Settler's Park Memory Care Community

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:

During the change of ownership survey, conducted 08/26/24 through 08/29/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope and number of citations.

Refer to deficiencies in the report.

OAR 411-054-0025 (1) Facility Administration: Operation

(1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents related to the MCC entry door for 1 of 1 sampled resident (#2) who was an elopement risk. Findings include, but are not limited to:

Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status and was identified in the acuity interview as having multiple elopement attempts.

The resident's 06/29/24 service plan, temporary service plans (TSPs), incident reports, and 06/29/24 through 08/26/24 observation notes and 24-hour communication reports were reviewed. Observations were made, and staff and the resident were interviewed. The following was identified:

* On 08/26/24 when this surveyor entered the MCC unit, the MCC entrance door was observed to take 18-20 seconds to close.

* On 08/26/24 at 3:10 pm, Staff 16 (Care Partner) confirmed the MCC door’s delayed closure, and stated staff had been trained to wait by the door until it closed whenever Resident 2 was observed near the door.

The resident’s record identified exit-seeking behavior with multiple elopement attempts and that Resident 2 had incidents of leaving the locked and secure MCC unit through the MCC entrance door behind someone else entering or exiting the MCC unit.

On 08/28/24, Staff 1 (Memory Care Administrator) and Staff 2 (Assisted Living Administrator) stated they were aware the MCC entrance door’s delayed closure, and that Resident 2 had been found outside of the locked and secure MCC unit because of this.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents related to the MCC entry door was discussed with Staff 1, Staff 2, Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule out abuse and report incidents to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 2 of 2 sampled residents (#s 1 and 2) with resident-to-resident altercations or unwitnessed injury falls. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and was identified in the acuity interview as a high fall risk.

Resident 1's observation notes, dated 05/26/24 through 08/26/24, were reviewed and the following was identified:

* Unwitnessed fall with “hip strain, right contusion of the left shoulder, acute bilateral ankle pain.”

During an interview at 2:45 pm on 08/27/24, Staff 3 (Wellness Director/RN) confirmed no investigation had been completed for the unwitnessed fall.

The facility was asked to report the unwitnessed injury fall to the local SPD office prior to survey exit. Confirmation was received on 08/29/24.

The need to investigate injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

2. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status. The resident was identified to have physical and verbal aggression towards other residents and was an elopement risk.

The resident’s observation notes, temporary service plans, incident reports, and 24-hour communication reports dated 06/29/24 through 08/26/24, were reviewed, and facility staff were interviewed. The following was identified:

a. There was no documented evidence the facility completed an investigation with all required components for the following incidents:

* 07/13/24 –Resident 2 was observed to stand in another resident’s doorway and when approached, the resident stated “[Resident 2] grabbed [his/her] shirt and was shaking [him/her] angrily”;
* 07/23/24 – Unwitnessed injury fall;
* 08/13/24 – An unsampled resident reported to staff that “[Resident 2] grabbed [his/her] arm” and “it hurt”; and
* 08/21/24 – Staff reported that Resident 2 attempted to “force” his/her way into another resident’s apartment.

b. There was no documented evidence the facility reported the incident on 08/21/24 to local SPD.

On 08/27/24 at 3:48 pm, Staff 1 (Memory Care Administrator) and Staff 2 (Assisted Living Administrator) confirmed no investigation had been completed for any of the above events and the event on 08/21/24 was not reported to local SPD.

The facility was asked to report the resident-to-resident altercation to the local SPD office prior to survey exit. Confirmation was received on 08/29/24.

The need to investigate incidents of abuse or suspected abuse and injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1, Staff 2, Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

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

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident 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 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status.

