Farmington Square Medford

Based on interview and record review, it was determined the facility failed to ensure all incidents and injuries of unknown cause were investigated to rule out abuse and reported to the local SPD when abuse was not reasonably ruled out for 1 of 3 sampled resident (#1) whose facility records were reviewed for incidents and injuries of unknown cause. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's Disease. Review of Resident 1's 06/29/22 through 09/25/22 progress notes and incident investigations, and interviews with staff, revealed the resident was identified to have a bruise to her abdomen on 08/05/22.   On 08/05/22, facility staff documented in an investigation related to the bruise, it was "unclear of where it occurred or when." The investigation indicated the resident was unable to state how s/he obtained the bruise and determined abuse was ruled out as "resident had gone to the hospital on 07/22/22." Documentation in the resident's facility record, indicated the resident returned from the hospital on 07/26/22, 10 days before the bruise was identified. The facility was instructed to report the injury of unknown cause to the local SPD on 07/28/22. Fax confirmation was provided to survey prior to exit. The need to reasonably rule out abuse related to injuries of unknown cause was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Wellness Director) on 07/28/22. They acknowledged the findings.

1. The Executive Director completed a self report regarding the incident for resident #1 and provided the survey team fax confimration of reporting. 2. The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Abuse Investigations & Reporting Policy, and the Incident/Accident Report Policy. The Executive Director will receive additional training on the Oregon Abuse Reporting Guide. 3. The Wellness Director and Executive Director will review and investigate Incident Reports daily following the Quality Assurance - Health Services Review Schedule. 4. The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored at least weekly to resolution and that interventions were re-evaluated to determine effectiveness for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. 1.  Resident 2 was admitted to the facility in 2020 with diagnoses including dementia. a. Resident 2's current service plan noted the resident was at risk for falls and directed staff to check the resident's room one time per shift for tripping hazards and to ensure walkways were clear. The resident was to be encouraged to use his/her walker for safety. Review of the progress notes dated 07/2022 through the time of the survey 09/26/22, temporary service plans dated 09/01/22 and 09/13/22 and incident reports reviewed between 07/2022 and 09/26/22 noted the resident experienced seven injury or non-injury falls. The temporary service plan dated 09/01/22 noted the resident was placed on hourly checks, staff were directed to offer assistance with transfers, offer assistance with ADL's, offer food and drink and ensure the room was clean and there were no tripping hazards. Resident 2 was noted to be found on the floor on 09/09/22 and 09/12/22 and there was no documented evidence the facility reviewed the service planned interventions to determine if they were in place at the time of the incidents and/or continued to be effective. Resident 2 was observed during the survey on 9/26/22 and 09/27/22 to walk independently and was cued repeatedly by staff to use his/her walker. Resident 2 was identified to be at risk for falls, had multiple interventions to reduce the potential for future falls and the investigations failed to review whether or not the interventions were in place to determine effectiveness. b.  Resident 2's current service plan noted the resident consumed regular textured food and liquids, was to be reminded of meal times, identified food likes and dislikes and had no history of weight loss or gain. Review of the facility weight records noted the following: 05/2022:  249 pounds; 06/2022:  251 pounds; 07/2022:  no weight documented; 08/2022:  212 pounds; 09/2022:  228 pounds; and 09/27/22: 230.6 pounds. Between 05/2022 and 08/2022 Resident 2 lost 37 pounds or 14.8% of his/her body weight.  Between 08/2022 and 09/2022 Resident 2 gained 16 pounds or 7.5% of his/her body weight. Resident 2's weight fluctuations resulted in significant changes of condition. Resident 2's progress notes dated 07/15/22 through 09/27/22 and assessment dated 07/19/22 noted the resident had experienced a decline in condition, changes to diuretic medications, hospice admission and had swelling in his/her right lower extremity. The resident was noted to have visibly "lost weight" and the resident's weights would be monitored. Resident 2 was observed during the survey on 09/27/22 to eat 100% of the breakfast meal which included a nutritional supplement and 100% of the lunch meal independently. In an interview on 09/27/22 at 2:00 pm, Staff 2 (RN) verified the resident had weight fluctuations, hospice had been notified and changes were made to his/her diuretic medication however there was no documented evidence of the interventions in the resident record. Resident 2 experienced changes of condition related to weight fluctuations. There was no documented evidence actions/interventions were determined regarding the resident's weight fluctuations. Resident 2's weights were reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Wellness Director) on 09/28/22 at 9:50 am. Staff acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's Disease. Review of the resident's 06/29/22 through 09/25/22 progress notes, temporary service plans, and home health RN notes, 09/01/22 through 09/25/22 MAR, 08/14/22 service plan and Service Plan Development form, and interviews with staff, revealed the following: A 07/22/22 hospital discharge summary indicated the resident had been hospitalized from 07/22/22 through 07/26/22 with a urinary tract infection. In an 08/23/22 RN quarterly assessment, the RN stated the resident visited the emergency department of the local hospital for a urinary tract infection again on 08/05/22. During an interview with Staff 19 (MT) and Staff 14 (CG) on 07/27/22 and 07/28/22, they reported the resident did not "bounce back" after the urinary tract infections. Prior to the illnesses, the resident had walked short distances with a walker, and was a one-person transfer for dressing and toileting. At the time of the survey, staff reported the resident required two staff for transfers for dressing, toileting and bed mobility, no longer walked with a walker, and used a wheelchair for mobility. There was no documentation the facility evaluated the resident following the significant decline in mobility, transfers, and ADLs, referred the resident to the RN, documented the change and updated the service plan. b. Documentation in the progress notes revealed the resident experienced the following short-term changes of condition for which the facility failed to determine what actions and interventions were needed for the resident, and/or did not monitor the conditions at least weekly through resolution: * COVID-19; * Urinary tract infection symptoms; * Skin-tear forearm; * Skin-tear upper right arm; * Skin tear right elbow; and * Bump on back of his/her head following a fall. The need to ensure residents were evaluated and referred to the RN following significant changes of condition and actions and interventions determined and documented, with monitoring at least weekly through resolution of the changes was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Wellness Director) on 09/28/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 08/2020 with diagnoses including Alzheimer's disease. Review of the resident's progress notes, dated 06/16/22 through 09/19/22 and 13 months of weight records revealed the resident experienced the following changes in condition: * 07/02/22-Weight loss of 7.9% total body weight in three months (from 04/01/22 through 07/01/22) which was a severe loss; * 07/05/22- Covid-19 diagnosis; * 07/09/22-Resident to resident altercation resulting in back pain; * 08/24/22- Injection to right eye; * 08/30/22-Lesion removed from left buttock; The facility lacked documented evidence Resident 3's significant weight loss was referred to the facility RN for assessment in a timely manner, interventions for the resident's Covid-19 diagnosis were shared with staff on each shift, and the resident to resident altercation resulting in back pain, injection to the right eye, and the lesion removed from his/her left buttock were monitored at least weekly, through resolution. The need to ensure significant changes of condition were referred to the RN, and short term changes of conditions had interventions determined, communicated to staff on each shift and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Wellness Director) on 09/28/22. They acknowledged the findings.

