Print Inspection: UWEV

The findings of the re-licensure survey, conducted 06/06/22 through 06/08/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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-licensure survey conducted, 10/31/22 through 11/01/22, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

3. Resident 1 was admitted to the facility in 08/2018 with diagnoses including dementia.

Review of the resident's 03/06/22 through 06/06/22 facility record revealed the following:

On 04/18/22, an investigation was initiated which indicated the resident was taken via ambulance in restraints to the emergency department at the local hospital due to behaviors. Facility documentation indicated the resident's behaviors included taking things off of doors and walls and going outside in a wheelchair stating s/he was going to Walmart. The resident was subsequently diagnosed with a urinary tract infection at the emergency department and discharged back to the facility.  

There was no documented evidence the facility investigated the incident further to rule out abuse, documented follow-up actions, or that the administrator reviewed the incident report.

During an interview with Staff 1 (Executive Director) on 06/08/22, he indicated he was unclear how the incident escalated to the resident being restrained and taken to the hospital.

The facility was instructed to report the incident to the local AAA department on 06/08/22.

The need to ensure all incidents of abuse or suspected abuse were thoroughly investigated and reported to the local AAA when abuse was not reasonably ruled out was discussed with Staff 1 and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings. A confirmation of the report to AAA was provided prior to exit.

Based on interview and record review, it was determined the facility failed to promptly investigate incidents of abuse or suspected abuse and failed to immediately notify the local SPD office or the local AAA office of incidents of abuse or suspected abuse for 3 of 7 sampled residents (#s 1, 7 and 9). The facility failed to investigate a report that Resident 7 demonstrated self-harming behavior. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 11/2018 with diagnoses including right-sided hemiplegia and hemiparesis.

A review of the resident's record, including progress notes dated 03/01/22 through 06/06/22 and a skin condition communication form dated 03/31/22, and staff interviews, revealed the following:

* A 03/31/22 progress note indicated the resident had "scabs and bruising on [his/her] right arm" and the "shower aid [sic] also mention [sic] that resident tends to pinch [his/her] right arm out of frustration."

* A progress note dated 06/02/22 revealed the resident had "skin discoloration" on his/her arms, and the shower aide indicated the resident pinched him/herself "when upset."

There was no documented evidence either incident was investigated to rule out abuse and/or neglect or reported to the local SPD office, or that interventions were implemented to prevent this self-harming behavior from reoccurring.

In an interview on 06/08/22, Staff 2 (Wellness Director/RN) reported the resident had been self-harming in the same way since before she began working at the facility in 01/2022.

The facility was instructed to report the incidents to the local AAA office on 06/08/22.

The need to immediately investigate incidents of self-harming behavior, and to report to the local SPD office if needed, was discussed with Staff 1 (Executive Director) and Staff 2 on 06/08/22. They acknowledged the findings. A confirmation of the report to the AAA office was provided prior to exit.

2. Resident 9 was admitted to the facility in 05/2022 with diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease, and congestive heart failure.

The resident's facility record, including progress notes and incident reports dated 05/19/22 through 06/07/22, was reviewed and the resident and staff were interviewed. The following was identified:

* A progress noted dated 05/20/22 indicated the resident had a fall, was unable to remember how s/he fell, and was experiencing right hip, right leg, and lower back pain.

* An incident report dated 05/20/22 related to the same fall revealed a caregiver found the resident on the floor partly under his/her bed. The report stated the "resident was shivering and was very cold and had urinated" him/herself and indicated the resident stated s/he fell during the night but was unable to remember how.

Staff 11 (CG) was interviewed on 06/07/22 and reported she found the resident on the floor the morning after his/her first night at the facility. Staff 11 stated the resident had been on the floor all night because "NOC [night shift] shift wasn't notified [the resident] was here, so they weren't doing checks." Staff 11 indicated evening shift staff were aware the resident had moved in, but there was no communication with staff on the night shift.

In an interview on 06/07/22, the resident acknowledged s/he was found on the floor the morning after his/her first night in the facility. Resident 9 reported s/he didn't know how s/he got there or why s/he slept on the floor under his/her bed all night.

There was no documented evidence the fall was investigated to rule out abuse and/or neglect or reported to the local SPD office.

In an interview on 06/08/22, Staff 2 (Wellness Director/RN) verified the incident was not investigated.

The facility was instructed to report the incidents to the local SPD office on 06/08/22.

The need to promptly and thoroughly investigate all incidents, and report to the local SPD office when necessary, was discussed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings. Confirmation of the report to the local SPD office was received prior to exit.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to promptly investigate incidents of abuse or suspected abuse and failed to immediately notify the local SPD office or the local AAA office of incidents of abuse or suspected abuse for 3 of 7 sampled residents (#s 1, 7 and 9).

1. Resident 1: Staff training on resident rights and de-escalation review and revise care plan to better match resident preferences. Trauma informed care incorporated into the care plan.

Resident 7:  Psych eval, care plan reviewed and updated, behavior monitoring initiated, give care staff interventions to follow, provide additional staff.

Resident 9: Moved out 6/10/22

2. Staff training on resident rights, abuse and neglect, trauma informed care, care plans updated to match current assessed needs. Admission checklist in place, 24hr communication tool to be implemented.  

3.  Administrator, Community Nurse and Resident Care Coordinators review incident log daily, consultant performs weekly review of incident log, review 24hr tool daily, reviews with Administrator and RCCs.

