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The findings of the Change of Ownership survey, conducted 10/09/23 through 10/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit following the Change of Ownership survey on 10/09/23, conducted 03/18/24 through 03/21/24, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the Change of Ownership survey on 10/09/23, conducted 09/04/24 through 09/05/24, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 10/12/2024, conducted on 10/14/24, 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 and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:

A tour of the facility conducted on 10/09/23 identified a copy of the most recent re-licensure survey, including all revisits and plans of correction, was not accessible in a conspicuous location.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed on 10/11/23 with Staff 2 (Vice President of Operations). She acknowledged the findings.

1.Facility placed required posting per OAR in an accessible and conspicuous location.

2.When a new license is received it will be posted and any new surveys will be put in the binder and be accessible.

3.License will be reposted annually upon receipt and/or with change in administration.

4.Administrator and/or designee

2. On 10/12/23 at 12:15 pm, an unsampled resident reported to the survey team that the kitchen had run out of one of the entree options the resident had wanted for lunch - roasted chicken. The posted lunch time was from 11:30 am - 1:00 pm. The menu indicated the other entree choice for lunch was sirloin pork roast.

At 12:30 pm, a different unsampled resident reported to the survey team that the kitchen had run out of the dessert during lunch that day, so the resident and his/her tablemate did not receive desserts. The menu indicated the dessert that day was peach crisp.

In an interview on 10/12/23 at 12:15 pm, Staff 13 (Cook) confirmed the facility had run out of the chicken during lunch service that day. In a follow-up interview at 1:45 pm, Staff 13 and Staff 32 (Dietary Aide) confirmed the facility had run out of dessert that day for lunch.

The facility failed to treat residents with dignity and respect by failing to plan meal service so that all meal options offered were available to all residents during the scheduled meal time.

The issues with meal options was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC) on 10/12/23. They stated they had heard similar complaints the previous two weeks and were in the process of rectifying the situation.

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity in a homelike environment and to have medical and other records kept confidential. Findings include, but are not limited to:

1. On 10/10/23 at approximately 11:00 am, Resident 7 walked over to Staff 22 (MT), who was standing at a medication cart in the hallway in front of the nursing station. Staff 22 proceeded to take Resident 7's CBG and administer an insulin injection in the hallway.

On 10/10/23 at approximately 11:30 am, a MT was observed to approach an unsampled resident who was seated at a dining table in the dining room. The MT proceeded to take the resident's CBG and administer an insulin injection to the resident at the dining table. There were other residents present in the dining room at the time.

The facility failed to administer personal care services in a manner that protected the residents' privacy and dignity.

The failure to provide care services in a manner that protected residents' privacy and dignity was discussed with Staff 7 (Director of Health and Wellness) on 10/10/23. She acknowledged MTs were not performing the tasks as they had been instructed, and said she would meet with them immediately.

On 10/11/23 at 11:00 am, Staff 22 was observed in a third floor hallway administering an injectable medication to an unsampled resident. Following this, Staff 22 folded the computer screen halfway closed, without locking screen or the computer, and entered another unsampled resident's room. This allowed private resident information to be visible.

On 10/12/23, the need to ensure residents received services in a manner that protected privacy and dignity and to have medical and other records kept confidential was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 (Assisted Living RCC). They acknowledged the findings.

1.Med Techs will be Inservice on resident right and privacy regarding administration of services (CBGS and insulin) and protecting resident healthcare information. DCS and culinary team will be in-service on resident rights and privacy regarding resident meal services.  

2.Licensed nurse and/or Administrator to complete a pass observation. Administrator and Director of Culinary Services to review menus for availability and quantity weekly.

3.Weekly med pass observation for 4 weeks then monthly thereafter. Weekly review of menu availability.

4.Licensed nurse and Administrator, Director of Culinary Services and Administrator, and/or designee.

Based on interview and record review, it was determined the facility failed to conduct investigations for falls to rule out abuse or suspected abuse, or report the falls where abuse could not be ruled out to the local Seniors and People with Disabilities (SPD) office for 1 of 3 sampled residents (#6) whose records were reviewed for falls. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 07/2021 with diagnoses including weakness, history of falls, and dementia.

Progress notes, dated 07/09/23 through 10/11/23, service plan dated 09/22/23, Temporary Service Plans (TSPs), and Resident Incident Reports were reviewed and revealed the following unwitnessed falls:

* 07/01/23;

* 07/04/23;

* 07/06/23, two falls;

* 08/11/23;

* 09/10/23;

* 09/15/23;

* 09/18/23, two falls; and

* 10/06/23.

There was no documented evidence the fall on 08/11/23 had been investigated to rule out abuse or suspected abuse.

Resident 6 had the following fall interventions in place:

* "Ensure walker, wheelchair, assistive devices are in good condition, resident able to use and in easy reach of resident";

* "Ensure necessary items are within easy reach";

* "Ensure proper bed height";

* "Remove excess furniture that interferes with egress and resident mobility";

* "Encourage [the resident] to use [his/her] wheelchair for help with ambulation";

* "Ensure TV remote is next to resident";

* "Remind [the resident] to use [his/her] call pendant if [s/he] needs help making a snack or cleaning up something";

* "Encourage community exercise program"; and

* "Encourage [the resident] to wear shoes or non-slip socks at all times."

There was also a Service Checkoff List which was provided to the staff monthly with the expectation staff would document daily on taking out trash, making the bed, escorting to all meals, assisting with ADLs, providing "frequent" safety checks, and assisting with all transfers.

On the dates Resident 6 fell, documentation did not reflect care staff had been following the interventions in the service plan and TSPs, or had provided services listed on the Service Checkoff List.

On 10/12/23 at approximately 1:00 pm, the need to ensure the facility conducted a thorough investigation to determine whether the resident's service plan was being followed at the time of the falls was discussed with Staff 8 (Assisted Living RCC).

The need to conduct investigations to rule out possible abuse or suspected abuse when residents fell was reviewed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 on 10/12/23. They acknowledged the findings.

1.Resident 6 chart will be reviewed, and investigated regarding unwitnessed falls. Community to report to SPD according to OAR. Caregivers will be in-serviced service plans, temporary service plans, and

2.Licensed Nurse and/or Administrator to review Resident 6 EHR during weekly clinical meeting. Residents EHR audit to be conducted weekly for 4 weeks to ensure unwitnessed falls are reported to SPD according to OAR.

3.Licensed nurse to conduct weekly EHR audit weekly for 4 weeks and to be reviewed during weekly clinical meeting with Administrator.

4.Licensed nurse and Administrator and/or designee.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 10/10/23 at 10:30 am, the facility kitchen was observed to need cleaning in the following areas:

a. Food spills, splatters, debris, dust and black matter were observed on or underneath the following:

* The ceiling vent above bread storage area had significant amount of dust build-up;

* The ceiling above prep area had significant splashes;

* The exterior (lids and sides) of the large food bins had food debris and black scuff marks;

* The flooring throughout the kitchen including underneath the large mixer, counters, oven/stove/grill and the dishwashing area, had significant build-up of black matter;

* The oven doors, sides and knob area had food drips/splashes;

* The convection oven doors had grease drips/splatters;

* The sandwich refrigerator exterior doors and bottom shelf of interior had food drips/debris;

* The lower shelves beneath steamer, grill, serving and prep areas had food debris;

* The interior and exterior of the microwave had splatters and the counter underneath had food debris/crumbs;

* The dishwashing room had black matter on the wall behind the spray hose; and

* A three-tiered black cart with shelves which contained clean cups/glasses had significant build-up of debris.

b. Staff with beards were not using any type of hair restraints on their beards.