1. The Wellness Nurse completed a Change of Condition Assessment for Resident #1, #2, and #3 to identify current service plan and monitoring needs. 2.  The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Change of Condition (Short Term and Significant) policy. The Care Staff will receive additional training on the Stop and Watch Program for identifying and communicating a potential change of condition. 3.  The Executive Director, Wellness Director(s), and Wellness Nurse will review this area daily per the Quality Assurance - Clinical Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

2. Resident 2 was admitted to the facility in 2020 with diagnoses including dementia. Facility weight records noted the following: 05/2022:  249 pounds; 06/2022:  251 pounds; 07/2022:  no weight documented; 08/2022:  212 pounds; 09/2022:  228 pounds; and 09/27/22: 230.6 pounds. Between 05/2022 and 08/2022 Resident 2 lost 37 pounds or 14.8% of his/her body weight.  Between 08/2022 and 09/2022 Resident 2 gained 16 pounds or 7.5% of his/her body weight. Resident 2's weight fluctuations resulted in significant changes of condition. There was no documented evidence the facility RN completed an assessment including findings, resident status and interventions made as a result of the assessment. Refer to C270, example 1b.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's Disease. Review of the resident's 06/29/22 through 09/25/22 progress notes, 5/05/22 and 08/14/22 service plans, and interviews with staff revealed the resident experienced a significant decline in mobility and transfers following a urinary tract infection with hospital stay 07/22/22 through 07/26/22, and a urinary tract infection with a related visit to the emergency department of the local hospital on 08/05/22. There was no documented evidence the RN had assessed the resident's significant change of condition related to his/her ADLs and mobility. The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Wellness Director) on 09/28/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 08/2020 with diagnoses including Alzheimer's disease. Review of the resident's 09/2021 through 09/2022 weight records indicated Resident 3 lost 11.4 pounds between 04/01/22 and 07/01/22. This constituted a loss of 7.9% total body weight in three months and represented a significant change of condition. There was no documented evidence the facility RN completed a timely assessment of the weight loss which included findings, resident status, and interventions made as a result of the assessment. On 09/06/22. Staff 2 (RN) completed an assessment in regards to the resident's weight loss. In an 09/28/22 interview with Staff 1 (ED), and Staff 2, they confirmed the RN assessment was not completed timely. The need to ensure the facility RN conducted a timely assessment of Resident 3's severe weight loss was discussed with Staff 1, Staff 2 and Staff 3 (Wellness Director) on 09/28/22. They acknowledged the findings.