4. Administrator is responsible for corrections.  

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

On 06/06/22  at 2:20 PM, the facility kitchen was observed to be in need of cleaning and repair in the following areas:

* Ceiling vents throughout the kitchen had black matter on them;

* There was a box fan with a build-up of gray matter near the stove;

* Floors throughout the kitchen had a build-up of black matter, which was dense under sinks, tables, and appliances;

* Both hand-washing sinks had brown matter in the basin and by the faucets and areas where the caulk was missing;

* The caulk behind the triple sink had discolored and missing areas;

* Drains throughout the kitchen had black matter and debris in them; some had rust developing;

* Walls by the juice/coffee area and food preparation areas by the walk-in cooler had drips and splatters;

* Pipes under and near hand-washing sinks, triple sink, ice machines, and behind appliances had gray, black, and white matter with some areas where rust and corrosion had developed;

* The can opener had food matter on the piercing blade;

* There were food splatters on the stand mixer;

* There was a butcher block table with cuts in the wood and black smudges;

* Two storage bins for flour and sugar stored under a food preparation table and two stored in the dry storage room had brown/gray matter on the lids;

* In/out doors to the kitchen and the door to the walk-in cooler had black smudges near the handles and push plates;

* The standing freezer had drips and spills on the bottom shelf;

* There were drips and spills on the shelves in the walk-in cooler and freezer;

* The coating on walk-in cooler shelves had areas where it was chipped and rust had developed;

* Cutting boards used for food preparation had deep gouges; and

*There were multiple rips in the linoleum floor by the dry storage room.

The need to ensure the kitchen was maintained clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Executive Director) during a tour of the kitchen on 06/06/22. He acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident

Services Meals, Food Sanitation Rule

This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000.

1. Appropriate kitchen sanitation will benefit all residents poor sanitation has the potential to harm all residents.

2. All areas identified in the Statement of Deficiencies will be cleaned and/or repaired or replaced.  Dietary Manager will develop and implement daily, weekly and monthly cleaning checklists and train kitchen staff on performance of cleaning duties.

Maintenance Director will develop a schedule for cleaning mechanical and plumbing areas in the kitchen on a regular basis according to manufacturer recommendations.

3. Dietary Manager will audit kitchen cleanliness daily.  Administrator will inspect kitchen at least daily at random times. Consultant will inspect kitchen during on-site visits.

4. Dietary Manager and Administrator will be responsible to carry out the corrections.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements, were completed prior to the resident being admitted to the facility, or were updated quarterly for 7 of 9 sampled residents (#s 1, 2, 3, 4, 5, 8 and 9). Findings include, but are not limited to:

1. Residents 1, 2, 3, 4 and 8 had multiple evaluations which were not completed at least quarterly. The resident evaluations ranged from four to nine months since last completion.

The need to ensure resident evaluations were completed at least quarterly was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. The staff acknowledged the findings.

2. Move-in evaluations for Residents 2, 5 and 9 were reviewed and revealed one or more of the following required elements was not addressed:

* Customary routines;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* List of current diagnoses;

* Visits to health practitioner(s), emergency room, hospital, or nursing facilities in the past year;

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

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

* Ability to manage medications;

* List of treatments, including type, frequency, and level of assistance needed;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* Elopement risk or history; and

* Environmental factors which impact the residents' behavior, including, but not limited to, noise, lighting, and room temperature.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident

Move-in and Eval: Res Evaluation

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements, were completed prior to the resident being admitted to the facility, or were updated quarterly for 7 of 9 sampled residents (#s 1, 2, 3, 4, 5, 8 and 9).

1. Complete all overdue evaluations and update service plans for resident #s 1, 2, 3, 4, 5, 8 and 9 according to evaluated needs and preferences.

2. Review admission process, ensure all required elements are addressed in move-in evaluations.

3. All new admission evaluations will be reviewed for completeness by RCC and Community Nurse. Weekly audits of new admissions by consultant.

4.  Administrator, Community Nurse are responsible for corrections.

2. Resident 8 was admitted to the facility in 07/2007 with diagnoses including cerebral palsy.  

Observations of the resident, interviews with staff, and review of the service plan dated 03/22/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Cognition, communication needs, refusals and decision making;

* Sleeping on stomach, bedtime and morning routines;

* Supervision while eating, fluid placement, adaptive utensils, straw use and late meals;

* Dressing and incontinence care;

* Seat belt use and resident's ability to apply and remove;

* Fall risk and safety interventions; and

* Transfers and repositioning.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 04/2018 with diagnoses including diabetes and cellulitis.    

Observations of the resident, interviews with staff and review of the service plan dated 05/27/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Ankle brace and cane use;

* Fall risk, actual falls, and safety interventions;

* Changes to self-medication plan;

* Wheelchair vs. walker use;

* Dressing and transfer assistance;

* Leg deformity and subsequent limitations;

* Edema and leg elevation; and

* Skin risk and repositioning.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, provided clear direction to staff regarding the delivery of service and were followed  for 5 of 8 sampled residents (#s 1, 4, 6, 7 and 8) whose service plans were reviewed.  Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2018 with diagnoses including dementia.

Resident 1's 10/18/22 service plan, 03/06/22 through 06/06/22 progress notes and incident reports, weight records, and interviews with staff revealed the resident's service plan was not reflective of the resident's current status and care needs in the following areas:

* Assistance with grooming and bathing;

* Self-isolation;

* Weight loss;

* Smoking;

* Behaviors; and

* Mental health services from outside providers.

The service plan was not followed related to monthly weight monitoring.

The need to ensure service plans were reflective of the resident's current status and care needs and followed by staff was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 03/2019 with diagnoses including atrial fibrillation.