The areas of concern were discussed with Staff 6 (Culinary Services Director) on 10/10/23. The findings were acknowledged.

1.Kitchen will be cleaned. Cleaning schedule will be set up for Food spills, splatters, debris, dust, and black matter. This schedule will include weekly cleaning. Beard covers will be worn for staff who have a beard.

2. Audits will be done weekly until compliance is met and maintained. Then audits will move to monthly.

3.The plan of correction will be evaluated weekly for 4 weeks. Then, twice a month for one month.

4.Aministrator and Director of Culinary services or designee

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

Resident 2 was admitted to the facility in 10/2023. The Resident Evaluation and Service Agreement were reviewed. The following elements were not addressed:

* Customary routines including eating;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences, and traditions;

* Physical health status including list of diagnoses and list of medications and PRN use;

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

* List of treatments; and

* Complex medication regimen.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

1.Pre-admission evaluation Inservice will be conducted to include elements per OAR, with trained staff.  Resident 2 admission evaluation and service plan will be reviewed and updated according to OAR.   

2.Admission evaluations will be reviewed during weekly clinical meeting.

3.Weekly for 4 weeks.

4.Administrator and Licensed Nurse and/or designee.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all elements for 1 of 1 sampled resident (#9) whose new move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 02/2024 with diagnoses including depression and brain aneurysm. The "Milestone Resident Evaluation" and the "Comprehensive Nursing Assessment," both dated 02/08/24, were reviewed.

Review of the resident's record revealed the new move-in evaluation lacked the following elements:

* Customary routines, including eating and bathing;

* Communication and sensory including, ability to understand;

* Pain, including how the resident expresses pain or discomfort; and

* Complex medication regimen.

The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 34 (Executive Director), Staff 36 (Director of Health and Wellness LPN) and Staff 30 (Resident Care Director) on 03/21/24. They acknowledged the findings.

1.Community leadership will be inserviced on pre-admission process and documentation.  Resident 9's admission forms and the service plan will be reviewed and updated according to the OAR.  

2.Admission evaluations will be audited during clinical meeting, before move in by the clinical team and Executive Director.  

3. Pre-admission evaluations will be reviewed during weekly clinical meeting for 6 weeks.

4. Executive Director, DHW, and/or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's care needs or failed to provide a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 2 of 6 sampled residents (#s 4 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 05/2021 with diagnoses including Type 2 diabetes mellitus and renal failure.

a. During the acuity interview on 10/09/23, the facility reported the resident received hemodialysis treatment three days per week.

In an interview on 10/10/23, Resident 4 reported that upon return from dialysis (at approximately 5:45 pm), s/he felt extremely tired for the remainder of that evening, and often did not have the energy to finish dinner. Resident 4 stated s/he would like to have staff check on him/her following dialysis to ensure s/he was okay and to see if s/he needed anything.

b. In the interview on 10/10/23, Resident 4 also reported s/he was unable to organize various medical supplies that were delivered to his/her room and dispose of the empty cardboard shipping boxes. The resident explained s/he used a four-wheeled walker for ambulating due to impaired balance and could not bend over to pick up items from the ground for risk of falling. Resident 4's room was observed to be full of medical supplies and empty boxes which limited the resident's ability to move around the room freely and safely.

Resident 4's current service plan, dated 09/27/23, failed to include information and instructions for providing care in the following areas:

* Hemodialysis, including which clinic and what days;

* Additional support the resident needed and requested following hemodialysis; and

* Assistance needed with periodically organizing and tidying up his/her room.

The need to ensure the service plan was reflective of Resident 4's care needs and included instructions for staff for providing services was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 07/2021 with diagnoses including weakness, history of falls, and dementia.

The resident's service plan, dated 09/22/23, failed to include information and instructions for providing care in the following areas:

* Significant weight changes;

* Consistency in using the call system appropriately;

* Fluid preferences, including use of a straw with all beverages;

* Updated fall interventions;

* Interventions for refusing to change shirt;

* Friend's assistance with eating, escorting to meals, and toileting;

* Assistance with shaving;

* Where the resident ate "most meals";

* How often staff need to perform safety checks;

* Interventions for when the resident was "confused" or having hallucinations;

* Independence with activities;

* Low vision; and

* Use of a bed cane.

Resident 6 was identified as needing non-slip strips in front of his/her toilet and having personal items, including the television remote, within reach as fall interventions on TSPs. On 10/10/23 at 1:54 pm, observations of the resident's room revealed no non-slip strips in front of the toilet and the resident's water bottle and television remote were not within reach.

The need to ensure service plans were reflective of the resident's care needs and provided a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

1.Resident #4 and #6' chart will be reviewed and updated to reflect personalized services.

2.Service plans will be reviewed and updated, if indicated, 30 days after move-in, quarterly, and with significant change of conditions.

3.Every 90 days.

4.Administrator and/or Licensed Nurse.

3. Resident 10 was admitted to the facility in 04/2011 with diagnoses including congestive heart failure, dementia, and type 2 diabetes.

The current service plan dated 01/30/24 and progress notes from 12/11/23 through 03/18/24 were reviewed. Observations and interviews with staff and Resident 10 were completed during the survey. The following was identified:

The service plan failed to include information and instructions for providing care in the following areas:

* The resident's preference to sleep in their recliner chair;

* Emergency room visits due to Foley catheter falling out;

* Frequency of outside service provider visits and responsibilities;

* Use of psychotropic medications;

* Signs and symptoms of high blood sugar to include, dry mouth, excessive thirst and urinating large amounts;

* Current skin status and treatment; and

* Weight loss.

The need to ensure the service plan was reflective of Resident 10's care needs and included clear directions to staff regarding the delivery of services was discussed with Staff 34 (Executive Director), Staff 36 (Director of Health and Wellness LPN), and Staff 30 (Resident Care Director) on 03/21/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's care needs or failed to provide a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 3 of 3 sampled residents (#s 3, 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 02/2024 with diagnoses including depression and brain aneurysm.

The resident's service plan, dated 02/16/24, failed to include information and instructions for providing care in the following areas:

* Use of siderails; and

* Recent history of suicidal ideation including signs and symptoms of his/her depression, strategies to mitigate the signs and symptoms of depression, and when to alert the nursing staff.

The need to ensure the service plan was reflective of Resident 9's care needs and included instructions for staff for providing services was discussed with Staff 34 (Executive Director), Staff 36 (Director of Health and Wellness LPN) and Staff 30 (Resident Care Director) on 03/21/24. They acknowledged the findings.

