plans were reviewed. Findings include, but are not limited to:

Resident 5, 7, and 8's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 21 (Interim Director Memory Care) during the survey. No further information was provided.

1. Residents 7,8,10 will receive chart review to ensure residents updated evaluation and service plan via service plan team.

2. VP of Health and wellnesss will conduct EHR review of atrium residents that are due/pass due for their OR evaluation/service plan. Regional nurse will be notified of VP of Health and Wellness audit results. Regional nurse will review audit and collaborate with community RN to ensure OR evaluation/service plans are updated. Service plans will be review and updated utlizing service plan team.

3. Administrator will review OR evaluation/service plans due with community nurse during 1:1 weekly meeting.

4. Administrator and/or designee.

2. Resident 5 was admitted to the facility in 07/2021 with a diagnosis of dementia.

A review of the resident's current service plan, dated 07/13/23, progress notes dated 05/07/23 through 08/07/23, interim service plans (ISPs), and incident reports was conducted, and staff were interviewed. The following was identified:

Multiple short-term changes of condition, including falls, falls with injury, and skin injuries and conditions were not monitored for progress with at least weekly documentation and/or were not monitored through resolution. Interventions were not evaluated for effectiveness and the need for additional actions or interventions was not determined related to falls.

The need for all changes of condition to be monitored for progress, with at least weekly documentation through resolution, for interventions in place to be evaluated for effectiveness, and for the need for additional actions or interventions to be determined was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine actions or interventions needed for residents who experienced short-term changes of condition, communicate the actions or interventions to staff, monitor the interventions for effectiveness, and/or document weekly progress of the changes of condition through resolution for 2 of 2 sampled residents (#s 5 and 7) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 01/2022 with a diagnosis of dementia.

A review of the resident's current service plan, dated 04/28/23, progress notes dated 05/07/23 through 08/01/23, interim service plans (ISPs), and incident reports was conducted, and staff were interviewed. The following was identified:

Multiple short-term changes of condition, including resident-to-resident altercations and other behaviors, as well as a return from an emergency room visit, were not monitored and/or were not monitored through resolution.

The need for all changes of condition to be monitored, with at least weekly documentation through resolution, was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

1. Resident change of condition will be completed for residents 5 and 7. Resident service plan will be updated and reviewed. Staff have to review the service plan binder daily, prior to start of shift for all changes to resident service plans.

2.  Clinical team will review residents for change of condition. Staff will be inserviced on conducting a service plan review prior to start of shift.  The RN and LPN have been trained by the regional clinical nurse per OAR and Milestone clinical standards in regards to COC's documentation and monitoring.

3. Weekly and as needed per OARs.

4. Administrator, Community Licensed Nurse, and/or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed  and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 5) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 07/2021 with diagnoses including dementia.

a. During the acuity interview conducted 08/07/23, Staff 28 (RCC) reported Resident 5 required one- to two-person assist with transfers, full assist with ADLs, and had a recent fall with injury.

Progress notes, service plan dated 07/14/23, temporary service plans and evaluation dated 05/07/23 through 08/07/23 were reviewed. The service plan indicated the resident was able to transfer independently and ambulate using a four wheel walker and needed cueing and/or standby assistance for dressing and grooming. The service plan indicated the resident was on a mechanical soft diet.

Observations of the resident between 08/07/23 and 08/09/23 showed the resident used a wheelchair for mobility and was escorted/assisted with mobility to meals, The resident was observed in the dining room during multiple breakfast and lunch meals eating only puree-textured food.

In and interview on 08/07/23, Staff 9 (CG)  indicated Resident 5 required one- to two-person assistance with transfers and toileting, assistance with all ADL tasks, and was not able to ambulate, but used a wheelchair for mobility with escort assistance to meals. Staff 9 reported not being aware of when Resident 5 had declined from his/her previous status.

There was no RN available for interview during survey. Staff 29 (LPN) stated she was unable to find documentation of an RN assessment of the resident's significant change of condition decline in mobility and diet texture.

b. On 07/28/23 a progress note indicated the resident had an intact, firm red blood blister to the lateral plantar side of the right foot.

There was no documented evidence of an RN assessment of the unstageable wound to the right foot.

The need to ensure RN assessments were completed for significant changes of condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

1. A Change of Condition assessment will be completed by RN for resident 5. Service plan will be updated utilizing service plan team.

2. VP of Health and wellnesss will conduct EHR review of atrium residents that are due/pass due for their OR evaluation/service plan. Regional nurse will be notified of VP of Health and Wellness audit results. Regional nurse will review audit and collaborate with community RN to ensure OR evaluation/service plans are updated. Service plans will be review and updated utlizing service plan team.