The resident's move-in evaluation documentation dated 06/27/24 and 06/29/24 was reviewed and lacked the following required elements:

* Customary routines including sleeping, eating, and bathing;
* Interests, hobbies, social, and leisure activities;
* Mental health, including treatment and effective non-drug interventions;
* Pain including pharmaceutical and nonpharmaceutical interventions and how a person expresses pain or discomfort; and
* Nutritional habits, fluid preferences, and weight if indicated.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

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

(1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.(a) Resident evaluations must be:(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and(B) Performed at least quarterly, to correspond with the quarterly service plan updates.(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.(E) Documented, dated, and indicate who was involved in the evaluation process.(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location.(c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.(3) EVALUATION REQUIREMENTS AT MOVE-IN.(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.(c) The initial evaluation must contain the elements specified in section (5) of this rule, and address sufficient information to develop an initial service plan to meet the resident's needs.(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.(4) QUARTERLY EVALUATION REQUIREMENTS.(a) Resident evaluations must be performed quarterly after the resident moves into the facility.(b) The quarterly evaluation is the basis of the resident's quarterly service plan.(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.(5) The resident evaluation must address the following elements:(a) Resident routines and preferences including:(A) Customary routines, such as those related to sleeping, eating, and bathing;(B) Interests, hobbies, and social and leisure activities;(C) Spiritual and cultural preferences and traditions; and(D) Additional elements as listed in 411-054-0027(2).(b) Physical health status including:(A) List of current diagnoses;(B) List of medications and PRN use;(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and(D) Vital signs if indicated by diagnoses, health problems, or medications.(c) Mental health issues including:(A) Presence of depression, thought disorders, or behavioral or mood problems;(B) History of treatment; and(C) Effective non drug interventions.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) Activities of daily living including:(A) Toileting, bowel, and bladder management;(B) Dressing, grooming, bathing, and personal hygiene;(C) Mobility ambulation, transfers, and assistive devices; and(D) Eating, dental status, and assistive devices.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) Review of risk indicators including:(A) Fall risk or history;(B) Emergency evacuation ability;(C) Complex medication regimen;(D) History of dehydration or unexplained weight loss or gain;(E) Recent losses;(F) Unsuccessful prior placements;(G) Elopement risk or history;(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.(o) Environmental factors that impact the resident's behavior including, but not limited to:(A) Noise.(B) Lighting.(C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status.

The resident's current service plan, dated 06/29/24, and temporary service plans dated 06/29/24 through 08/26/24, were reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* Personal hygiene and grooming;
* Oral care;
* Bathing as needed every day, verbal prompting and cueing;
* Laundry assistance needed;
* Nighttime preparation and care;
* Elopement interventions including the door in-between the MC and AL medication rooms to remain closed;
* Pain management including how the resident expressed pain; and
* Behavior management including clear instruction to staff and 1:1 direct care to manage behaviors.

The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

2. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and depression.

The resident’s service plan, dated 06/28/24, and 05/21/24 through 08/26/24 observation notes and temporary service plans (TSPs) were reviewed, observations of the resident were made, and interviews were conducted. The service plan was not reflective and/or did not provide clear direction regarding the delivery of services in the following areas:

* Assistive devices including walker and wheelchair;
* Ambulation status;
* Transfer status;
* Dentition status;
* Shower assistance;
* Meal reminders;
* Presence of catheter;
* Dressing assistance;
* Pain; and
* Behavior interventions.

The need to ensure service plans were reflective of the resident’s needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

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

(1) If the resident has a Person-Centered Service Plan pursuant to 411-004-0030, the facility must incorporate all elements identified in the person-centered service plan into the resident's service plan.(2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.(a) The service plan must be completed:(A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and(B) Following quarterly evaluations.(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.(d) Changes and entries made to the service plan must be dated and initialed.(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.(g) The facility administrator is responsible for ensuring the implementation of services.(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.(b) The initial service plan must be reviewed within 30-days of move- in to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.(c) Staff must document and date adjustments or changes as applicable.(4) QUARTERLY SERVICE PLAN REQUIREMENTS.(a) Service plans must be completed quarterly after the resident moves into the facility.(b) The quarterly evaluation is the basis of the resident's quarterly service plan.(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift with weekly progress noted until the condition resolved for 2 of 2 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and depression.