A review of Resident 6's current service plan, last updated 05/24/22, weight records from 11/02/21 through 06/06/22, and meal monitoring documentation from 04/11/22 through 06/07/22 revealed the service plan was not being consistently followed related to meal monitoring.

The need to ensure staff consistently followed residents' service plans was discussed  with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

5. Resident 7 was admitted to the facility in 11/2018 with diagnoses including right-sided hemiplegia and hemiparesis.

A review of the resident's current service plan revealed it was not reflective of the resident's current needs and status and/or did not provide clear direction to staff in the following areas:

* Where the resident slept at night;

* Use of a seat belt for the resident's motorized wheelchair and his/her ability to apply and remove it;

* Evidence of self-harming behavior; and

* Meal assistance required.

The need to ensure service plans were reflective of residents' current status and needs and provided clear instructions to staff related to the provision of care was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

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

General

This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, provided clear direction to staff regarding the delivery of service and were followed for 5 of 8 sampled residents (#s 1, 4, 6, 7 and 8) whose service plans were reviewed.

1. Update resident Service Plans for resident #s 1,4,6,7 and 8 based on current evaluations to ensure they reflect each resident's current status and care needs, preferences and provide clear direction to staff providing care.

2. Community will bring in additional resources to assist staff in completing overdue evaluations and updating service plans to meet current evaluated needs and to develop a staggered, manageable schedule for quarterly reviews.

3. Administrator and Consultant will perform weekly random audits of Service Plans to ascertain currency and completeness.

4. Administrator, Community Nurse and RCCs are responsible for Service Plans being kept current.

5. Resident 2 was admitted to the facility in 03/2020 with diagnoses including diabetes.  

Observations of the resident, interviews with staff, review of the resident's 01/16/22 service plan, 03/01/22 through 06/06/22 progress notes, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Skin breakdown and skin infection;

* Medication changes;

* Hospitalization;

* Skilled nursing stay and re-admission.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

6. Resident 4 was admitted to the facility in 04/2018 with diagnoses including diabetes, edema, and neuropathy.

Observations of the resident, interviews with staff, and review of the resident's 05/27/22 service plan, 03/01/22 through 06/06/22 progress notes, physician communications, and incident investigations were completed.

a. The resident was noted to be alert and oriented and required assistance with dressing and transfers. The resident had a left leg deformity from an injury approximately a year previous.

* An incident report on 04/15/22 indicated the resident slipped out of his/her wheelchair and hit his/her head. The resident was sent to the emergency room for evaluation. The investigation was incomplete;

* An incident report on 04/17/22 indicated the resident was noted to have a fall during a self-transfer in his/her room. No injuries were noted. The investigation was incomplete;

* An incident report on 04/17/22 indicated the resident experienced a second fall in his/her bathroom. No injuries were noted. The investigation was incomplete;

* A progress note on 04/28/22 indicated the resident had a large bruise noted to the back. No investigation was completed; and

* An incident report on 04/29/22 indicated the resident experienced a fall in the bathroom. No injuries were noted. The investigation was incomplete.

There was no documentation in the resident's record the facility had completed thorough investigations of the falls and bruising to determine the cause, minimize reoccurrence, develop and implement interventions, and to re-evaluate existing interventions for appropriateness and effectiveness.  

In an interview on 06/06/22 the resident indicated s/he had no concerns with his/her care. The resident denied any mistreatment by staff or physical incidents with other residents. The resident further indicated s/he had a few falls previously and could not say for sure the cause. The resident did not feel like himself/herself at the time of the falls. The resident indicated it was currently difficult to stand and maneuver with his/her left leg.

b. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Emergency room visit and low blood pressure;

* Medication changes and self-administration changes;

* Weight changes and edema;

* Bruising to the back and cellulitis to the right leg; and

* Skin injuries.

The need to ensure actions or interventions were determined and documented when a resident experienced a short-term change of condition was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

7. Resident 8 was admitted to the facility in 08/2007 with diagnoses including cerebral palsy.

Observations of the resident, interviews with staff, and review of the resident's 03/22/22 service plan, 03/01/22 through 06/06/22 progress notes, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Skin breakdown;

* Falls;

* Weight fluctuations;

* Medication changes and missed medications;

* Choking episodes; and

* Refusals of care.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 08/2018 with diagnoses including dementia.

Review of Resident 1's 10/18/22 service plan and interim service plans, 03/06/22 through 06/06/22 progress notes and outside provider communications, 10/03/21 through 06/07/22 weight records and interviews with staff revealed the following:

a. Review of Resident 1's 10/18/21 service plan revealed s/he had a history of weight loss.

Weight records from 10/03/21 through 06/07/22 were reviewed. No weights were recorded between 10/03/21 and 01/03/22 and between 01/03/22 and 04/19/22.  

The resident's weight on 01/03/22 was 174.2 pounds. The resident's weight on 04/19/22 was 162.6 pounds. This represented an 11.6 pound or 6.6% loss of the residents total body weight in three months.

The resident's weight on 05/19/22 was 160 pounds. This represented an additional weight loss of 2.6 pounds for a total of 14.2 pounds or 8.15% of his/her total body weight.

Survey requested a current weight for the resident on 06/07/22. The resident's weight that day was 149.2 pounds. This represented a 10.8 pound or 7.2% weight loss in one month and a 25 pound or 14.36% total weight loss, both of which were considered severe.

During interviews with multiple staff, they indicated Resident 1 was able to feed him/herself and ate in his/her room.