3. Administrator will review OR evaluation/service plans due with community nurse during 1:1 weekly meeting.

4. Administrator and/or designee.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 08/29/22, Resident 2 was identified to be administered insulin injections by non-licensed staff.

Resident 2's MAR dated 08/23/22 through 08/29/22 were reviewed and revealed insulin had been given by Staff 9 and Staff 10 (MTs) on multiple occasions.

Delegations for Staff 9 completed 08/18/22 and Staff 10 completed 08/19/22 lacked documentation in the following areas:

* A current nursing assessment and condition of the client;

* The rationale the task can be safely delegated to an unlicensed CG;

* The skills, ability and willingness of the unlicensed CG;

* Written instructions that include risks, side effects, risk factors and whom to report the same;

* The frequency client should be reassessed, including rationale; and

* The rationale for how frequently the CG should be supervised and re-evaluated.

The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 3 (Director of Health and Wellness) on 08/30/22 at 1:42 pm and with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22 at 3:35 pm. They acknowledged the findings.

1. The action taken to correct the rule violation for each example/resident includes the implementation of new forms that will document all required components in accordance with regulation and in accordance to OSBN Division 47. The delegating RN was in the process of transferring delegations to staff nurse during the time of survey. New delegating RN completed all appropriate documentation on each resident and delegated staff member.

2. The use of the following forms will assure that the system for RN delegation has been corrected and the violation will not happen again.

* Initial Evaluation of Caregiver Competence for Delegation

* RN Delegation Assessment Evaluation

* RN Reevaluation - Supervision of Caregiver's Competence for Delegation

* RN Delegation Insulin Pen

* RN Delegation Glusose Measurement Related to Insulin Administration

3. The area needing correction will be evaluated every 60 days.

4. The Director of Health & Wellness will be responsible to see that the corrections are completed/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:

During the relicensure survey conducted 08/29/22 through 08/31/22, 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 282: RN Delegation and Teaching;

C 303: Systems: Medication and Treatment Orders; and

C 310: Systems: Medication Administration.

The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22 and 08/31/22. They acknowledged the findings.

1. The action taken to correct the rule violation for each example/resident will be a MAR audit on all residents.

2. Medication Dashboard will reviewed for accuracy and monitored including but not limited to: documentation of refusals, missed meds, held meds, PRN, medications, treatments,  MAR audit will be completed routinely.

3. Medication Dashboard will be reviewed by ongoing and offgoing med tech prior to end of shift. MAR audit will be completed montly by the 5th of the month on prior months MAR's.

4. Executive Director, Licensed Administrator and Director of Health & Wellness will be responsible to see that the corrections are completed/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 4 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility on 08/23/22 with diagnoses including diabetes. The facility was administering insulin to the resident multiple times daily.

Physician's orders and MAR both dated 08/23/22 - 08/29/22 for Resident 2 were reviewed and revealed the following:

Resident 2 had a physician's order to administer Humalog insulin (for diabetes management) subcutaneously before meals TID on a sliding scale which was based on the resident's blood glucose level (CBG).

* On 08/24/22 at 7:00 am the resident's CBG was 112. The physician's order directed staff to hold insulin and per the MAR, two units of insulin were administered.

The need for the facility to ensure medication orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. Findings were acknowledged.

1. The action taken to correct the rule violation for each example/resident is a full Medication Administration Audit for all residents that reside in the community for the month of August and September. In addition a chart review will be completed on each resident and Physician's Orders review to be sent.

2. To ensure the violation will not happen again the system will be corrected by auditing the MAR's and sending reviewed Physicians Order on a routine basis.

3. The area of correction will need to be evaluated on a monthly basis.

4. Licensed Nurse, Licensed Administrator and Executive Director will be responsible to see that the corrections are completed/monitored.

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

Resident 2 was admitted to the facility on 08/23/22 with diagnoses including diabetes and dementia.

Physician's orders and MAR both dated 08/23/22 - 08/29/22 for Resident 2 were reviewed and revealed the following:

* On 08/23/22, 08/25/22 and 08/26/22 at 7:00 am the resident's CBGs were documented as 119, 115 and 131 respectively. Based on the physician's order, Resident 2 required insulin to be held when CBGs were less than 150. The MAR was blank and medication notes indicated "outside of parameters." An interview with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22 at 12:45 pm confirmed the insulin was held, and it was the facility's expectation a zero be entered on the MAR.

The need to ensure the MARs were accurate was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. They acknowledged the findings.

1. The actions taken to correct the rule violation for each example/resident are as follows; education with all medication techs to ensure understanding of a safe medication administration system, 6 rights of medication administration posted on the med carts, medication audit on all residents, and physicians orders review on all residents.