The resident’s service plan, dated 06/28/24, 05/21/24 through 08/26/24 observation notes and temporary service plans (TSPs), and “MC Monthly VS [vital signs] and Weights Monitoring” logs, dated April 2024 through August 2024, were reviewed. The following was identified:

a. There was no documented evidence the facility determined and documented actions or interventions for the following short-term changes of condition:

* 06/2024 – Nine-pound weight loss in one month;
* 06/02/24 – Chafing and redness to buttocks;
* 07/03/24 – “Red spots” in brief; and
* 07/08/24 – Loose stools and pain.

b. There was no documented evidence resident-specific instructions or interventions were communicated to staff on each shift for the following changes of condition:

* 05/21/24 – Foley catheter placement;
* 06/2024 – Nine-pound weight loss in one month;
* 06/20/24 – Chafing and redness to buttocks;
* 07/02/24 – Foul odor in catheter bag;
* 07/03/24 – “Red spots” in brief;
* 07/08/24 – Loose stools and pain;
* 07/11/24 – IV placement for antibiotics;
* 08/01/24 – “Open” blister on right shin and blister on left shin;
* 08/09/24 – Witnessed fall;
* 08/24/24 – Unwitnessed fall; and
* 08/25/24 – Unwitnessed fall.

c. There was no documented evidence of weekly progress noted to resolution for the following short-term changes of condition:

* 06/2024 – Nine-pound weight loss in one month;
* 06/20/24 – Chafing and redness to buttocks;
* 07/03/24 – “Red spots” in brief;
* 07/05/24 – Urinary tract infection;
* 08/01/24 – “Open” blister on right shin and blister on left shin; and
* 08/09/24 – Witnessed fall.

The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift, and weekly progress was noted until resolution for short term changes of condition was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

2. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status.

The resident's 06/29/24 service plan, temporary service plans (TSPs), incident reports, current physician orders, and 06/29/24 through 08/26/24 observation notes and 24-hour communication reports were reviewed. Observations were made, and staff and the resident were interviewed. The following was identified:

There was no documented evidence resident-specific actions or interventions were determined for short-term changes of condition, the actions or interventions were communicated on all shifts, and/or changes were monitored through resolution, with progress noted at least weekly, for the following:

* 07/01/24 – Exit-seeking, elopement risk, verbally aggressive behavior;
* 07/01/24 – Emergency room and medication change;
* 07/04/24 – Skin on top of right foot redness;
* 07/10/24 – Behavioral disturbances and communication with doctor;
* 07/12/24 – Document behaviors each shift;
* 07/13/24 – Resident-to-resident altercation;
* 07/13/24 – Medication change;
* 07/14/24 – Resident attempted to exit memory care unit through the MC main entrance;
* 07/16/24 – Resident was found outside of the locked and secure MC unit in the assisted living facility;
* 07/17/24 – Medication change;
* 07/19/24 – Medication change;
* 07/23/24 – Unwitnessed injury fall;
* 07/24/24 – Medication change;
* 07/28/24 – Multiple attempts to elope through memory care entrance;
* 07/30/24 – Extra dose of medication given;
* 08/01/24 – Medication change;
* 08/02/24 – Indecent exposure;
* 08/13/24 – Resident-to-resident altercation;
* 08/14/24 – Medication change;
* 08/18/24 – Resident "forced" the main MC door open;
* 08/20/24 – Resident "forced" the main MC door open and “was able to get out”;
* 08/21/24 – Resident to resident altercation; and
* 08/23/24 – Psychotropic medication held due to signs of sedation.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored weekly through resolution was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

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

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

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

Resident 1 was admitted to the facility with diagnoses including dementia.