2. Resident 3 moved into the facility in 03/2022 with diagnoses including a history of stroke and hemiparesis. The resident had a recent history of falls and a wrist and shoulder fracture.

In an interview on 03/20/24, Staff 21 (CG) stated Resident 3 required the assistance of one staff during showers, dressing and incontinence care. The resident was able to assist with some aspects of bathing, dressing and hygiene but was unable to complete these tasks without assistance.

Observations of the resident and a review of the current service plan available to direct care staff, last updated 01/24/24, and interim service plans (ISP'S) showed the service plan did not reflect the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Flaccid left hand and left sided weakness, use of brace on left leg and splint on left hand;

* Bathing assistance and interventions for bathing refusals;

* Skin care required for left hand;

* Dressing assistance: "physical assistance with dressing" and precautions related to recent shoulder fracture;

* Non-pharmaceutical interventions for pain (massage device);

* Interventions for staff to attempt with behaviors of refusals to care, transfer assistance and yelling;

* Use of a call pendant; and

* Current fall interventions.

The need to ensure service plans were reflective of residents' needs and provided clear instruction, including what, when, how, and how often the services should be provided was reviewed with Staff 34 (ED) and Staff 36 (Director of Health and Wellness LPN) on 03/20/24. They acknowledged the findings.

1. Service Plan in-service/training will be conducted to include OAR 411-054-0034(1-4)

Residents 3,9 and 10 service plans will be reveiwed and  updated to reflect their current needs and provide clear director for delivery of services.

2. Service Plans will be reviewed/updated at the clinical meeting by the clinical team.

3. Review at the clinical meetings for 6 weeks, or until substantial compliance is met and maintained.

4. Administrator, DHW, and/or designee responsible.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team  that 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 who was going to provide services to the resident, for 5 of 7 sampled residents (#s 3, 4, 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3, 4, 5, 6, and 7's current service plans were reviewed during the survey. None of the service plans included documented evidence the service plan had been reviewed by the resident. There was no additional documentation in the residents' records as to whether the resident attended any kind of service plan review meeting or not.

Interviews with each resident indicated the residents had not attended any recent service plan review meeting nor had they reviewed their current service plan.

In an interview on 10/11/23, Staff 8 (Assisted Living RCC) stated residents were typically only included in the service plan review process if there was a significant change to the resident's care and services.

The need to ensure service plans were developed by a service planning team that included the resident was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 on 10/12/23. They acknowledged the findings.

1.Resident's #3, #4, #5, #6, #7 will receive chart review to ensure residents updated evaluation and service plan via service plan team.

2.Licensed Nurse will conduct EHR review of residents that are due/pass due for their OR evaluation/service plan. Administrator and VP of Health and Wellness will review audit and collaborate with community nurse 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, Licensed Nurse 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 that 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 who was going to provide services to the resident, for 1 of 3 sampled residents (#3) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 3's current service plan was reviewed during the survey. The service plan lacked evidence a Service Planning Team reviewed and participated in the development of the service plan.

In an interview on 03/20/24 at 1:30 pm, Staff 30 (Resident Care Director) was asked about the process for including all required participants, including the facility administrator or designee and any person of the resident's choice, in development of the service plan for residents. The facility was not able to provide documentation that the required participants were included in the service plan development.

The need to ensure service plans were developed by a service planning team was discussed with Staff 34 (Executive Director), Staff 30, and Staff 36 (Director of Health and Wellness LPN) on 03/21/24. They acknowledged the findings.

1. Clinical team will be inservice on components of service plan team per OAR 411-054-0036 (5).

Resident 3 will receive chart review to ensure resident has updated evaluation and service plan via service plan team.  

2. Director of Health and Wellness will conduct chart review and notify Chief Clinical Officer of audit results. Chief Clinical Officer will collaborate with community to ensure service plans are updated and reviewed utilizing service plan team.

3.Evidence of service plan team meeting will be reviewed at the clinical meeting for 6 weeks

4. Administrator, DHW, and/or designee responsible.

2. Resident 7 was admitted to the facility in 06/2022 with diagnoses including Type 2 diabetes mellitus, vascular dementia and history of cerebral vascular accident/transient ischemic attack (stroke).

Resident 7's record was reviewed. Facility staff documented the following incidents:

* On 07/17/23, Staff 24 (MT) documented she observed "tons of packages" of an artificial sweetener in Resident 7's room and noted the resident's CBGs had been "very Hi [sic]" the previous few days.

* On 09/23/23, Staff 30 (MT) documented the resident's CBGs had been in the high 200's and high 300's for the past few days and staff had reported the resident had been taking "handfuls" of sugar packages from the kitchen. Staff 30 documented the resident's personal trash bag was discovered to be "full of torn sugar packets." Staff 30 documented again on 09/25/23 that the resident's CBG at lunch was 540 and, upon entering the resident's room, discovered "over 100 sugar packets" that were all opened and empty. The kitchen later confirmed the resident had been observed taking pocketfuls of sugar packets from the dining room earlier that day.

On 09/30/23, the resident's primary care provider directed the facility to document on the MAR when the resident's CBG was elevated due to sugar packet intake.

There was no documented evidence the facility determined, documented and communicated to staff how they should respond when they observed Resident 7 taking sugar packets from the dining room or discovered packets in his/her room, whether they needed to notify anyone, and what monitoring and documentation should be implemented.

The facility's failure to determine, document and communicate to staff what actions or interventions were needed following the noted incidents was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, if actions or interventions were determined, those were communicated to staff on each shift, and had documentation of at least weekly progress noted until the condition resolved for 2 of 7 sampled residents (#s 6 and 7) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2021 with diagnoses including weakness, history of falls, and dementia.

Progress notes dated 07/09/23 through 10/11/23, the service plan dated 09/22/23, and Temporary Service Plans (TSPs) revealed the following changes of conditions:  

* Between 07/01/23 through 10/06/23, Resident 6 had ten falls;

* 08/03/23 - return to the facility from a rehabilitation center relating to a fall with a hip fracture;

* 08/23/23 - new medication, Aricept (for dementia); and

* Between 08/07/23 through 09/18/23, the resident had multiple notes relating to increased confusion.

Although some changes of condition were evaluated, the facility failed to consistently evaluate the resident's changes of condition to determine if actions or interventions were needed. Some actions or interventions were communicated to staff on each shift, but not consistently with each change. There was no documented evidence the above mentioned changes of condition had at least weekly progress noted until the conditions resolved.

The need to ensure changes of condition were evaluated to determine if actions or interventions were needed, communicate those actions and interventions to staff on each shift, and document at least weekly progress noted through resolution was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

1.Licensed Nurse and/or designee will review, update, and maintain ISP and short-term change of condition logs for Resident 6 and7. Licensed Nurse and/or designee to Inservice staff on ISP, notification process for resident change of condition and documentation.

2.Licensed Nurse and Administrator to review ISPs and short-term change of condition log during weekly clinical meeting for residents 6 and 7 until resolution is implemented by Licensed Nurse. Service plans to be updated with new approaches.

3.Resident 6 and 7 ISPs and short-term change of condition log will be reviewed during clinical meeting weekly for 3 weeks and then quarterly thereafter.