2. To ensure the violation will not happen again the system has been corrected by the reviewal of the medication dashboard at shift change by oncoming and offgoing med techs to follow up on refusals, missed medications, medications with attached documentation, and held medications.

3. The area needing correction will be evaluated at shift change by med techs and weekly by management.

4. Licensed Nurse, Licensed Administrator and Executive Director will be responsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to employ a full-time Administrator scheduled on-site at least 40 hours per week. Findings include, but are not limited to:

In an 08/08/23 interview, Staff 21 (Interim Director Memory Care) stated he and the ALF Administrator rotated being in the facility every two weeks, with each covering both the ALF and the MCC while the other was out of state.

The need to employ a full-time Administrator scheduled to be on-site at least 40 hours per week was reviewed with Staff 21 on 08/10/23. He acknowledged the findings.

1. Interim administrator is in place and recruitment continues for full-time position.

2. Recruitment and retention of full-time administrator.

3. Weekly

4. Administrator and/or designee.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC), fire and life safety instruction was provided to staff on alternate months and there was documented evidence of changes made to ensure the evacuation standard was being met. Findings include, but are not limited to:

On 08/30/22, review of facility fire drill and fire and life safety instruction records, from 03/2022 through 08/2022, and interviews with staff indicated the facility was not documenting:

* The escape route used;

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

* Number of occupants evacuated;

* Evidence the facility provided fire and life safety instruction to staff every other month as required;

* Evidence alternate routes were used during fire drills; and

* Evidence evacuation levels were being met.

Additionally there was no documented evidence of the changes the facility made to ensure the evacuation standard was met.

On 08/30/22, the need to ensure fire drills were documented with all required elements, fire and life safety instruction was provided to staff on alternate months and the facility documented the immediate changes they made to meet the evacuation standard was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator). They acknowledged the findings.

1. The action taken to correct the rule violation for each example/resident is added documentation to the fire drill logbook to ensure required documentation is recorded moving forward.

2. The system has been corrected so this violation will not happen again by the addition of required documentation to the Tel's fire drill logbook.

3. The area needing correction will be evaluated on a monthly basis.

4. Maintenance Director and Executive Director will be responsible to see tha the corrections are complete/monitored.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. This is a repeat citation. Findings include, but are not limited to:

Review of fire and life safety records on 08/08/23, for April 2023 through July 2023, identified the following required components were not documented:

*Escape route used;

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

*Evacuation time-period needed; and

*Number of occupants evacuated.

On 08/08/23, the need to ensure documentation of fire drills included all required components was discussed with Staff 21 (Interim Director Memory Care) and Staff 24 (Maintenance Director). They acknowledged the findings.

1.  Fire drills will be completed per OARs.

2. The Maintence Director and Administrator will be inserviced of Fire drills per OAR/OFC by Regional Maintence team.

3. Documentation of fire drills will be reviewed monthly during Administrator and Maintence Director 1:1 weekly meeting.

4. Administrator and/or Designee.

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

Refer to C 231, C 252, C 260, C 420, C 513, and Z 164.

Refer to C 231, C 252, C 260, C 420, C 513, and Z 164

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

Refer to C 231 and C 513.

1. Atrium has implemented different strategies to meet compliance expectations for repeat issues cited including but not limited to increased oversight from Milestone Regional support team during this Plan of Correction period including the implementation of a dedicated regional operations specialist to oversee the community's compliance with all standards.

2. Enhanced monitoring of systems compliance, training, and accountability to corrective steps is by Milestone regional team.

3. Routine scheduled and unscheduled observation of all staff, systems and processes is in place by Milestone to ensure Flagstone Atrium meets all expectations of State and Company.  

4. The atirum administrator with direct oversight from the dedicated Regional Operations Specialist during this plan of correction period and the Milestone regional team thereafter.    

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit and all exterior pathways and accesses to the facility's common use areas were maintained in good repair. Findings include, but are not limited to:

The interior and exterior of the MCC were toured on 08/29/22. The following issues were noted:

* The pathways throughout the locked courtyard had 1-2" drop-offs from pathway to garden bed;

* During the initial tour on 08/29/22 at 11:49 am, the housekeeping storage room was unlocked with multiple chemical cleaning agents accessible to residents and no staff in the area;

* During a second observation on 08/29/22 at 12:59 pm, the storage room was unlocked;

* On 08/29/22 at 1:19 pm, the need to ensure all toxic materials were maintained in locked storage was discussed with Staff 2 (MCC Administrator) who reported she would address the issue immediately. The findings were acknowledged at that time. Follow-up observation confirmed the door was locked; and

* During the environmental walk through on 08/30/22 with Staff 1 (ED) and Staff 2, the housekeeping storage unit was unlocked. Staff 1 instructed Staff 5 (Director of Maintenance) to fix the locking mechanism immediately.