The resident’s 05/21/24 through 08/26/24 observation notes were reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified:

Review of observation notes indicated the resident had an indwelling Foley catheter placed on 05/21/24. The resident was observed with the catheter in place at 9:45 am on 08/27/24. The new catheter constituted a significant change of condition for which an RN assessment was required. During an interview at 2:20 pm on 08/27/24, Staff 3 (Wellness Director/RN) stated there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure a timely RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

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

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for PRN medications were included on the MAR for 1 of 1 sampled resident (#1) who had PRN pain medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility with diagnoses including dementia.

The resident's 08/01/24 to 08/26/24 MAR and current physician orders were reviewed and revealed the following:

The following prescribed and administered PRN medications lacked resident-specific parameters or instructions for unlicensed staff, including which medication to administer first, second, or third:

* Acetaminophen (for pain);
* Phenazopyridine (for pain); and
* Tramadol (for pain).

The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, nonpharmacological interventions were tried with ineffective results for 2 of 2 sampled residents (#s 1 and 2) who had orders for PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status.

The resident's 08/01/24 to 08/26/24 MAR, observation notes dated 06/29/24 through 08/26/24, and current physician orders were reviewed. The following was identified:

The resident had an order for lorazepam, one tablet by mouth every eight hours as needed for anxiety. The MAR indicated staff administered the PRN medication on two occasions from 08/01/24 to 08/26/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the medication.

On 08/28/24 at 9:41 am, Staff 16 (MT) confirmed staff would administer the resident’s PRN lorazepam before attempting a non-drug intervention.

The need to ensure documentation that staff administered PRN psychotropic medications only after attempting nonpharmacological interventions with ineffective results was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

2. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia.

The resident’s 08/01/24 through 08/26/24 MAR, observation notes dated 05/21/24 through 08/26/24, and current physician orders were reviewed. The following was identified:

The resident had an order for hydroxyzine, one tablet by mouth four times daily as needed for anxiety. The MAR indicated staff administered the medication on five occasions between 08/01/24 and 08/26/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the medication.

The need to ensure documentation that staff administered PRN psychotropic medications only after attempting nonpharmacological interventions with ineffective results was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements that staff were providing to each resident in their acuity-based staffing tool (ABST) for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

The resident's ABST, last updated 05/21/24, current service plan dated 06/28/24, and temporary service plans dated 05/21/24 to 08/26/24 were reviewed. The following was identified:

The resident's ABST failed to capture adequate staff time for the following resident needs:

* Non-drug interventions for behaviors;
* Cueing or redirecting due to cognitive impairment or dementia;
* Escorting to meals;
* Transferring in or out of a bed or a chair including need for two staff; and
* Dressing and undressing.

The need to ensure care time and care elements that staff provided to residents were accurately captured on the ABST was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2024 with diagnoses including dementia and altered mental status.

The resident's ABST, last updated 08/05/24, current service plan dated 06/29/24, and temporary service plans and observation notes dated 06/29/24 to 08/26/24 were reviewed. The following was identified:

The resident's ABST failed to capture adequate staff time for the following resident needs:

* Personal hygiene such as shaving and mouth care;
* Monitoring physical conditions and symptoms;
* Leisure activities;
* Non-drug interventions for behaviors;
* Providing treatments;
* Bathing; and
* Dressing and undressing.

The need to ensure care time and care elements that staff provided to residents were accurately captured on the ABST was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR 411-054-0037 (1)(2)(a)(c) Acuity Based Staffing Tool: Development

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall:
(a) Select and implement the Department?s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule.
(b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average.
(c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents.
(d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1).
(e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule.
(f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.
(g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident?s legal representative, or the Long-Term Care Ombudsman.

(2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements:
(A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule.
(B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element.
(C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident.
(D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day.
(E) Identify the date the resident?s ABST evaluation was last completed.
(F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to develop and maintain an updated posted staffing plan based on the results of an acuity-based staffing tool (ABST) and failed to consistently staff to meet or exceed the staffing plan 24 hours a day, seven days a week. Findings include, but are not limited to:

The facility’s ABST was reviewed with Staff 1 (Memory Care Administrator) and Staff 2 (Administrator) at 11:00 am on 08/28/24. The following was identified:

a. A facility staffing plan was posted in the MCC; however, Staff 1 stated the posted staffing plan was outdated and from the prior owner of the facility.

b. The staffing plan determined by the facility’s ABST was as follows:

* Day shift – Five direct care staff;
* Evening Shift – Four direct care staff; and
* Night Shift – Two direct care staff.