4.Administrator and Licensed Nurse and/or designee

2. Resident 10 was admitted to the facility in 04/2011 with diagnoses including congestive heart failure, dementia, and type 2 diabetes.

A review of the resident's clinical record, including the current service plan, dated 01/30/24 and progress notes from 12/13/23 through 03/18/24 were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:

* 01/08/24 - Insulin dose increased;

* 01/24/24 - Resident reported burning sensation from catheter and urinating excessively;

* 02/04/24 - ER visit related to Foley catheter placement;

* 02/15/24 - Resident reported concern with urinating excessively;

* 03/03/24 - Staff documented the resident was having high CBGs;

* 03/04/24 - ER visit related to Foley catheter placement;

* 03/05/24 - Insulin dose increased;

* 03/16/24 - ER visit related to Foley catheter placement;

* 03/17/24 - Morning CBG was 545; and

* 03/17/24 - ER visit related to Foley catheter placement and returned to facility on 03/17/24 with diagnosis of hyperglycemia.

The need to ensure resident-specific action or interventions for short-term changes of condition were documented, communicated to staff on each shift, and monitored at least weekly through resolution was discussed with Staff 34 (Executive Director), Staff 36 (Director of Health and Wellness LPN), and Staff 30 (Resident Care Director) on 03/21/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions or interventions determined and documented, and residents' changes of condition were monitored, consistent with evaluated needs and with progress noted at least weekly to resolution for 2 of 3 sampled residents (#s 3 and 10) who experienced short-term changes of condition. Resident 3 sustained injuries from repeated falls. This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 03/2022 with diagnoses including a history of stroke and hemiparesis and had repeated falls.

The current service plan, interim service plans (ISP's), progress notes from 12/11/23 through 03/18/24, and incident reports were reviewed and showed the following:

a. Resident 3 experienced four falls between 12/20/23 and 03/07/24, as follows:

* 12/20/23 - unwitnessed fall in the resident's apartment, no injury;

* 01/17/24 - unwitnessed fall in the resident's apartment resulting in right wrist fracture;

* 03/03/24 - unwitnessed fall in the resident's apartment resulting in "small bruise to the top of right foot ... causing some pain"; and

* 03/07/24 - unwitnessed fall in the resident's apartment resulting in left shoulder fracture diagnosed at urgent care clinic on 03/11/24.

In an interview on 03/19/24, Resident 3 stated s/he had some pain in his/her shoulder and was waiting on a doctor's appointment. Resident 3 had a sling in place on the left arm. Observations of the resident's apartment showed a manual wheelchair with attached footrests next to the closet door, a recliner and small side table next to the recliner and in front of the TV. The resident's bed was in a low position and placed against the wall in far corner of the room. A single point cane was laying on the floor next to the recliner.

In an interview on 03/19/24, Staff 36 (Director of Health and Wellness LPN) stated the resident's falls occurred while transferring him/herself without calling for assistance from staff and the resident had been encouraged to call for assistance before transferring.

ISP's dated 12/20/23 through 03/12/24 were reviewed. The ISP's following the falls on 12/20/23, 03/03/34 and 03/07/24 instructed staff to "ensure walkers, wheelchairs, assistive devices are in good condition, resident able to use and in easy reach of resident."

There was no ISP following the fall on 01/17/24 that resulted in the wrist fracture.

The facility documented the following interventions in fall investigation reports:

* 12/20/23 - "remind resident to ask for help when alone and may need assistance. Ensure no trip hazards";

* 01/17/24 - "RCD will coordinate with resident to call wheelchair company to fix broken footrest";

* 03/07/24 - "monitor proper placement of power cords and remove foot pegs from wheelchair when not in use"; and

* 03/19/24 - "educate resident on using call pendant for assistance".

The record lacked evidence the determined actions or interventions had been communicated to staff on each shift for staff to follow and monitored for effectiveness. The resident continued to fall and sustained multiple injuries, causing a serious risk to the health, safety, and welfare of the resident.

b. The following short-term change of condition, documented in the progress notes, lacked documented evidence of being monitored at least weekly to resolution:

* 03/03/24 - bruise to the top of the right foot.

The need to ensure changes of condition had actions or interventions developed, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 34 (ED) and Staff 36 on 03/20/24. They acknowledged the findings.

1. Clinical team will be inserviced on Interim Service Plan and Alert Charting process and procedure related to short term change of condition. Resident 3 and 10 EHR will be reviewed and updated accordingly.  

2. Clinical team will review/audit short term change of contion(s) and communicate changes to care staff accordingly.

3. Review at the clinical meeting for 6 weeks.

4. Executive Director and  DHW, and/or designee responsible.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition had determined actions or interventions identified, the determined actions or interventions were communicated to staff on each shift and the resident's changes of condition were monitored with progress noted at least weekly to resolution for 1 of 4 sampled residents (# 15) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 15 moved into the facility in 12/2019 with diagnoses including anxiety disorder and heart failure.

The current service plan, interim service plans (ISP's) and progress notes from 05/14/24 through 09/03/24 were reviewed and showed the following:

* 06/26/24 - On 06/24/24, the resident returned from the emergency room related to bleeding; and

* 06/30/24 - The resident requested to be sent to the hospital.

In an interview on 09/05/24, Resident 15 stated s/he went to the hospital and received a new diagnosis of an aneurysm. The resident further stated s/he had surgery at the hospital and was transferred to rehabilitation. S/he returned to the facility sometime in August 2024.

In a review of the resident's 08/01/24 - 09/05/24 MAR, staff documented they administered an evening dose of scheduled medications on 08/09/24, which was the first dose of medications in August 2024. The resident's progress note, an interview with the resident and the MAR review showed the resident had been out of the facility from 06/30/24 to 08/08/24, for more than 30 days.

There was no documented evidence the changes of condition had determined actions or interventions needed for the resident, communicated to staff on each shift nor was the resident monitored following the return from the emergency room and hospital stay.  

Resident 15's changes of condition were discussed with Staff 30 (Resident Care Director), Staff 34 (ED) and Staff 35 (RN) and on 09/05/24. They acknowledged the findings.

Please note from SOD this is ID PREFIX TAG C270

1. Resident #15 chart will be reviewed by clincial team.

2. Staff will be inserviced on short term change of condition to include interventions for resident needs, weekly documentation, and communication to each shift.

3.Monitoring systems will be reviewed weekly duirng clinical meetings for 4 weeks.

4. Administrator, Licenses Nurse, and/or Designeee  

Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, for 1 of 1 sampled residents (#6) who experienced severe weight loss. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 07/2021 with diagnoses including weakness, history of falls, and dementia.

Review of the resident's weight records revealed the following:

* 05/03/23 - 162.2 pounds;

* No weight obtained in 06/2023;

* 07/03/23 - 149 pounds;

* 08/11/23 - 149.1 pounds;

* 09/03/23 - 148.4 pounds; and

* 10/05/23 - 150.2 pounds.

From 05/03/23 to 08/11/23, the resident lost 13.1 pounds which constituted a severe weight loss of 8.07% in three months. This weight loss represented a significant change of condition and required an RN assessment.