Staff 11 (CG) reported in an interview on 06/08/22 that a few months ago she found about 15 or 16 meals in the resident's refrigerator. Due to this, staff checked her refrigerator regularly.

On 06/07/22, Staff 16 (CG) reported the resident eats about "50/50". Sometimes s/he eats; sometimes s/he does not. He stated he regularly finds full or partial meals in the resident's refrigerator.

During the acuity interview on 06/06/22, Staff 1 (Executive Director) indicated Resident 3 had recent behavioral issues and might become upset if attempts were made to interview him/her.   

There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident when s/he began to lose weight or monitored the resident at least weekly through resolution of the changes. The resident continued to lose weight.

b. On the evening of 04/18/22, Resident 1 was transported via ambulance to the hospital in restraints due to behaviors. The resident was diagnosed with a urinary tract infection and transferred back to the facility the same night. While at the hospital, the resident's right wrist was x-rayed for reasons not stated on the discharge summary. There was no documented evidence the facility evaluated the resident when she returned to the facility, determined what actions and interventions were needed and documented monitoring of the resident at least weekly through resolution of the changes.

The need to determine and document what actions and interventions were needed for the resident when s/he experienced a short-term change of condition and monitor the resident at least weekly through resolution of the changes was discussed with Staff 1 and Staff 2 (Wellness Director/RN). They acknowledged the findings.

4. Resident 3 was admitted to the facility in 09/2019 with diagnoses including cellulitis.

Review of Resident 3's 03/06/22 through 06/07/22 facility record revealed the resident experienced the following short-term changes of condition:

* 03/03/21: Cellulitis with wounds on right leg;

* 03/17/22: Redness and rash under arms, groin and breast areas;

* 05/03/22: "Bleeding wound" on buttocks; and

* 05/05/22: Blister on left lower leg.

During an interview on 06/07/22, the resident reported the wounds on his/her legs and the skin redness/rash had healed. S/he stated the buttocks wound was ongoing and that caregiving staff bandaged the wound for him/her. This was confirmed during an interview with Staff 11 (CG) on 06/08/22.

Review of the 03/06/22 through 06/07/22 MAR/TAR revealed no instruction to staff related to wound care and no indication wound care had been provided.

There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident and monitored the changes at least weekly to resolution.

On 06/07/22, the survey team requested the RN assess the buttocks wound. The RN assessment completed that day revealed the bandage on the resident's buttocks covered a closed area with flaking skin.

The need to determine and document what actions and interventions were needed when the resident experienced short term changes of condition, communicate them to staff on all shifts, and monitor the changes at least weekly to resolution was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff, and implemented, and interventions were monitored for effectiveness for 7 of 8 sampled residents (#s 1, 2, 3, 4, 6, 7, and 8). The facility failed to monitor Resident 7 after reported self-harming behavior. Resident 1 experienced ongoing weight loss. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 11/2018 with diagnoses including right-sided hemiplegia and hemiparesis.

A review the resident's record, including progress notes dated 03/01/22 through 06/06/22 and a skin condition communication form dated 03/31/22, and staff interviews revealed the following:

* A 03/31/22 progress note indicated the resident had "scabs and bruising on [his/her] right arm" and the "shower aid [sic] also mention [sic] that resident tends to pinch [his/her] right arm out of frustration."

* A progress note dated 06/02/22 revealed the resident had "skin discoloration" on his/her arms, and the shower aide indicated the resident pinched him/herself "when upset."

There was no documented evidence interventions were determined and implemented or the resident's behavior was monitored to prevent the self-harming behavior reoccurring.

In an interview on 06/08/22, Staff 2 (Wellness Director/RN) reported the resident had been self-harming in the same way since before she began working at the facility in 01/2022.

The need to investigate incidents of self-harming behavior, and to report to the local SPD office if needed, was discussed with Staff 1 (Executive Director) and Staff 2 on 06/08/22. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 03/2019 with diagnoses including atrial fibrillation.

Review of the resident's record, including the current service plan, most recently updated 05/24/22, weight records from 10/28/22 through 06/06/22, and meal monitoring documentation from 04/11/22 through 06/07/22 and staff interviews revealed the following:

The resident weighed 134.4 pounds on 11/02/21 and 110.5 pounds on 05/02/22. This was a loss of 23.9 pounds, or 17.78% of his/her total body weight, in six months. This constituted a severe weight loss.

Meal monitoring was implemented on 04/11/22, and daily weights started 04/12/22. Records indicated the resident's meal intake was not consistently documented between 04/11/22 and 06/07/22. Weight records indicated the resident was weighed on all but three days from 04/12/22 through 06/06/22. There was no documented evidence these interventions were monitored for effectiveness or additional interventions were determined and implemented to prevent further weight loss.

The resident was observed eating dinner in the dining room on 06/07/22. S/he was observed to eat approximately 25% of the meal; staff documented s/he ate between 76% and 100% of the meal. Resident 6 was not observed in the dining room at any meals on 06/08/22. Neither the resident or staff was available for interview to determine if s/he ate meals in his/her room on that day.

In an interview on 06/08/22, Staff 2 (Wellness Director/RN) indicated the resident received a health shake daily.

On 06/08/22, Resident 6 weighed 111 pounds. This was half of a pound more than s/he weighed on 05/02/22.

The need to determine and develop interventions for changes of condition and monitor them for effectiveness was discussed with Staff 1 and Staff 2 on 06/08/22. They acknowledged the findings. No additional information was provided.