Review of the 08/01/24 through 08/26/24 facility schedule indicated the facility was consistently staffing the MCC as follows:

* Day shift – Three direct care staff;
* Evening shift – Three direct care staff; and
* Night shift – Two direct care staff.

Staff 1 confirmed at 11:00 am on 08/28/24 the facility was not staffing to the levels determined by the ABST.

The need to use an ABST to develop and routinely update the facility’s posted staffing plan and to consistently staff to meet or exceed the staffing plan was discussed with Staff 1, Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of Updates/Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident?s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility?s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility?s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility?s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire and to keep a written record of fire safety training, including content of the training sessions and the residents attending as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 08/27/24, Staff 5 (Maintenance Director) was asked to explain the facility's process and to provide documentation for instructing residents in fire and life safety procedures upon admission and annually. Staff 5 stated there was no system or documentation in place since the facility changed ownership in 02/2024.

The need to instruct residents in fire and life safety procedures within 24 hours of admission and re-instruct at least annually, and to keep a written record of the content of the training sessions and the residents attending was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

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

(5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

This Rule is not met as evidenced by:

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

The facility was toured on 08/26/24 at 3:08 pm. The following was identified:

* Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, vents, ledges, and baseboards;
* The chairs in the dining room had gouges of wood missing from the frames and stains on the fabric;
* The couch in the television room had peeling vinyl on the seat and arms, rendering it uncleanable;
* Several light fixtures in the halls and common areas were not functioning;
* The dining room and television room flooring was scratched and gouged; and
* The baseboard and the door frame in the bathroom of Room 7 was missing, exposing unfinished wall material.

The building was toured with Staff 1 (Memory Care Administrator) and Staff 5 (Maintenance Director) on 08/28/24 and the areas needing cleaning and repair were reviewed. They acknowledged the findings.

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

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locking mechanism on shared bathroom doors for residents who shared a room and were not bedbound. Findings include, but are not limited to:

During the acuity interview on 08/26/24 at 2:09 pm, six unsampled residents were identified as sharing a room, including one shared bathroom.

On 08/27/24 at 9:21 am, Staff 11 (MT) stated none of the resident rooms had a locking mechanism for the shared bathroom door, including those rooms with two residents. Observations of resident units on 08/27/24 confirmed the shared bathrooms lacked a locking mechanism to ensure privacy in resident units.

On 08/28/24 at 11:00 pm, Staff 1 (Memory Care Administrator) and Staff 3 (Assisted Living Administrator) confirmed none of the resident rooms had a locking mechanism for the shared bathroom door and multiple rooms had the capacity to be shared.

The need to ensure privacy and dignity related to shared resident units and the capacity to lock bathrooms was discussed with Staff 1, Staff 2, Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities:
(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the outdoor courtyard was physically accessible to all residents. Findings include, but are not limited to:

On 08/26/24 at 3:51 pm, the memory care was identified to have three doors that provided access to the courtyard. The threshold in each doorway had a transition to ground level ranging from one half inch to two inches that created inaccessibility for residents who wanted to access the courtyard independently.

On 08/28/24 at 9:34 am, Staff 2 (Assisted Living Administrator) and Staff 11 (MT) stated there were several residents who ambulated independently with the use of an assistive device and who were unable and/or had difficulty accessing the courtyard due to the thresholds.

The need to ensure residents had physical accessibility to the courtyard was discussed with Staff 1 (Memory Care Administrator), Staff 2, Staff 3 (Wellness Director/RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(b) The setting is physically accessible to an individual.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their room. Findings include, but are not limited to:

Resident 2’s care plan, dated 06/29/24, listed the resident’s ability to use a key independently as “not applicable”.