The need to ensure all toxic materials were maintained in locked storage and common use areas were free from drop-offs was discussed with Staff 1 and Staff 2 on 08/30/22. They acknowledged the findings.

1. The action taken to correct the rule violation for each example/resident are as follows:

a) To correct the drop off from pathway to garden bed a contractor has been contacted to fill in the bark to make even surface from pathway to garden bed.

b) Housekeeping closet had the door knob changed to coded door handle to ensure that the door would not be left unlocked.

2. To ensure this violation will not happen again the system will be corrected by routine observation of pathways and garden beds with a specific awareness to ensure there are no uneven surfaces.

3. The area needing correction will be evaluated on a monthly basis.

4. Maintenance Director and Executive Director will be completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean, in good repair and free from unpleasant odors. Findings include, but are not limited to:

The MCC was toured on 08/29/22 at 11:49 am. The following areas were observed to need cleaning and/or repair:

* Rooms M102, M103 and M106 had scraped doors and/or door frames with bare wood exposed;

* Hallway walls near rooms M105, M108, M110, M112 and the restroom near the dining room had protruding nails, screws or staples;

* Walls near room M107, the nurse's station, the laundry room, the emergency exit near room M107, the kitchenette and throughout the dining room had chipped paint;

* Carpet was frayed at the threshold of M109, in the small TV room and around the drain in front of M113;

* Handrails throughout the MCC were scraped and gouged with bare wood exposed;

* Flooring throughout the dining room was scraped, gouged and/or uneven;

* Chairs throughout the dining room had scrapes and gouges in the wood;

* Furniture in the small TV room was stained; and

* Urine odors were noted near the small TV room and in the restroom near the dining room.

The surveyor toured the environment with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. They acknowledged the above areas needed to be cleaned and repaired.

1. The following actions will be taken to correct the rule violation for each example/resident:

* Apartment doors and door frames will be repaired and painted to ensure there is no bare wood exposed.

* Hallway walls had nails, screws and staples removed and will be repaired.

* Walls throughout the community that have chipped paint will be repaired and repainted.

* Carpet in small TV room will be replaced.

* Carpet around drains and at thresholds will be repaired.

* Handrails will be repaired of scrapes, gouges, and bare wood.

* Chairs will be refinished to correct scrapes and gouges in wood.

*

* Urine smell in small TV room will be addressed by carpet replacement and implementation of routine cleaning schedule of bathroom near dining room.

* Furniture in small TV room will be replaced.

2. To ensure the violation will not happen again the system will be corrected by the implementation of community audit and check off list of buildings general repair needs.

3. The area needing correction will be evaluated on a quarterly basis.

4. Maintenance Director and Executive Director will be responsible to see that the corrections are completed/monitored.

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

Observation during the survey from 08/07/23 through 08/08/23 revealed the following areas in need of cleaning or repair:

* The staff laundry room had dirt and debris throughout on the floor and linoleum, which was torn and gouged, making it an uncleanable surface;

* There was a pervasive odor in the front hallway; and

* Resident bathrooms were dirty and apartment rugs had not been vacuumed.

In an interview with care staff on 08/08/23, they stated they had not vacuumed resident rooms or cleaned resident sinks, toilets, or bathroom floors in approximately one month, since housekeeping staff left.

On 08/08/23, the surveyor discussed and reviewed areas which required cleaning or repair with Staff 21 (Interim Director Memory Care) and Staff 24 (Maintenance Director), who acknowledged the findings.

1. Resident bathrooms, laundry rooms, and pervasive odor will be cleaned, repaired and/or odor deotorized.

2.Administrator and Maintenance Director will ensure interior materials and surface will be kept clean and in good standing by conducting routine walk through out the community

3.Weekly during 1:1 meeting.

4. Administrator and/or Maintenance staff.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. This is a repeat citation.  Findings include, but are not limited to:

During observations conducted 01/09/23 the following were found to need cleaning and/or repair:

* Resident room 111 had mold on the inside back wall of the bathroom vanity cupboard, and mold and cracked flooring around base of toilet; and

* Resident room 108 A had multiple spots of dried brown debris on carpet near foot of bed.

On 01/09/23 these findings were reviewed on a walk-through of the resident rooms with Staff 37 (Executive Director), and with Staff 22 (Resident Care Director/MCC Administrator), Staff 38 (RN Consultant), and Staff 39 (RN) on 01/09/23. They acknowledged the findings.