There was no documented evidence the RN completed an assessment which included documentation of findings, the resident's status, and interventions made as a result of the assessment for Resident 6's severe weight loss.

The need to ensure significant changes of condition were assessed by an RN and included documentation of findings, the resident's status and interventions made as a result of the assessment was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

1.A Change of Condition assessment will be completed by RN for resident 6. Service plan will be updated utilizing service plan team.

2.Licensed Nurse will conduct EHR review of community residents that are due/pass due for their OR evaluation/service plan. VP of Health and Wellness will be notified of audit results. Administrator and VP of Health and Wellness will review audit and collaborate with RN to ensure OR evaluation/service plans are updated. Service plans will be reviewed and updated utilizing service plan team.

3.Administrator and Licensed Nurse will review OR evaluations/service plans during weekly clinical meeting.

4.Licensed nurse, Administrator, and/or designee

2. Resident 10 was admitted to the facility in 04/2011 with diagnoses including congestive heart failure, dementia, and type 2 diabetes.

A review of the resident's clinical record, including the service plan dated 01/30/24, progress notes from 12/13/23 through 03/18/24, blood sugar records from 01/01/24 through 03/18/24 and interviews with facility staff and the resident identified the following:

The resident had an order to monitor CBGs twice a day. Blood sugar records revealed the following:

* Between 01/01/24 and 01/31/24, the resident had two CBGs over 300; and

* Between 02/01/24 and 03/18/24, the resident had 29 CBGs over 300 and 400 and three CBGs over 500.

According to the records, the resident's CBGs were stable in January. The resident's CBGs in February and March showed a significant change of condition related to unmanaged high blood sugars that required an RN assessment.

The resident was interviewed on 03/19/24 at 2:00 pm. Upon entering the resident's apartment, the resident was observed lying in his/her bed. The resident appeared lethargic and displayed symptoms of a dry mouth. Resident 10 stated s/he was not feeling good and was tired. The resident reported his/her last A1c (a blood test that measures the average blood sugar level over the past 2-3 months) was 12, and stated that was too high. During the interview, a CG walked into the apartment and emptied the resident's Foley catheter bag. The CG reported she had to frequently empty the resident's catheter bag throughout her shift due to large amounts of urine output. The resident expressed s/he was very thirsty and requested some water from the CG. Observation of the resident's apartment showed numerous empty drinking cups placed throughout the apartment.

In an interview on 03/21/24 at 12:35 pm, Staff 35 (RN) indicated she was aware of the high blood sugars and that the facility was working with the resident's nurse practitioner regularly. Staff 35 reported that due to insurance purposes, one of the resident's oral diabetic medications was no longer covered. Since that change, the facility had been trying to find a treatment that worked. Staff 35 further indicated Resident 10's eating habits and non-compliant behaviors contributed to the resident's elevated blood sugars.

Resident 10 experienced a significant change of condition related to unmanaged high blood sugars. There was no documented evidence the facility RN had completed an assessment to include findings, resident status, and interventions made as a result.

The need to ensure an RN assessment was completed, which documented findings, resident status, and interventions made was discussed with Staff 34 (Executive Director), Staff 36 (Director of Health and Wellness LPN), and Staff 30 (Resident Care Director) on 03/21/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed and included findings, resident status and interventions made as a result of the assessment for 2 of 2 sampled residents (#'s 3 and 10) who had significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 03/2022 with diagnoses including a history of stroke and hemiparesis (left affected side).

Review of the resident's 12/11/23 through 03/18/24 progress notes showed the following:

* 01/18/24: "resident returned from ER with diagnosis of right wrist fracture" and was put on alert monitoring.

On 03/19/24, an RN assessment following the wrist fracture was requested.

The RN assessment, dated 01/22/24, following the wrist fracture was reviewed and included information on the resident's status: "fall reported ... [s/he] requested Ice and thought [s/he] might need an X-ray. [S/he] was sent to the ER returned with a DX [diagnosis] of fractured wrist. [S/he] received a brace but often refuses to wear the brace direct care staff report." The assessment also included "[S/he] is going out to Pt therapy." The assessment did not document findings or interventions made as a result of the assessment. There was no information related to how the wrist fracture of the resident's dominant hand affected his/her ability to perform ADL's and no instruction to staff on use of the hand brace or any changes to the service plan.

The need to ensure an RN assessment, which included findings, resident status and interventions made as a result of the assessment for significant changes of condition was reviewed with Staff 34 (ED), Staff 35 (RN) and Staff 36 (Director of Health Services LPN) on 03/21/24. They acknowledged the findings.

1. The RN was educated by th survey team evaluation components, follow-up, completion of an ISP, and the importiance of the documented resolution.

Change of condition assessment will be completed by RN for resident 3 and 10. Service plan will be updated utilizing service plan team.

2. The service plans will be reviewed/audited at the clinical meeting for change of condition monitoring.

3. Review at the clinical meeting for 6 weeks.

4. Administrator, DHW, and/or designee responsible.

Based on interview and record review, it was determined the facility failed to have a system to coordinate care with outside providers in order to ensure the continuity of care for 2 of 2 sampled residents (#s 3 and 10) who received outside services. Findings include, but are not limited to:

1. Resident 10 was admitted to the facility in 04/2011 with diagnoses including congestive heart failure, dementia, and type 2 diabetes.

During the entrance conference on 03/18/24, Resident 10 was identified to be receiving outside services.

Resident 10's record was reviewed during the survey and the following was identified:

* On 01/22/24, an "After Visit Summary" indicated the resident was seen at his/her urology clinic regarding urinary incontinence and that a urinary catheter had been placed. The outside provider noted the resident had a follow-up appointment scheduled for 02/22/24.

There was no documented evidence the follow-up appointment had been implemented.  

* A progress note dated 02/04/24 indicated the resident's catheter had come out the previous night and the facility was sending the resident to the emergency room for a new catheter. The resident returned from the emergency room on 02/04/24. The "After Visit Summary" indicated the resident was treated at the emergency department for "displacement of Foley catheter," and a new catheter had been placed. Instructions provided to the facility included the following:

"Please continue previous orders to maintain an indwelling Foley catheter and continue ongoing maintenance/monitoring through the patient's urology clinic" and to "schedule an appointment with the urologist as soon as possible for a visit in four weeks (around 03/03/24)" for catheter exchange.

There was no documented evidence the facility coordinated with the urology clinic.

* A progress note dated 02/13/24 by Staff 40 (LPN) noted she had attempted to make an appointment with the urologist, and a call back was pending.

There was no documented communication or coordination of care between the facility and the urology clinic.

* On 03/04/24, an "After Visit Summary" indicated the resident was treated at the emergency room for "Foley catheter problem," and a new catheter had been placed.

* A progress note dated 03/04/24 by the resident's nurse practitioner indicated the resident's chronic Foley management had been referred to Home Health (HH), and an intake appointment was to occur tomorrow, 03/05/24.

There was no documented evidence the HH appointment had been implemented.  

* A coordination of care note dated 03/12/24 by an HH/RN noted their agency was not managing the resident's catheter care. Per urology notes, "Only they [Urology Clinic] will do the monthly changes due to patient's anatomy and difficulty with placing the catheter."   