On 08/27/24 at 9:21 am, Staff 11 (MT) stated there were a few residents who had keys and were able to lock and unlock their room independently.

On 08/28/24 at 11:00 am, Staff 1 (Memory Care Administrator) and Staff 2 (Assisted Living Administrator) confirmed residents were not issued a key to their room unless requested and were able to use independently.

The need to ensure residents were provided a key to their room was discussed with Staff 1, Staff 2, Staff 3 (Wellness Director/RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

This Rule is not met as evidenced by:

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

Refer to C150, C160, C231, C361, C363, C422, and C513.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 12 and 15) completed all preservice orientation training and 2 of 2 newly hired staff (#s 12 and 15) demonstrated satisfactory performance in any duty they were assigned within the first 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 2 (Assisted Living Administrator) at 9:45 am on 08/28/24. The following was identified:

a. There was no documented evidence Staff 12 (MT), hired 02/26/24, and Staff 15 (Care Partner), hired 05/23/24, completed required preservice orientation training prior to beginning job duties in one or more of the following:

* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Fire safety and emergency procedures;
* Infectious disease prevention;
* Home and community-based services; and
* Preservice dementia training.

b. There was no documented evidence Staff 12 and Staff 15 demonstrated satisfactory performance in assigned job duties within 30 days of hire in one or more of the following areas:

* Role of service plans;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identifying, documentation, and reporting changes of condition;
* Conditions that require assessment, treatment, observation, and reporting;
* General food safety, serving, and sanitation; and
* Medication and treatment administration.

At 9:45 am on 08/28/24, survey requested Staff 12 complete medication and treatment administration demonstration prior to administering medications and treatments, and confirmation was received prior to survey exit.

The need to ensure staff completed all preservice orientation training prior to beginning job duties and staff demonstrated competency in any duty they were assigned within the first 30 days of hire was discussed with Staff 1 (Memory Care Administrator), Staff 2, Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

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

(1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

This Rule is not met as evidenced by:

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

Refer to C252, C260, C270, C280, C310, and C330.

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

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's care plan for 2 of 2 residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Residents 1 and 2's current service plans were reviewed during survey. Each of the service plans lacked information and staff instruction related to individualized nutrition and hydration status and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities and to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and service plans were reviewed.

The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified:

* There was no documented evidence an activity evaluation or individualized activity plan had been completed for either resident.

During an interview at 3:35 pm on 08/27/24, Staff 6 (Memory Care Coordinator) confirmed the facility had not completed an activity evaluation or activity plan for either sampled resident.

The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR 411-057-0160(2d) Activities

(d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of their rooms at any time for multiple sampled and unsampled residents. Findings include, but are not limited to:

During the change of ownership survey, conducted from 08/26/24 to 08/29/24, observations of resident rooms revealed multiple rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Multiple unsampled residents and sampled residents’ family members were observed approaching staff and/or waiting to be let into their respective rooms.

During an interview on 08/27/24 at 10:30 am, Staff 1 (Memory Care Administrator) stated resident room doors were locked because of one resident who wandered and tried to enter other residents’ rooms.

The need to ensure residents were not locked outside of their rooms at any time was discussed with Staff 1, Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