1.  Apartments 111 & 108 were deep cleaned, areas of concern were remedied. Housekeeping standards of all Atrium aparements were inspected for compliance with State and Milestone standards.  

2. Housekeeping team will continue to be educated to infection control standards, and cleaning expectations on a routine basis.  Care staff will be trained on cleaning procedures for surface cleaning expectations, reporting of housekeeping and maintenance needs per Milestone policy.  Maintenance Team will complete apartment inspections on preventative maintenance rounds per Milestone expectations.  

3. Daily inspections are to be completed by the Atrium Administrator with enhanced routine inspections by the dedicated Regional Operations Specialist during the plan of corrections period.

4. The atirum administrator with direct oversight from the dedicated Regional Operations Specialist during this plan of correction period and the Milestone regional team thereafter.    

Based on observation and interview, it was determined the facility failed to ensure each resident unit had no more than two residents and residents did not enter a room through another resident's bedroom. Findings include, but are not limited to:

The MCC was toured on 08/29/22 at 11:49 am and revealed three residents were living in room M109. Upon further investigation, it was determined two of the residents had to enter and walk through the third resident's room to get to their own unit.

The need to ensure each resident unit be limited to no more than two residents and that residents may not enter a room through another resident's bedroom was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. They acknowledged the findings.

1. The action taken to correct the rule violation for this example/resident was the request of a waiver to the rule which allows the resident to continue to reside in the apartment.

2. To ensure the violation will not happen again the system will be corrected by the current waiver approved by DHS. Once the resident moves out and waiver expires, another resident will not be moved into the apartment.

3. The area needing correction will be evaluated on a quarterly basis.

4. The Licensed Administrator and Executive Director will be responseble to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area, access to a flushing rim clinical sink with a handheld rinsing device in the soiled linen area and soiled clothing and linens were laundered in a washing machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:

During a tour of the MCC laundry room on 08/29/22 at 11:49 am, it was observed there were two washing machines, two dryers, one utility sink and one point of entry.

In an interview with Staff 12 (CG) on 08/29/22 at 1:03 pm, she stated soiled linens were brought to the community laundry room, rinsed in the utility sink if really soiled and then washed separately with laundry detergent in one of the two washing machines.

In an interview with Staff 5 (Director of Maintenance) on 08/29/22, he confirmed the facility water temperatures were set between 114 and 115 degrees Fahrenheit, the soiled bed linens were washed in the industrial machines located in the ALF and other soiled linens were washed in the community laundry room. This surveyor and Staff 5 confirmed together the detergent used in the facility lacked disinfectant.

The need to properly launder soiled clothing and linens was reviewed with Staff 5 on 08/29/22 and with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. They acknowledged these findings.

1. The following actions will be taken to correct the rule violation for each example/resident:

a) Waiver request has been submitted for staff to use flushing rim clinical sink with handheld rinsing device in Assisted Living facility.

b) Laundry detergent with chemical disinfectant was purchased and will the only standara used throughout the community and in all laundry rooms.

2. To ensure the violation will not happen again the system will be corrected by routine purchasing of appropriate laundry detergent with chemical disinfectant.

3. The area needing correction will be evaluated on a monthly basis.

4. Maintenance Director and Executive Director will be responsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to keep common areas occupied by residents during times of extreme heat cooled with fans or air conditioning. Findings include but are not limited to:

* The common area common/activities area was noted to be at 78 degrees Fahrenheit on 08/07/23 and 08/08/23.

* The outside temperatures were 89 degrees Fahrenheit.

In an interview with Staff 24 (Maintenance Director), he stated the main air conditioning unit had broken. Staff 21 (Interim Director Memory Care) stated he would place an emergency call to the heating and cooling contractor to repair the air conditioner.

On 08/08/23, at 8:30 am, the interior courtyard doors were observed to open, letting in cool air, and the following was noted:

* The outside temperature at that time was 75.2 degrees Fahrenheit.

* The common/activities area temperature was noted to be 74 degrees Fahrenheit.

Staff 24 brought in two portable air conditioning units at 11:30 am.

At 2:30 pm, the common/activities area temperature was again noted to be at 78 degrees Fahrenheit. The outside temperature was 89.6 degrees Fahrenheit.

The need for fans to be available or air conditioning during extreme summer heat was discussed with Staff 21 and Staff 24.  They acknowledged the findings.

1.  The air conditioning unit has been repaired and is working properly.  The thermostats in the Memory care unit will demonstrate temperatures per OAR.  