OAR 411-054-0040 (1-2) Change of

Condition and Monitoring

This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff, and implemented, and interventions were monitored for effectiveness for 8 of 8 sampled residents (#s 1, 2, 3, 4, 6, 7, and 8).

1. Resident 7: Psych evaluation, behavior monitoring, interventions service planned to provide staff with instructions to help prevent self-harm.

Resident 6: Weekly weights, RCCs and RN to monitor weights and document significant change of condition and coordinate with provider when warranted. Implement interventions to prevent further weight loss, review and update resident food preferences, offer snacks, fluids, meal supplements, finger foods.

Resident 1:

a. Weights taken and recorded as ordered, RCCs and RN to monitor weights for significant change. Investigate to determine reasons for resident's change in eating habits, food hoarding and subsequent weight loss, implement interventions based on investigation results. Resident's weight is near baseline. Educational nutrition counseling.

b. Staff training on alert charting, appropriate documentation, actions and interventions after a resident has a change of condition/is hospitalized

Resident 3: Seen by provider and referred to home health wound provider who now follows wounds and provides wound care.

Resident 2: Facility will monitor and document all further changes in condition at least weekly until resolved to ensure appropriate intervention are in place.

Resident 4:

a. Resident denied harm, facility staff to receive training on investigations and abuse and neglect.  

b. Facility will put systems in place to monitor changes of condition at least weekly until resolved to ensure appropriate interventions are in place.

Resident 8: Facility will implement systems to monitor changes of condition at least weekly until resolved to ensure appropriate interventions are in place.

2. Staff to receive training on monitoring and reporting changes in condition to facility nurse. Facility to implement 24hr communication tool to facilitate communication between shifts and facility nurse. Significant change procedure reviewed and step by step outline of expected actions available to staff.

3. Changes of condition will be discussed in weekday meetings. Community Nurse will notify Administrator and Consultant by email any time a resident experiences a significant change of condition. Consultant will review changes of condition weekly.

4. Administrator, Community Nurse are responible for corrections.

2. Resident 6 was admitted to the facility in 03/2019 with diagnoses including hyperlipidemia, hypothyroidism, and atrial fibrillation.

A review of the resident's current service plan, most recently updated on 05/23/22, weight records from 11/02/21 through 06/06/22, and meal monitoring records from 04/11/22 through 06/07/22, as well as observation of the resident and interviews with staff, identified the following:

* 11/02/21: 134.4 pounds; and

* 05/02/22: 110.5 pounds.

This was a loss of 23.9 pounds, or 17.78% of his/her total body weight, in six months, which is considered severe.

There was no documented evidence a significant change of condition assessment had been completed by the RN for this severe weight loss.

In an interview on 06/08/22, Staff 2 (Wellness Director/RN) verified she had not completed a significant change of condition assessment for the resident's weight loss.

The need for the RN to complete change of condition assessments in a timely manner for all significant changes of condition was discussed with Staff 1 (Executive Director) and Staff 2 on 06/08/22. They acknowledged the findings.

Refer to C270, example 2.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident and updated the service plan for 2 of 2 sampled residents (#s 6 and 8) who experienced significant weight changes. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 07/2007 with diagnoses including cerebral palsy.   

Weight records, RN notes, and progress notes dated 03/01/22 to 06/01/22 indicated the resident experienced the following:

* A 6.0 pound weight gain from 03/01/22 to 03/23/22. This constituted a 5.16% severe weight gain in less than one month; and

* A 9.0 pound weight gain from 03/01/22 to 04/06/22 which constituted a 7.74% severe weight gain in one month.

The resident's 05/01/22 and 06/01/22 weights showed an additional one pound gain which was not significant for the resident.

Observations of and interviews with the resident on 06/07/22 and 06/08/22 in their room, at lunch meals, and at both dinner meals showed the resident was able to feed himself/herself after items were delivered to the table. The resident had multiple snacks in his/her room and was provided Ensure milkshakes on two occasions while in his/her room.

Interviews with staff from 06/06/22 through 06/08/22 indicated the resident required extensive assistance with all ADL care. The resident could make his/her needs known but would not initiate care or other needs. Staff indicated the resident frequently slept late and would miss meals. The resident was never fond of breakfast but would get up later in the day. The resident could feed himself/herself and take in fluids once they were set up. The resident required a straw for fluids and food to be bite-size pieces. The resident had a sweet tooth and had candy and snacks in his/her room but required assistance from staff to get items set up to eat. The resident also received Ensures daily.  

The facility failed to ensure an RN assessment was completed for the severe weight gains with documented findings, resident status, and interventions made as a result of the assessment.

In an interview on 06/08/22, Staff 2 (Wellness Director/RN) indicated she believed the weight gain was due to the foods the resident was selecting. Staff 2 stated the resident ate well but did stay up late and sleep late most days, which affected the meals s/he was choosing to eat. Staff 2 further stated the resident did not have any acute issue going on at the time that would contribute to a gain. The resident did not have any problems with edema that would have affected his/her weight. Staff 2 indicated she was aware of the weight gain but had not completed an assessment.

The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. The staff acknowledged the findings.

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

Resident Health Services

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident and updated the service plan for 2 of 2 sampled residents (#s 6 and 8) who experienced significant weight changes.

1. Resident 8: Community will provide nutritional counseling, resident is returning to baseline weight after a medical procedure.

Resident 6: Weekly weights, RCCs and RN to monitor weights and document significant change of condition and coordinate with provider when warranted. Implement interventions to prevent further weight loss, review and update resident food preferences, offer snacks, fluids, meal supplements, finger foods.