OAR 411-057-0170(9) Resident Rooms

(9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 07/12/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 07/12/22, conducted 10/03/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the second revisit to the kitchen inspection of 07/12/22, conducted 12/13/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facilities kitchen, food storage areas, food preparation, and food service on 07/12/22 revealed:* Splatters, spills, debris, and drips noted: - Surfaces an underneath storage shelves, cabinets, and drawers throughout the kitchen; - Metal storage shelves throughout the kitchen and walk in refrigerator; - Walls throughout the kitchen; - Floors and drains; - The vents, outer surface, and underneath the ice machine; - The dishwashing area walls, floors, and equipment; - Both sides and the interior of the range, grill, and oven; - The range hood; - Food storage bins; - Behind and underneath appliances; - The surface and underneath the tray line steam table; - The plate warmer; - Food preparation counters; - Interior of the microwave; - The stand mixers; - Garbage cans and lids; - The mop bucket storage area; and - A radio on the counter by the stand mixer.* The walk in freezer had a leak creating a build up of ice build from the ceiling to the floor.* Food was stored on the floor of the freezer.* Multiple dented cans of food were noted in they dry storage area;* Bagged food items were stored on the floor of the dry storage area; and* A Styrofoam cup was left in a bag of rice.* Dust and debris noted on cages of three fans blowing onto the tray line, preparation areas, and into the dish washing area.* Undated food items and food items with dates older than seven days were noted in the refrigerators.* The back entrance to the kitchen was left open allowing the entrance of flies and pests. * The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million.* Staff were observed to not change gloves between tasks or sanitize hand upon entering the kitchen. * Staff in the kitchen did not have hair restrained; and * Caregiving staff assisting with meal service and delivery were not using aprons.A box of frozen Halibut fillets was observed to be left on the kitchen counter at 8:45 am. It was still on the counter at 9:15 am. Dietary staff stated it was to be used for lunch, and they were waiting to get the number of fillets needed. The need to thaw items on the lowest shelf in the refrigerator or under cold running water was explained. Staff acknowledged the information. The Halibut was not moved to the refrigerator or under cold running water. Staff 1 (Executive Director) was requested to intervene. The fillets were still frozen. b. Observations of the Memory Care food storage area on 07/12/22 revealed:* Spills, splatters and debris in the reach-in refrigerator;* The refrigerator lacked a thermometer; and* Cupboards, drawers, and handles were sticky to the touch with spills and splatters. The Surveyor and Staff 1 toured the kitchens, and the areas in need of cleaning and repair were reviewed. He acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the facilities kitchen, food storage areas, food preparation, and food service on 10/03/22 revealed:* Splatters, spills, debris, and drips noted: - Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen; - Metal storage shelves throughout the kitchen and walk in refrigerator; - Racks in walk in refrigerator; - Cart used for food delivery; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Drains; - The outer surface and underneath the ice machine; - Behind and beside the range; - Interior of the microwave; - The stand mixers; and - Garbage cans and lids;* The walk in freezer had a leak creating a build up of ice from the ceiling to the floor.* Dented can noted in they dry storage area;* A scoop left in the bin of sugar.* Dust and debris noted on cage of fan blowing into the dish washing area.* Undated food items noted in the refrigerator.* Staff were observed to not change gloves between clean and dirty tasks or sanitize hands upon entering the kitchen. * Staff in the kitchen did not have hair and beards restrained.* The reach in refrigerator in the MCC unit did not have a thermometer. The Surveyor and Staff 2 (Dietary Manager) toured the kitchen, and the areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C240.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 240.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C240.

The findings of the re-licensure survey conducted 04/12/21 through 04/14/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey on 4/14/21, conducted 8/17/21 through 8/18/21, 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.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 04/14/21, conducted on 02/14/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services.

Based on observations and interviews, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Failure to implement recommendations placed residents at risk for exposure to the COVID-19 virus. Findings include, but are not limited to:Between the dates of 2/16/21 and 2/18/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:* Staff 3 (Memory Care Director) stated the MCC staff were self-screening including temperatures prior to reporting to work;* Staff 3 stated some staff may be taking their eye protection home rather than utilizing the storage containers provided for them; and* Some MCC staff were observed wearing their facemask under their nose, would readjust over the nose without hand hygiene.The areas were reviewed with Staff 1 (Executive Director) and the need for a designated screener, appropriate facemask donning and storage of PPE was discussed during the survey.