1.The Wellness Nurse completed a Change of Condition Assessment for Resident #1, #2, and #3 to identify current service plan and monitoring needs. All resident weights will be reviewed to determine the need for a Change of Condition assessment and interventions. 2.  The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Change of Condition and Weight Loss or Gain Policies. The Wellness Nurse will take a refresher course on the Role of the RN in Community Based Care. 3.  The Executive Director, Wellness Director(s), and Wellness Nurse will review this area daily per the Quality Assurance - Clinical Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 2020 with diagnoses including dementia. Physician orders dated 07/27/22 noted treatment orders for minor cuts/abrasions and skin tears. The current service plan dated 09/05/22 directed staff to change Resident 2's dressing every other day and to monitor for signs and symptoms of infection. During an observation on 09/27/22 at 10:00 am, Staff 17 (MT) administered wound care to Resident 2's left elbow.  Staff 17 removed a soiled Band-Aid, applied wound cleanser, gauze and a tegaderm dressing to the resident's left elbow. In interviews with Staff 17 and Staff 21 (MT) they stated they changed the resident's dressing approximately every other day or as needed. Resident 2 was observed to receive a treatment, the record noted treatment instructions and staff acknowledged dressing changes had occurred. There was no documented evidence Resident 2's treatments were being documented. The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Wellness Director) on 09/28/22.  Staff acknowledged the lack of treatment documentation.

1. All Treatment Administration Records will be reviewed to ensure accurate records. 2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Orders Policy and Procedure. 3.  The Wellness Director(s) and Wellness Nurse will review daily per the Quality Assurance - Health Services and Clinical Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

4.  A tour of the environment in Cottage B, conducted on 09/27/22, revealed the following areas were in need of cleaning and/or repair: Laundry room: *The wall and flooring on the dirty side of the laundry room had a build up of dirt and debris and areas on the wall where paint had chipped away creating a non-cleanable surface; *The countertop on the clean side of the laundry room had missing laminate approximately 3 inches long by 2 inches wide creating a non-cleanable surface; *There was brown/gray matter along the top and bottom of the flushing rim sink. The laundry room was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Wellness Director) on 09/28/22 at 9:50 am.  Staff 1 stated she would ensure the laundry rooms were on the cleaning schedule.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: 1. A tour of the environment in Cottage D, conducted on 09/27/22, revealed the following areas were in need of cleaning and/or repair: a. Laundry room: * The sprinkler valve pipe system and hot water heater were coated with a thick layer of gray matter; * The vinyl floor in the middle of the room had an approximately 12 x 18 inch area where the vinyl flooring had been ripped and partially removed; there were gaps between the seams of the flooring where black matter had accumulated; * There was a build-up of dirt and debris on the floor throughout the laundry room and black matter at the base of the water heater; * An 8-10 inch hole in the drywall was observed below the utility sink and multiple smaller holes in the drywall behind the washer and dryer; * There was extensive peeling of the paint on the inside of the lid to the washing machine, and a build-up of brown matter on the inside and outside of the lid; and * There were chips in the laminate countertops and cabinets. b. Shower room: * An approximately 10 inch slit through the drywall was observed above the sink; * Shower tiles against the back of the stall had missing grout; and * The light fixture on the ceiling was missing two screws and was hanging slightly down. c. Room D18 had multiple stains in the carpet and the overhead light did not work. d. An upholstered chair by the entrance had a brown stain on the seat; two chairs in the back hallway had darkened areas on armrests. The need to maintain the environment clean and in good repair was discussed during a tour of the environment with Staff 1 (ED) on 09/28/22. She acknowledged the findings. 2. Observations of building A the on 09/26/22 and 09/28/22 showed the following areas in need of cleaning or repair: a. Laundry Room: * The mop sink had thick black debris along the bottom and base. b. Shower room: * There were tiles missing along the base of the bathtub; and *  Flooring, was discolored with a black matter buildup on the tiles and grout. 3. Observations of building C on 09/28/22 showed the following areas in need of cleaning or repair: * Laminate flooring along the left wall in the laundry room was cracked where it met the wall leaving an uncleanable surface and had black debris along the base of the dryer and hot water tank. The need to ensure the facility was maintained clean and in good repair was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 09/28/22. They acknowledged the findings.