2. Community will monitor weights monthly or more frequently as needed. Implement and train staff on facility policy on monitoring for and reporting changes of condition to the facility nurse and using the ISP system to monitor and chart on changes. RN to perform an assessment, develop interventions and update the service plan timely.

3. Administrator, facility nurse and RCCs will review all residents with changes of condition on weekdays. Community Nurse will prepare a monthly weights report. Consultant and Administrator will review reports.

4. Administrator is responsible to oversee Community Nurse and ensure weights are monitored, timely assessments and interventions are in place for residents with changes of condition.  

2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including diabetes, edema, and skin breakdown.   

During review of the resident's record it was determined the resident received outside provider services related to home health nursing for wound care.   

Observations of the resident, interviews with staff, and review of outside provider notes and progress notes from 04/21/22 through 06/07/22 were completed.

The resident received home health wound care prior to his/her admission to the skilled nursing facility in February 2022. The resident returned to home health wound services upon return to the assisted living facility in April 2022. The first visit was noted on 05/02/22. Wound care visits were to occur 2-3 times per week.

In an interview on 06/07/22 the resident indicated wound care came in to see him/her and do any dressing changes. The resident did not currently have any dressings in place or open wounds noted to the lower legs.

Home health nursing wound care notes were not consistently documented. One note was documented between 05/02/22 and 06/07/22.

The need to ensure on-going coordination of care was maintained and documented was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 2 of 4 sampled residents (#s 1 and  2) who received services from an outside provider. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2018 with diagnoses including dementia.

Review of the resident's 03/06/22 through 06/06/22 facility record revealed the following:

Resident 1 visited the emergency department at the local hospital on 04/18/22 for behavioral issues.  Instructions on the discharge summary included a follow-up visit to the resident's primary care physician in three days.

There was no documented evidence the resident visited his/her primary care physician as instructed or that attempts to do so had been made.

The need to coordinate care with outside providers in order to ensure continuity of care was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc:

On- and Off-Site Health Srvc

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 2 of 4 sampled residents (#s 1 and 2) who received services from an outside provider.

1.Resident 1: Community coordinating care with resident's PCP.

Resident 2: Weekly Skin checks by nurse until resolved, staff trained to monitor for skin changes and intiate ISP, Home health following wounds.

2. Community policy and procedure for coordination of care will be implementated, staff trained and held accountable for follow through.

3. Weekly audits of resident appointments, new orders, and provider communications by Administrator, Community Nurse and Consultant.

4. Administrator, Community Nurse, RCCs are responsible for corrections.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 3 sampled residents (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2018 with diagnoses including osteoarthritis and diabetes.  

Resident 4's signed physician orders, dated 04/28/22, included the following order:

Norco tablet 7.5-325 mg give 1 tablet every 6 hours PRN for pain.

Resident 1's Controlled Substance Disposition logs and MARS for 05/01/22 through 06/07/22 showed the following:

* On 05/08/22 at 12:46 a.m. a dose was signed out on the disposition log, but was not reflected on the MAR;

* On 05/09/22 at 12:16 a.m. a dose was signed out on the disposition log, but was not reflected on the MAR;

* On 05/21/22 at 9:09 a.m. a dose was signed as administered on the MAR, but the disposition log had no corresponding time for the administered dose;

* On 05/25/22 at 6:00 a.m. a dose was signed out on the disposition log, but was not signed as administered until 8:37 a.m.;  

* On 05/27/22 at 12:17 a.m. a dose was signed as administered on the MAR, but the disposition log was signed at 12:19 p.m.; and

* On 06/03/22 at 7:48 a.m. a dose was signed as administered on the MAR, but was not reflected on the disposition log.

Comparison of the medication dosing cards showed the amount of medication left was reflected accurately on the disposition logs.

The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. No additional documentation was provided. The staff acknowledged the findings.

OAR 411-054-0055 (1)(e) Systems:

Tracking Control Substances

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 3 sampled residents (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy.

1. Resident 4:  Resident received medication as ordered.

2. Wellness Director resigned. Med Techs to receive additional training on appropriate documentation of controlled substances.

3. Community Nurse and Administrator to perform random audits of controlled substance book min 3x/wk to verify documentation in the book and eMAR agree.  Weekly PRN audit.  Consultant to review controlled substance documentation weekly.

4. Administrator, Community Nurse are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were located in the resident's facility record for all medications the facility was responsible to administer for 3 of 7 sampled residents (#s 1, 7 and 9) whose facility records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2018 with diagnoses including dementia.

A review of the resident's 05/01/22 through 06/06/22 MARs and physician orders revealed the following medications were being administered without a signed physician's order:

* Seroquel (major depression);

* Acetaminophen (pain and fever);

* Bisacodyl suppository (constipation);

* Multivitamin (supplement);

* Fluoxetine (anxiety/depression);

* Milk of Magnesia (constipation); and

* Albuterol inhaler (respiratory).

The need to ensure written, signed physician orders were located in the resident's facility record for all medications the facility was responsible to administer was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 11/2018 with diagnoses including hemiplegia and hemiparesis of the right side.

A review of the resident's 05/01/22 through 06/06/22 MARs and physician orders revealed the following medications were being administered without a signed physician's order:

* Cyclobenzaprine (a muscle relaxer); and

* Phenazopyridine (for urinary pain relief).

The need to have signed physician orders in the resident chart was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

3. Resident 9 was admitted to the facility in 05/2022 with diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease, and chronic heart failure.