2. Back-up fans will be avaiblable as needed.

3.  Administrator and Maintence Director will review thermostats during weekly 1:1 meeting.

4. Administrator, Maintenance Director and/or designee.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

During a walk-through of the facility on 08/29/22 at 11:49 am, exit doors to the courtyard were found to have no working audible alarm or system in place to alert staff when a resident exited the building.

The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22 at 1:06 pm. They acknowledged the findings and alarms were installed prior to survey exit.

1. The action taken to correct the rule violateion for each example/resident was corrected by implementation of door alarms on exits.

2. To ensure the violation will not happen again the system will be corrected by routine monitoring of door alarms.

3. The area needing correction will be evaluated on a weekly basis.

4. Maintenance Director, Licensed Administrator and Executive Director will be responsible to see that the corrections are complete/monitored.

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

Refer to C 231, C 240, C 420, C 510, C 513, C 515, C 530, and C 555.

Refer to C 231, C 240, C 420, C 510, C 513, C 515, C 530, C 555

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, C 350, C 420, C 513, and C 540.

Refer to C 231, C 350, C420, C513, and C 540

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

Refer to C 231 and C 513.

Refer to C231.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 12, 13 and 14) completed pre-service orientation topics, all areas of pre-service dementia care training, and failed to complete all required training and demonstration of competency. Findings include, but are not limited to:

Training records were reviewed with Staff 8 (Business Office Manager) and Staff 1 (ED) on 08/31/22. The following were identified:

a. There was no documented evidence Infectious Disease Prevention training was provided to Staff 12 (CG) hired on 07/20/22, Staff 13 (CG) hired on 04/15/22, and Staff 14 (CG) hired on 08/03/22.

b. There was no documented evidence Staff 12, 13 and 14 had completed pre-service dementia care training for:

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

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

c. There was no documented evidence that Staff 12 and Staff 13 completed the required training in changes associated with normal aging.

d. There was no documented evidence that Staff 14 completed the required training in:

* Identification, documentation and reporting changes of condition;

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

* General food safety, serving and sanitation.

The need to ensure newly-hired, direct care staff completed all orientation training prior to beginning any job duties, pre-service training was completed prior to working independently and newly hired staff demonstrated and documented required 30 day competencies was reviewed with Staff 1 and Staff 8 on 08/31/22. They acknowledged the findings.

1. The action taken to correct the rule violation for each example/resident; staff was trained and competency was documented. In addition, the assignment of the following Relias courses to all staff to ensure that all staff have received required training on standard precautions for infection control.

a) Infection Control: Essential Principles [REL-ALL-0-IFEP] [0.5 hr]

b) Personal Protective Equipment [REL-PAC-0-PPE] (0.25 hr]

c) Infection Control: Isolation and Cohorting [REL-PAC-0-ISOCO] (0.5 hr)

d) Transmission-Based Precautions [REL-SRC-0-TBP] (0.5 hr)

2. To ensure this violation will not happen again the system has been corrected by the use of the onboarding checklist for each employee that will be completed within 30 days of hire date. Training system has also been updated to automatically assign new hires the appropriate training courses required upon hire and prior to working with residents.

3. The area needing correction will be evaluated on a monthly basis.

4. Business Office Manager, Licensed Administrator and Executive Director will be responsible to see that the corrections are completed/monitored.

Based on interview and record review,  it was determined that the facility failed to ensure 1 of 4 newly hired direct care staff (# ) completed pre-service orientation topics and all areas of pre-service dementia care training. This is a repeat citation. Findings include, but are nit limited to:

Training records were reviewed with Staff  (Business Office Assistance) on 08/08/23. The following were identified:

a. There was no documentation that Staff  (MT) hired on 02/06/23  completed and the Infectious Disease Training.

b. There was no documented evidence Staff  (MT) hired on 02/06/23 had completed pre-service dementia care training for:

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

* How to recognize behaviors that indicate a change in resident's condition; and

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

The need to ensure newly-hired, direct care staff completed all orientation training prior to beginning any job duties and pre-service training was completed prior to working independently was reviewed with Staff  (BOA) and Staff  (ID) on 08/08/23. They acknowledged the findings.

Based on observation, 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 252, C 260, C 282, C 300, C 303, and C 310.

Refer to C 252, C 260, C 282, C 300, C 303, C 310.

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

Refer to C 252, C 260, C 262, C 270, and C 280.

Refer to C 252, C 260, C 270 and C 280

Based on observation and interview, it was determine the facility failed to provide a daily program for hydration for residents. Findings include, but are not limited to:

Observations on 08/07/23 revealed the air conditioning in the common/activities area was not working, there were no fans placed in the area, and the facility was not providing hydration passes for the residents. The temperature of the room reached 79.9 degrees Fahrenheit.