There was no corresponding documentation in the resident's record regarding his/her catheter management from the urology clinic.

* On 03/16/24 and 03/17/24, "After Visit Summaries" indicated the resident was treated at the emergency department for "displacement of Foley catheter," a new catheter had been placed, including instructions to schedule an appointment with the resident's nurse practitioner as soon as possible.

There was no documented evidence the follow-up appointments with the nurse practitioner had been implemented.  

During an interview on 03/21/24 with Staff 35 (RN), she indicated that the resident's urologist was notified of the resident's emergency room visits through the hospital system; however, she could not provide any documentation that the resident's urology clinic had been notified. Staff 35 confirmed the urology clinic was overseeing the resident's catheter management.

The need to have an effective system for coordinating care with on-site and off-site health care providers to ensure continuity of care was discussed with Staff 34 (Executive Director), Staff 36 (Director of Health and Wellness LPN), and Staff 30 (Resident Care Director) on 03/21/24. They acknowledged the findings.

2. Resident 3 moved into the facility in 03/2022 with diagnoses including history of stroke and hemiplegia.

During the acuity interview it was reported Resident 3 had recent frequent falls.

Review of the resident's clinical record, including the current service plan, and comprehensive nursing assessments dated 01/22/24 and 03/14/24 identified the following:

* "Occasionally forgets things and misinterprets situations, alert and oriented." and "may forget things when intoxicated.";

* The nursing assessment, dated 01/22/24, following a fall with wrist fracture stated "[S/He] is going to out Pt therapy"; and

* The nursing assessment, dated 03/14/24, following a fall with shoulder fracture stated "continues to go to out patient PT..."

In an interview on 03/19/24 at 9:30 am, Staff 36 (Director of Health and Wellness LPN) was asked about outside provider notes for Resident 3's physical therapy visits. Staff 36 stated the resident had not provided any documentation. At 12:54 pm, Witness 1 (Resident 3's power of attorney) was at the facility. Witness 1 had obtained and provided physical therapy notes (dated 11/27/23 through 02/02/24) upon request from the facility earlier that day.

There was no documented evidence the facility had tried to coordinate off-site health services for Resident 3 who could not or chose not to self-manage their health services and provide relevant information to the off-site provider, including a protocol to facilitate the receipt of information from the provider

The need to ensure the facility had a process to coordinate off-site health services for residents who cannot or chose not to self-manage their health services was discussed with Staff 34 (ED), Staff 35 (RN) and Staff 36. They acknowledged seeking assistance from the resident's designated decision maker, when needed, to help coordinate services with outside providers.

1. In-service/training will be completed on the review proccess of the 3rd party providers notes. Per the OAR the out-patient providers will be asked to provide notes or an after-visit summary which will be put through a triple check system with the final check being nursing. Resident 3 and 10 will will have outside provider notes reviewed and coordinated care with 3rd party provider accordingly.

2. The after visit documents will be reviewed in weely clinical meeting.

3. Review at the clinical meeting for 6 weeks.

4. Administrator, DHW, and/or designee responsible.

3. Lunch service was observed on 10/10/23 and 10/11/23 between 11:20 am and approximately 12:30 pm. During the meal service, dietary aides were observed pushing open the kitchen doors while entering and exiting the kitchen with the palms of their hands and fingers. This contaminated their hands at which point they should have washed or sanitized their hands before handling food plates. However, the dining staff were not observed to wash their hands as required.

The need to ensure dining staff followed infection prevention practices during meal times was reviewed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a safe, sanitary and comfortable environment and maintain proof of vaccination or documentation of a medical or religious exemption as required in OAR 333-019-1010(4). Findings include, but are not limited to:

1. During an interview on 10/11/23 at 2:53 pm, Staff 2 (Vice President of Operations) confirmed the facility was not reporting monthly on COVID-19 vaccination status for staff members. She stated the last report was made in July 2023.

2. A medication pass was observed on 10/11/23 from 11:00 am through 11:14 am. During the medication pass, the MT was observed to administer an injectable medication to a resident in a hallway. The MT had gloves on, then removed the gloves after the medication administration, entered information into the computer, and subsequently entered another resident's apartment without performing hand hygiene.

The need to ensure staff provided a safe, sanitary and comfortable environment and the facility reported monthly on COVID-19 vaccination status was reviewed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

1.Business Office Manager and/or designee will conduct community staff audit for vaccination status. Staff will be Inservice on infection prevention practices.  

2.The information from initial audits will be given to the infection control specialist. Each week Business Office Manager will give roster that includes new staff and their vaccination status.  Administrator and Licensed Nurse to conduct infection prevention service.

3.Administrator will enter this information into the OHA portal at least monthly. Administrator and/or designee to conduct infection prevention practice round during weekly 1:1 meeting with Licensed nurse and Director of Culinary Services for 3 weeks.

4.Administrator, Community Licensed Nurse, BOM, Director of Culinary Services and/or designee.

Based on interview and record review, it was determined the facility failed have a system for tracking controlled substances administered by the facility for 1 of 2 sampled residents (#3) who were administered PRN narcotic medications. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2022 with diagnoses including stroke, hemiparesis, and coronary artery disease.

The resident was prescribed the following PRN narcotic medication: Hydrocodone APAP 5-325 mg "every six hours as needed for breakthrough pain only."

Review of Resident 3's 10/01/23 through 10/09/23 MAR and the Controlled Substance Disposition Record revealed:

* 10/2023 MAR documented hydrocodone was administered to Resident 3 on 10/05/23 at 12:31 am. At 12:34 am the MT wrote an exception note on the MAR that the PRN Hydrocodone had been given for "breakthrough pain."

* On 10/11/23 the controlled substance tracking system was reviewed with Staff 18 (MT). When Staff 18 opened the narcotic storage section of the medication cart to check Resident 3's remaining hydrocodone, she discovered there was no hydrocodone.

* Staff 18 consulted the controlled substance tracking log to find the status of the medication and discovered there was not a page or entry for Resident 3's Hydrocodone in the log. Staff 18 was not able to locate the medication or the tracking log for Resident 3's hydrocodone.

* Later, on 10/11/23, Staff 8 (Assisted Living RCC ) located a tracking log page for Resident 3's hydrocodone in the 02/2023 controlled substance log. The page documented the last tablet of the medication had been given on 02/23/23.  

In interview on 10/11/23, Staff 8 confirmed the MAR did not match the controlled substance tracking log.

The need to ensure controlled substances were tracked accurately was reviewed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 on 10/12/23. They acknowledged the findings.

1.Staff will be in-service on the following: Medication administration, Controlled substance tracking process, Medication rights. Resident 3 controlled medication will be audited by Licensed Nurse and/or Designee. Resident 3 Physician will be notified for request to send E-script for controlled substance.

2. Staff in-service on controlled substance tracking process. Licensed nurse and/or Administrator to conduct a Narcotic book vs. EMAR audit.

3.Weekly narcotic book and EHR/EMR review.  