A review of the resident's 05/19/22 through 06/07/22 MARs, physician orders, and progress notes from 05/19/22 through 06/07/22 revealed the resident was prescribed multiple medications, including apixaban (a blood thinner) for "chronic atrial fibrillation."

A 05/20/22 progress note written by Staff 2 (Wellness Director/RN) indicated the resident was admitted to the facility with written physician orders, but without medications. There was no clearly documented evidence related to when any medications were received by the facility. Documentation of administration of medications was inconsistent.

The need to follow physician orders as written was discussed with Staff 1 (Executive Director) on 06/14/22. He acknowledged the findings.

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

Treatment Orders

This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were located in the resident's facility record for all medications the facility was responsible to administer for 3 of 7 sampled residents (#s 1, 7 and 9) whose facility records were reviewed.

1. Residents 1 & 7:  Medication recap initiated to reconcile all orders, verified orders to be entered into PCC and verified by RCCs, Community Nurse, Administrator

Resident 9: moved out of community on 6/10/22/22/2

2. Medication recap for all residents will be completed, community staff to ensure valid orders are obtained for all medications and treatments.  Admission process reviewed and checklist implemented for facility staff. RCCs to verify new residents have medications upon admission.

3. Community Nurse will review all admissions weekly to verify orders are in place and residents are receiving medications as ordered. Community Nurse and/or Administrator to perform random audits of orders. Consultant to review audits.

4. Community Nurse, Administrator are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure the MAR was complete and accurate and included resident-specific parameters for the administration of PRN medications for 4 of 7 sampled residents (#s 1, 3, 7, and 9) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2018 with diagnoses including dementia.

Review of the resident's 05/01/22 through 06/06/22 MAR revealed both Milk of Magnesia and a bisacodyl suppository were listed to be administered PRN for constipation. There were no resident-specific parameters on the MAR which instructed staff as to which medication to administer first.

The need to ensure the MAR included resident-specific instructions for the administration of PRN medications was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 09/2019 with diagnoses including irritable bowel syndrome.

Review of the resident's 05/01/22 through 06/06/22 MAR, current physician orders, 10/19/21 service plan, and interviews with staff and the resident revealed the following:

* During the acuity interview on 06/06/22, Staff 1 (Executive Director) stated Resident 3 had skin issues on his/her legs and bottom. On 06/08/22, the resident reported staff regularly changed the dressing on his/her left buttock wound. Staff 11 (CG) confirmed this during an interview on the same date. There was no documented evidence staff initialed the MAR when they provided the treatment.

* Resident 3 had PRN orders for Milk of Magnesia and bisacodyl suppository for constipation. There were no resident-specific parameters listed on the MAR which instructed staff which medication to administer first.

The need to ensure the MAR was accurate and included resident-specific parameters for the administration of PRN medications was discussed with Staff 1 and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

3. A review of Resident 7's 05/01/22 through 06/06/22 MARs and physician orders identified the following deficiencies on the MARs:

* No reason for use of aspirin;

* An order for Metformin (for diabetes) was entered incorrectly;

* Two PRN antihistamines were lacking parameters;

* Blanks; and

* Multiple duplicate orders.

The need for an accurate MAR was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

4. A review of Resident 9's 05/19/22 through 06/07/22 MARs and progress notes revealed numerous inconsistencies in documentation related to administration and availability of multiple medications.

The need for accurate documentation of availability and administration of medications was discussed with Staff 1 (Executive Director) on 06/14/22. He acknowledged the findings.

OAR 411-054-0055 (2) Systems:

Medication Administration

This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the MAR was complete and accurate and included resident-specific parameters for the administration of PRN medications for 4 of 7 sampled residents (#s 1, 3, 7, and 9) whose MARs were reviewed.

1. Resident 1:  orders to be reviewed, parameters clarified

Resident 3: Wound care provided by home health; orders reviewed parameters clarified

Resident 7:  Pharmacy review of orders requested, orders reviewed, duplicate orders removed, blank orders removed, Metformin order corrected; reason for aspirin added.

Resident 9:  Moved out of community 6/10/22

2. All new orders will be checked by both RCCs, Med Tech, Community Nurse and Pharmacy for accuracy.

3. Administrator will perform random weekly audits of new orders to verify accuracy and completeness.  Administrator will review audit results with RCCs, Community Nurse and Consultant.

4. Administrator, Community Nurse are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 12 and 14) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed 06/08/22.

There was no documented evidence Staff 9 (CG), Staff 12 (CG), or Staff 14 (MT/CG), hired 04/20/22, 05/02/22 and 04/18/22, respectively, demonstrated competency in one or more of the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

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

* General food safety, serving, and sanitation.

The need to ensure documented evidence all direct care staff demonstrated competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

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

This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 12 and 14) demonstrated competency in all assigned job duties within 30 days of hire.

1. All residents have potential to be impacted by untrained staff.

2. Business office manager will assign new employee training and track completion using matrix.

*Changes associated with normal aging;

*Identification, documentation, and reporting of changes of condition;

*Conditions which require assessment, treatment, observation, and reporting.

*General food safety, serving, and sanitation.

Additionally, Community Nurse and/or designee will complete competency verification with new care staff within 30 days of hire.

3. Administrator review training status with BOM weekly. Consultant to perform random audits of employee files weekly.

4. Administrator and Business Office Manager are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 20 and 23) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 06/08/22.

There was no documented evidence Staff 20 (MT/CG), hired 07/14/04, or Staff 23 (MT/CG), hired 08/15/16,  had completed at least 12 hours of annual training, to include at least six hours of training related to dementia care.

The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/RN) on 06/08/22. They acknowledged the findings.