The facility was instructed to provide a daily hydration program for the residents.

The need for a daily hydration program for the residents, especially during times of high temperatures, was discussed with Staff 21 (Interim Director Memory Care) on 08/07/23, 08/08/23, and 08/09/23. He acknowledged the findings. A daily hydration program was implemented prior to survey exit.

1. A routine hydration pass process was implemented on 8/15.

2. Staff to offer residents water/hydration between meals.  

3. Administrator, Memory Care Director and/or designee will monitor hydration pass process weekly.

4. Administrator and Memory Care Director

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans and provide a meaningful activity program for 1 of 4 sampled residents (#4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, anxiety and behavioral disturbance.  

Although there was some information related to the resident's past interests, the documentation lacked the following components:

* 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.

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

Observations of residents watching television shows and movies were made on 08/29/22 and 08/30/22.

The unit's activity calendar reflected that a "Reading Circle" was to begin at 10:30 am on 8/30/22. There was no "Reading Circle" activity observed.

On 08/30/22 at 10:50 am Staff 15 (CG) reported there was no designated activity person for the unit and staff try to do activities "when they can."

The lack of an activity evaluation, individualized activity plan and a meaningful activity program was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. They acknowledged the findings.

1. The action taken to correct the rule violation for each example/resident was corrected by the implementation of personal behavior plans and updating Personal Well Being Profiles that will include the required components and give specific detals as to what, when, how, and how often staff should offer and assist the resident with more individualized activities.

2. To ensure that the violation will not happen again the system will be corrected by the implementation of Personal Behavior Plans and updating resident activitiy calendar to offer activities in brackets of time to serve the resident needs based on being in the moment

3. The area needing correction will be evaluated on a monthly basis.

4. Life and Leisure Director, Licensed Administrator and Executive Director will be responsible to see that the corrections are completed/monitored.

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, and failed to consistently provide meaningful activities for all residents which promoted or helped sustain physical and emotional well-being, for 4 of 4 sampled residents (#s 5, 6, 7, and 8) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5, 6, 7, and 8's records were reviewed and identified there were no individualized activity evaluations completed and/or the activity evaluations did not address the following:

* 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

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

There were no specific activity plans developed from the evaluations completed which detailed what, when, how, and how often staff should offer and assist the resident with individualized activities.

Observations and interviews during survey indicated the residents were dependent on staff to initiate activities. On 08/07/23 there were no structured or unstructured activities offered, with the exception of a care staff providing coloring pages to four residents after the surveyor brought the lack of activities to their attention. There were 13 to 15 residents observed throughout the day watching television, sleeping in chairs, staring, or walking around the common/activities area.

On 08/07/23, Staff 9 (CG) reported there was activity staff in the MCC Tuesday through Friday and every other Saturday.  She reported that on days when there were no activity staff they would put movies on for the residents to watch.

On 08/09/23 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 21 (Interim Director Memory Care), who acknowledged the findings.

1. Resident 5,7, and 8 Service plans have been updated to include and reflect person centered, resident specific activities and interests per OARs.

Activity Plans have been updated to include:

* 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

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

* Activity plans that reflect how often staff should offer and assist the resident with individualized activities.

* Activities are offered daily, including weekends and evenings, that include both structured and unstructured activities that are reflective of the residents past and current interests per the guidance and requirements of OARs.

2. Activity assessments will occur before move in, after any Significant change of condition and then every 90 days.  Activity program will consistently provide meaningful activities for all residents which promote and help sustain physical and emotional well-being, per OARs.

3. Activity plans will be reviewed monthly for compliance by Activities Director, Memory Care Director, Executive Director and/or designee.

Based on observation, interview, and record review, it was determined the facility failed to initiate and coordinate outside consultation or acute care when indicated for behaviors impacting the resident and others in the community for 1 of 2 sampled residents (#7) who demonstrated behaviors. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 01/2022 with a diagnosis of dementia.

Review of the resident's clinical record, interviews with staff, and observations of the resident revealed the following:

* The resident had experienced multiple resident-to-resident altercations;

* There were multiple documented incidents of the resident behaving in a verbally aggressive and/or abusive manner toward residents and staff;

* Staff reported the interventions described in the resident's service plan did not help de-escalate the resident's behaviors; and

* There was documentation in the resident's progress notes the facility was attempting to find another placement for the resident.

There was no documented evidence the facility had initiated or coordinated with an outside consultant regarding the resident's ongoing disruptive behaviors.