1. An internal building inspection will be completed with identified concerns addressed by cleaning or repairing the items. 2. The Maintenance Director and Executive Director will receive additional training on the Quarterly Building Inspection. 3. The Maintenance Director and Executive Director will review quarterly per the Quality Assurance - Maintenance Review Schedule. 4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231 and C513.

Refer to C231 and C513

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 9, 13, 22 and 23) completed all pre-service orientation topics, 3 of 4 newly hired staff (#s 9, 22 and 23) completed pre-service dementia training, 6 of 6 staff (#s 9, 11, 12, 13, 22 and 23) completed infectious disease prevention training, 1 of 4 newly hired staff (# 9) demonstrated competency in all assigned job duties within 30 days of hire, and 2 of 2 long-term staff (#s 3 and 20) completed a total of 16 hours of annual training. Findings include, but are not limited to: Staff training records were reviewed on 08/27/22. The following was identified: 1. There was no documented evidence Staff 9 (CG), Staff 13 (CG), Staff 22 (MT), or Staff 23 (CG), hired 08/16/22, 06/26/22, 07/06/22, and 07/01/22, respectively, completed one or more of the following pre-service orientation topics: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; and * Signed job description. 2. There was no documented evidence Staff 9, Staff 22 and Staff 23 completed all required pre-service dementia training within 30 days of hire. 3. There was no documented evidence Staff 9, 11, 12, 13, 22 and 23 completed the infectious disease prevention training. 4. There was no documented evidence Staff 9 demonstrated competency within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * 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; and * MT competency training. 5. There was no documented evidence Staff 3 (Wellness Director) or Staff 20 (MT), hired 04/09/15 and 05/20/15, respectfully, completed the required 16 hours of annual in-service training, to include at least six hours of dementia care training. The need for new and long-term staff to complete all required training in the specified time frames was discussed with Staff 1 (ED) and Staff 4 (Business Office Manager) on 09/27/22. They acknowledged the findings.

1. All employee records will be reviewed to ensure documented completion of pre-service orientation, pre-service dementia training, competency demonstration, and annual continuing education are completed. 2. The Executive Director and Business Office Director will receive additional training on General & Memory Care Orientation, Training Checklists, and skills Observations. 3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule. 4. The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270, C280 and C315.

Refer to C270, C280, and C315

Based on observation and interview, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident. Findings include, but are not limited to: On entrance to Cottage A of the memory care community on 09/26/22 there was a monthly activity calendar posted for scheduled activities to be conducted daily with the residents. Frequent observations of the memory care unit on day shift and swing shift between 09/26/22 and 09/28/22 showed a lack of scheduled or unscheduled activities provided for the residents. Approximately 6-8 residents were gathered in the common areas at one time throughout the day. The residents were observed sitting in the common areas both awake and asleep, additional residents were observed wandering the halls back and forth with minimal interaction by staff and the remaining residents were in their apartments asleep. A movie or television show was running on the TV in the two common areas throughout the day. Staff interviews conducted between 09/26/22 and 09/28/22 revealed the person assigned to activities was in cottage A just one to two days a week. The care staff were generally aware they should conduct activities with the residents but indicated there was not enough time. During the re-licensure survey conducted 09/26/22 through 09/28/22, there was a lack of scheduled and unscheduled activities provided for residents living in Cottage A of the memory care community. The need to ensure the facility consistently provided meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the residents was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Wellness Director) on 09/28/22. The staff acknowledged the findings.

1. An Activity Assessment will be completed for all residents and the individualized plan will be updated in the resident service plan. 2.  The Executive Director and Life Enrichment Director will receive additional training on the Activities Guide. 3.  The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

The findings of the re-licensure survey, conducted 9/26/22 through 9/28/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 09/28/22, conducted 05/01/23 through 05/02/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.