4. Administrator and Licensed Nurse and/or Designee

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept and included resident-specific parameters and staff instruction for 1 of 1 sampled resident (#10) whose MAR was reviewed. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 04/2011 with diagnoses including congestive heart failure, dementia, and type 2 diabetes.

Resident 10's 03/01/24 through 03/18/24 MAR was reviewed and revealed:

The resident had orders for staff to check CBGs twice daily. The MAR lacked resident-specific parameters including when staff should contact the RN or prescriber.

In an interview with Staff 35 (RN) on 03/21/24, she acknowledged the resident's CBG monitoring was lacking resident-specific parameters and staff instructions.

The need to ensure MARs were accurate and contained resident-specific parameters and instructions for staff was discussed with Staff 34 (Executive Director), Staff 36 (Director of Health and Wellness LPN), and Staff 30 (Resident Care Director) on 03/21/24. They acknowledged the findings.  

1. Staff will be in-serviced/trained on medication administration documentation, and communication related to ordersing needing clarification by PCP. Resident 10 will have CBGs and medication list sent to PCP for review and clarification related to parameters.  

2. The PRN medications will be reviewed and audited by the staff nurses. Conducted weekly for 3 weeks and then monthly therafter.

3. Review at the weekly clinical meeting for 3 weeks and then monthly therafter.

4. Administrator, DHW, and/or designee responsible.

2. Resident 2 was admitted to the facility in 10/2023.

The resident was not identified as self-administering his/her medication during the acuity interview on 10/09/23. Record review revealed the resident was self-administering ofloxacin (antibiotic eye drops).

On 10/09/23 at 2:50 pm, Resident 2 confirmed self administering the physician prescribed eye drops twice a day and showed the surveyor that s/he stored the medication under the seat of his/her four-wheeled walker.

The facility was unable to provide a written order for self-administration.  

The need to have a written order from a physician or other legally recognized practitioner for a resident to self-administer medications was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 05/2021 with diagnoses including Type 2 diabetes mellitus and renal failure. Resident 4 was identified as administering some of his/her medications during the acuity interview on 10/09/23.

Review of Resident 4's record identified the following:

* Resident 4 had a signed physician order for Estradiol (for hormone replacement) to apply every night at bedtime. The MAR indicated Resident 4 was self-administering that medication.

* There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer Estradiol.

The need to have a written order from a physician or other legally recognized practitioner for a resident to self-administer medications was discussed on 10/11/23 with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Health and Wellness Director), and Staff 8 (Assisted Living RCC). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure there was a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 3 of 3 sampled residents (#s 1, 2, and 4) who self-administered medications. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2022.

During the acuity interview on 10/09/23, Resident 1 was not identified as self-administering his/her medication. However, upon record review, Resident 1 was self-administering all of his/her prescription medications. The facility was unable to provide a written order for self-administration.

In an interview on 10/10/23, Staff 7 (Director of Health and Wellness) stated they did not have a physician's order for the resident to self-administer medications.

The need to have a written order from a physician or other legally recognized practitioner for a resident to self-administer medications was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7, and Staff 8 (Assisted Living RCC). They acknowledged the findings.

1.Resident #1, #2 and #4's PCP were contacted regarding medication self-administration. Medication self-administration orders were obtained prior to survey exit.

2.EHR/EMR will be reflective of Medication self-administration order per physician orders.

3.Medications Self-administration orders will be reviewed quarterly.

4.Licensed Nurse, Administrator and/or designee.

Based on observation and interview, it was determined the facility failed to ensure a licensed administrator was scheduled to be on-site in the facility at least 40 hours per week. Findings include, but are not limited to:

Survey entered the facility on 10/09/23 at 9:00 am and requested to speak with the administrator. Staff 5 (Business Office Assistant) reported the administrator was not in the facility. When asked who was in charge in the administrator's absence, she stated Staff 8 (Assisted Living RCC) who was also present at the time of survey entrance.

During an interview on 10/09/23 at 4:25 pm, Staff 11 (Vice President of Health and Wellness) confirmed there was no full time licensed administrator for the facility and regional employees would be covering for this week.

The need to have a licensed administrator on-site in the facility at least 40 hours per week was discussed with with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8. They acknowledged the findings.

1. Adminsistrator has been hired and is on-site 40 hours per week.

2. Regional team to collaborate with administrator on weekly basis for retention

3. Weekly

4. Administrator and Regional Team

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) which met the regulation. Findings include, but are not limited to:

On 10/11/23 at 9:09 am, the facility's Eldermark ABST was reviewed and discussed with Staff 1 (Assistant ED, RCC),  Staff 7 (Director of Health and Wellness), Staff 11 (Vice President of Health and Wellness), and Staff 33 (Memory Care 2 RCC).

Staff 1 and 4 were unable to identify how all 22 required ADLs were captured in the Eldermark ABST, and then how the minutes entered in the tool were used to generate a staffing plan.

Additionally, the documents provided for the assisted living facility's 61 residents lacked evidence the ABST addressed all 22 required ADLs for each resident.

The need to have all required ADLs included on the facility's ABST with the amount of staff time needed to provide care was discussed with Staff 1, Staff 3 (Vice President of Compliance), Staff 7, and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

1.Administrator created a new account for ABST on Oregon state website.

2.The community will be using the ABST provided on the Oregon state portal.

3.Administrator will update portal to be reflective of resident assessment upon move in, 30 and 90 days after move in, and then with significant change of condition.

4.Administrator and/or designee.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 25 and 26) demonstrated competency of skills in all assigned job duties within 30 days of hire, and 2 of 3 newly hired staff (#s 25 and 27) were trained in First Aid and abdominal thrust. Findings include, but are not limited to:

Training records were reviewed on 10/10/23 and revealed the following:

a. Staff 25 (CG), hired on 05/14/23, lacked documented evidence of competency within 30 days of hire in the following required topics:

* Changes in normal aging (completed 06/22/23); and

* Identification, documentation, and reporting changes of condition (completed 06/22/23).

b. Staff 26 (CG), hired 07/13/23, lacked documented evidence of competency within 30 days of hire in the following required topics:

* Role of service plans in providing individualized care (completed but not dated);

* Providing assistance with ADLs (completed but not dated);

* Changes associated with normal aging (completed on 10/03/23);

* Identification, documentation, and reporting changes of condition (completed but not dated); and

* General food safety, serving, and sanitation.

c. Additionally, there was no documented evidence Staff 25 had completed First Aid and abdominal thrust training within 30 days of hire or that Staff 27 (MT), hired 04/27/23, had completed abdominal thrust training.

On 10/11/23 at 9:58 am, Staff 5 (Business Office Assistant) confirmed the facility had identified they did not have an effective system for tracking training.

On 10/12/23, the need to ensure staff had documented evidence of competency demonstration within 30 days of hire and completion of First Aid and abdominal thrust training was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC). They acknowledged the findings.

1.Business Office Manager and/or designee to conduct employee file audit for staff 25, 26, and 27.

2.Training will be conducted for staff per OAR as needed per audit results. Business Office Manager will collaborate with Administrator, and Licensed Nurse for scheduling staff training per OAR.