The need for the facility to initiate and coordinate with an outside consultant or acute care related to ongoing behaviors which impacted the resident and others in the community was discussed with Staff 21 (Interim Director Memory Care) on 08/09/23. He acknowledged the findings.

1. Resident 7 currently remains at community with challenging behaviors. Community leadersip has been working with DSHS caseworkers since 7/20/23, when he was removed by The Dalles PD and EMS to be tranported to the ER, to transfer resident to a more appropriate facillity.Staff will be inserviced on de-escelation techniques.

2. Community will continue to identify, document, and report to DSHS caseworker due to resident inappropriatness for the urgency of higher level of care placement. DSHS will be notified on a continuous basis by administer, regional clinical team and/or designee to ensure resident is appropriatly placed elswhere. Due to potential harm to self, other residents, staff, and visitors.

3.Continuous evaluation.

4. Administrator and/or designee

Based on observation and interview, the facility failed to maintain access to secured outdoor spaces and walkways which allowed residents to enter and return without staff assistance. The findings are as follows:

On 08/07/23, during a tour of the building, it was observed that both courtyard doors were locked. The exterior courtyard door had a sign stating "keep door locked at all times." The interior courtyard door had a sign stating "keep locked in inclement weather." There was no specific policy regarding what inclement weather meant.

On 08/07/23, in an interview with Staff 33 (CG), s/he stated residents only went outside when accompanied by staff.

On 08/08/23, in an interview with Staff 24 (Maintenance Director), he stated that one resident was defecating in the flower beds of the interior courtyard so they locked it. He was unaware if the resident's behaviors had been service-planned.

On 08/08/23, the need to ensure the facility provided residents access to the secured outdoor spaces was reviewed with Staff 21 (Interim Director Memory Care). He acknowledged the findings.

1.Community will comply with OAR 411-057-0160, accsess to outdoor space and walkways for community residents. Community may secure the doors during  nightime hours and/or severe weather, complying with OAR 411-057-0160.  

2.Administrator, and/or designee will randomly evaluate doors for accsessability.

3. Administrator and/or designee will evaluate the need for correction randomly and correct issues with compliance immediately.

4. Administrator and/or designee.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury and the doors to the secured outdoor area remained unlocked during the daytime. Findings include, but are not limited to:

The facility was toured on 08/29/22 at 11:49 am.

The secured courtyard area had two chairs that were easily moveable and not of sufficient weight or design to prevent resident injury.

On 08/29/22 at 12:26 pm one of the two doors to the outdoor courtyard was locked from the inside. An interview with Staff 12 (CG) confirmed the courtyard doors were usually open. A second inspection on 08/29/22 at 2:59 pm revealed one of the two doors to the outdoor courtyard remained locked. A final inspection on 08/30/22 at 8:47 am revealed both doors to the outdoor courtyard were locked.

The need to ensure furniture in the outdoor recreation area was of sufficient weight and design as to prevent resident injury and the doors to the secured courtyard were unlocked during the daytime was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 08/30/22. They acknowledged the findings. On 08/31/22 at 8:55 am, one of the two lightweight chairs remained in the courtyard. Staff 1 was informed the lightweight chair in the courtyard was still present.

1. The action taken to correct the rule violation for each example/resident was the removal of the lightweight furniture from the courtyard area and schedule implementation to ensure that the courtyard doors are unlocked.

2. To ensure the violation will not happen again the system will be corrected by the the implementation of a schedule for staff to unlock the courtyard doors during day time hours.

3. The area needing correction will be evaluated on a weekly basis.

4. Maintenance Director, Licensed Administrator and Executive Director will be responsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked outside of their rooms and failed to have individual identifiers to assist residents in recognizing their rooms. Findings include but are not limited to:

On 08/07/23 it was observed that multiple sampled and non-sampled resident rooms were locked and there were no personal identifiers outside of resident rooms for residents who could not recognize their name on the door.

Care staff were requested to ensure resident rooms were unlocked.

On 08/08/23, it was observed that rooms 104, 105, 106 108, 110, and the common area bathroom remained locked. Residents were in the common area/activities room.

The need to ensure residents were not locked out of their rooms and that rooms had individualized identifiers to assist residents in recognizing their rooms was discussed  on 08/08/23 with Staff 21 (Interim Director Memory Care),  He acknowledged the findings.

1. Staff will be inserviced on OAR 411-057-170 to communicate importance of ensuring resident room doors are unlocked.

2.  Doors will be routinely checked during staff oncoming rounds and randomly by Administrator and/or designee.  Maintenance Director will research product for non-locking doorknobs for resident rooms.  

3. Doors will be routinely checked during staff oncoming rounds and randomly by Administrator and/or designee

4. Administrator and Memory Care Director