OAR 411-054-0070 (5-7) Annual Training and Other Requirements

This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 20 and 23) completed the required minimum 12 hours of in-service training annually.

1.  All residents have potential to be impacted by untrained staff.

2. All staff will be educated on the 12 hours of annual inservice training requirement and will register for Relias and/or Oregon Care Partners to complete required training. Business Manager will assign courses and notify dept supervisors of the status of their staff's training every month.

3. The Business Office Manager will track staff completion of required CEUs.  Administrator will monitor progress monthly. Consultant will perform random audits of employee files.

4. Administrator, Business Office Manager are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and fire and life safety instruction was provided to staff as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of fire and life safety records provided by the facility on 06/07/22 revealed a lack of documented evidence the facility conducted fire drills every other month and provided fire and life safety instruction to staff on alternate months.

The need to ensure fire drills were conducted and fire and life safety instruction was provided to staff as required by the OFC was discussed with Staff 1 (Executive Director) on 06/08/22. No further documentation was provided.

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

Safety: Safety

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and fire and life safety instruction was provided to staff as required by the Oregon Fire Code (OFC).

1.  All residents have the potential to be impacted by this failed practice.

2. Maintenance Director will plan fire drills every other month and provide fire and life safety instruction to staff on alternate months.

3. Maintenance Director will provide Administrator with monthly reports of fire and life safety activity, fire drills and fire and life safety education. Consultant will review monthly reports.

4. Maintenance Director, Administrator are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. Findings include, but are not limited to:

Fire and life safety records reviewed on 06/08/22 lacked documented evidence the following required elements were completed:

* Instruction provided to residents on fire and life safety procedures within 24 hours of admission.

* A written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

The need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 1 (Executive Director) on 06/08/22. He acknowledged the findings.

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

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually.

1.  All residents have the potential to be impacted by this failed practice.

2. Admission process reviewed and admission checklist implemented to ensure residents receive appropriate fire and life safety training for the community within 24hrs of admission.  Resident Handbook updated to included fire and life safety instructions.

3. Admission checklists will be audited weekly by the Administrator and Consultant.

4. Administrator is responsible for corrections.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the resident courtyards on 06/06/22 showed the following:

* Multiple drop-offs of 2-4 inches along pathway edges and resident patios;

The need to ensure pathways in the resident courtyard did not have potential tripping hazards was shown to and discussed with Staff 1 (Executive Director) on 06/07/22. He acknowledged the findings.

OAR 411-054-0300 (3)(a-h) General

Building Exterior

This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair.

1. All residents who use the courtyard are potentially impacted.

2. Community will bring in top soil, build up the surface to be level with the sidewalk, tamp it down and plant seed to correct the drop offs.

3. Maintenance Director will walk the grounds weekly and make note of any areas needing improvement and report to Administrator.  Administrator and Consultant to visually verify progress of indentified problem areas.

4. Administrator, Maintance Director are responsible for corrections.

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

Observations of the facility on 06/06/22 and 06/07/22 showed the following areas in need of cleaning or repair:

* Multiple walls, doors, and door frames in the facility had scrapes, dings, chips, missing pieces of plaster, and spills;

* Chipped and scraped cupboards were observed in the dining room;

* Debris was observed in the commercial washing machine drain, there were gouges and dings to the floor, the floor was separating at the seams, and there was a chipped wall with missing plaster near the dryer;

* Room 138 had strong urine odors in the living room that did not dissipate, carpet baseboard was pulling away from the wall, and chipped pieces of wall edges were noted in the bathroom;

* Gouges were noted to the floor of the large elevator;

* A chunk of door was missing from room 211;

* Black/brown stains, of varying sizes from large to small, were noted in multiple areas of the hallways, outside the kitchen, in the dining room, outside the staff lounge, in front of the resident mailboxes, medication room, and room 418 linen room, and in front of numerous resident rooms on both floors of the facility. A green stain was noted outside room 202 and a white/yellow stain was noted outside room 107; and

* Carpet baseboards were pulling away from the wall near rooms 104 and 129, and carpet was fraying and pulling apart near the RCC office.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) on 06/07/22. He acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General

Building: Doors-Walls, Cleanable

This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair.

1. All residents are impacted when environment is not clean and in good repair.

2. Chipped or damaged walls, doors, and door frames will be filled and/or repaired and painted.

Chipped cupboard doors will be refinished.

Laundry room and kitchen drains will be cleaned and/or replaced. Chipped walls repaired.

Floor will be repaired or replaced.

Room 138 carpet will be treated with an enzyme cleaner to remove odor.

Carpet baseboards will be reattached to walls. Chipped walls repaired.

Carpet stains throughought the building will be pretreated and shampooed.  Carpet is being replaced in sections with vinyl plank.

Frayed carpet seams will be repaired/replaced.

3. Administrator will perform a weekly walk-through with maintenance director to review status of repairs and any new issues. Consultant will review progress weekly.

4. Administrator, Maintenance Director are responsible for corrections.

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

Observations on 06/06/22 and 06/07/22 showed exit doors to the resident courtyards and side exits of the facility did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (Executive Director) on 06/07/22. He acknowledged the findings.

OAR 411-054-0300 (11-13) Call System

This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building.

1. All residents have the potential to be impacted.

2. Exit alarms will be installed on all exterior doors. Staff educated on policy and procedure.

3. Maintenance Director will perform weekly checks of door alarms. Maintenance Director will send an email results to Administrator and Consultant.

4. Maintenance Director, Administrator are responsible for corrections.