3.Onboarding check list to include training per OAR. Business Office Manager and Licensed Nurse to review weekly for one month.

4.Business Office Manager, Administrator, and/or Licensed Nurse.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 23, 24, and 28) completed the required minimum 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 10/10/23.

There was no documented evidence Staff 23 (CG), hired 09/20/20, Staff 24 (MT), hired 07/10/19, and Staff 28 (CG), hired 08/02/21, had completed a minimum of 12 hours of annual in-service training based on hire dates relating to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training.

On 10/11/23 at 9:58 am, Staff 5 (Business Office Assistant) confirmed the facility had not been tracking the time spent on resident care training during the monthly All Staff meetings.  

On 10/12/23, the need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness), and Staff 8 (Assisted Living RCC). They acknowledged the findings.

1.Business Office Manager and/or designee to conduct employee file audit for annual trainings per OAR.

2.Annual training for direct care staff per OAR will be conducted for staff #23,24,28, and per audit results.  Business Office Manager will collaborate with Administrator and Licensed Nurse for scheduling staff annual training per OAR.

3.Onboarding check list to include training per OAR. Business Office Manager, Administrator and/or designee, Licensed Nurse to review weekly for one month

4.Administrator, Business Office Manager, Licensed Nurse and/or designee.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC) and document all required elements. Findings include, but are not limited to:

Fire and life safety records were reviewed on 10/10/23 at 9:20 am.

Fire drill documentation lacked documented evidence of fire drills occurring every other month at different times of day and lacked the following required elements:

* Escape route used;

* Evacuation time period needed;

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

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

During an interview on 10/10/23 at 9:30 am, Staff 3 (Maintenance Director) confirmed fire drills were not occurring every month and lacked required elements.

On 10/12/23, the need to conduct fire drills that included all required elements according to the OFC was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 (Assisted Living RCC). They acknowledged the findings.

1.  Fire drills  and Disaster 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. Implementation of consultant fire drill report fillable form.

3. Documentation of fire drills including

but not limited to C, D, G, E and disaster drills will be reviewed monthly during Administrator and Maintence  1:1 weekly meeting.

4. Maintence Director and/or designee.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 10/10/23 at 9:20 am.

There was no documented evidence of a written record of annual re-instruction to residents including content and residents attending, 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.

During an interview on 10/10/23 at 9:30 am, Staff 3 (Maintenance Director) confirmed a written record of annual re-instruction on fire and life procedures for residents was unable to be located.

The need to ensure residents were provided instruction as required by the OFC was discussed with Staff 1 (Assistant ED, RCC), Staff 3 (Vice President of Compliance), Staff 7 (Director of Health and Wellness) and Staff 8 (Assisted Living RCC) on 10/12/23. They acknowledged the findings.

1.Training for residents will be completed per OAR

2.Facility fire and life safety procedures will be added to the resident move in packet and kept in resident files.  

Documentation will be maintained by Maintenance staff or Administrator in regards to annual training of residents.

3.Weekly during 1:1 meeting between Administrator and Maintenance Staff.  

4.Administrator and/or Maintenance staff.

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

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

Refer to C252, C 260, C262, C 270, and C 280

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

Refer to C270.

Refer to C270

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. Findings include, but are not limited to:

The interior of the building was toured on 10/09/23 and 10/10/23. The following issues were noted:

On 10/09/23 and 10/10/23 an unlocked storage room on the second floor was observed to have multiple containers of toxic cleaning chemicals.

The need to ensure all toxic materials were maintained in a locked storage was discussed on 10/11/23 with Staff 2 (Vice President of Operations) and Staff 10 (Maintenance Director). They acknowledged the findings.

1. Toxic cleaning chemicals will be kept in a locked storage area.

2. Housekeeping will be in-serviced on toxic chemicals maintained in a locked storage unit.

3.  Maintenance Director and/or Administrator will monitor for compliance with OAR by conducting weekly audit for month.

4.Maintenance Director, Administrator, and/or designee.

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 03/18/24 and 03/19/24 showed the following areas in need of cleaning or repair:

* The carpet in the dining room and the first, second, and third-floor hallways had multiple dark stains of varying sizes;

* Areas of carpet buckling were observed throughout the dining room;  

* Large sections of carpet near the nurse's station were frayed and pulling apart;

* Multiple dark stains on the carpet were noted in the stairwells;

* Multiple walls, doors, and door frames in the facility had scrapes, dings, chips, or gouges;

* Multiple benches in the hallways, on second and third floors, had dark spots/stains of various sizes;

* The couch on the third floor had dark spots/stains on the cushions and armrests; and

* The majority of resident apartments on the second and third floors had multiple dark stains on the carpet, of varying sizes.

The areas in need of cleaning and/or repair were discussed with Staff 34 (ED) on 03/21/24. She acknowledged the findings.

Community needs to ask for an extension for this tag. Waiting to hear back what the process is for this, then we will finish the POC.

1.Community is undergoing remodal. This will include replacement of of carpet, repair of multiple walls and door frames to be free of scrapes, dings, chips or gouges.

Couch on 3rd floor will be cleaned and/or replaced.

2. Community undergoing remodal

3. Executive Director and Maintanence Director will review weekly during 1:1 meeting.

4. Executive Director and Maintance Director and/or designee.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and clothing. Findings include, but are not limited to:

The resident laundry room on the second floor was inspected on 10/11/23.

In an interview on 10/11/23 on the process of washing soiled resident laundry, Staff 23 (CG) stated caregivers rinsed soiled resident laundry in the "common sink" and the soiled resident laundry was washed in the residential washers with laundry detergent provided by the facility. Staff 23 stated the residential washers did not have any means to ensure a minimum rinse temperature of 140 degrees Fahrenheit, and their laundry detergent did not have a chemical disinfectant component.

The need to ensure soiled resident laundry was properly rinsed and disinfected was discussed with Staff 2 (Vice President of Operations) and Staff 10 (Maintenance Director) on 10/11/23. They acknowledged the findings.

1.Maintenance Director to conduct an audit of residential washers.

2.Maintenance Director collaborate with Regional Maintenance Director and Administrator on audit results. Resident washers will have a minimum temperature of 140-degree Fahrenheit or chemical disinfectant.

3.Weekly for 3 weeks

4.Maintenance Director, Administrator and/or Designee.

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

During a tour of the facility on 10/09/23 the following was observed:

* The door in the northwest stairwell that opened to the parking lot did not have an alarm; and

* The exit doors from the assisted living facility to the exterior of the building failed to have a working alarm or other acceptable system to alert staff when residents left the building.

On 10/11/23 and 10/12/23, the lack of alarms or other acceptable system on exit doors was discussed with Staff 2 (Vice President of Operations), Staff 10 (Maintenance Director) and Staff 3 (Vice President of Compliance). They acknowledged the findings.

1. Maintenance Director and/or Regional Maintenance Director will consult with a third-party vendor to obtain alarms on the door in the northwest stairwell and exit door from the assisted living.

2. Alarms will be in place for exit doors.

3.Alarms will be monitored weekly for three weeks after imputing and once a month thereafter.

4.Maintenance Director, Administrator, and/or designee.