Based on observations and interviews, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Failure to implement recommendations placed residents at risk for exposure to the COVID-19 virus. This is a repeat citation. Findings include, but are not limited to:During the pandemic, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:* Staff observed not properly wearing face shields and touching PPE without practicing hand hygiene; and* Eye protection in the PPE storage area was not stored in the designated area.On 8/18/21, the following guidance was provided to Staff 15 (Executive Director):* Educate staff on the importance of wearing PPE properly while in the facility;* Educate staff on the need to practice hand hygiene every time they touched or adjust their PPE; and* Educate staff on proper storing of disinfected reusable eye protection.The need to implement infection control guidance to help minimize resident's exposure to COVID-19 was reviewed with Staff 15 during the survey. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to thoroughly investigate incidents that included all required components including a description of the event, person present and follow up action in order to reasonably conclude the incident was not the result of suspected abuse and failed to report to the local SPD office for 1 of 1 sampled resident (#1) who had an unwitnessed incident resulting in a hip fracture. Findings include but are not limited to:Resident 1 was admitted to the facility in 6/2017 with diagnoses including dementia.An investigation dated 12/13/20 at 4:00 am, noted the resident was found on the floor in the "common area." The incident was unwitnessed and the resident was unable to describe the event prior to being found on the floor. The resident was sent out to the hospital where s/he was diagnosed with a hip fracture.The facility failed to document all the required components of the investigation to reasonable conclude that abuse was ruled out. It was not evident the incident was reported to the local SPD.In interview on 4/14/21 Staff 1 (Executive Director) indicated she was unable to recall if the incident was reported and stated it should have been due to the nature of the injury.Later that day, Staff 1 reported and showed documentation that the 12/13/20 incident was reported to the local unit on 4/14/21.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The main facility kitchen was toured on 4/13/21 at 9:30 am. The following areas were in need of cleaning or repair:* There was black debris on the caulking along the warewashing area counters; * There was dirt build-up on the ceiling ventilation vents;* The interior of the range hood and the fire suppressant pipes had grease build-up and had collected dust and lint;* The guides around the top of the plate warmer had dried debris; * The top shelf above the steam table and the wall shelf above the rear prep counter had dust build-up;* The interior bases of the lower steam table cabinets had dried white-colored water deposits;* The stand mixers had dried debris on the underside of the motor head;* The lids of the grain bins had spilled debris on them; and* The exhaust fan grates inside the walk-in refrigerator and freezer units had dust build-up.Additionally, there were two significantly dented cans of butterscotch pudding in the dry storage room and the facility did not have test strips to ensure sanitizers were mixed to the proper chemical strength.The areas needing cleaning, the dented cans of food and the need for test strips was reviewed with Staff 13 (Director of Dining Services) and Staff 1 (ED) on 4/13/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests and opportunities for active participation in the community at large. Findings include, but are not limited to:During the survey, there was a lack of unscheduled and scheduled activities that occurred for residents who were unable to self-initiate activities or the community at large. The posted activity calendar on a dry eraser board revealed the daily scheduled activity program ended at 11:30 am. A program for the afternoon hours was lacking. The facility's disclosure statement disclosed "0.5" staff for life enrichment for the day and evening shift.On 4/12/21 at 2:55 pm Staff 9 (MT) reported they had just the one caregiving staff on for that evening as the other caregiver was pulled to cover the ALF side. During an interview on 4/12/21 at 3:00 pm, Staff 5 (CG) was asked about a life enrichment coordinator. Staff 5 stated the life enrichment coordinator "leaves at 2:00 pm" and " we are it" for providing an activity program in the afternoon hours.On 4/12/21, during the afternoon hours, four residents were observed in the TV area and Resident 1, who was a fall risk, was observed to be redirected by staff to sit back down on more than one occasion. A banana was later offered to the resident. Resident 1's service plan noted instructions to staff to "redirect" resident with "puzzles, games, or looking at magazines ..." None of the identified activities were observed to occur during the survey for Resident 1.The written activity calendar provided during the survey was repetitive in nature and revealed coffee "shoppe" at 8:00 am every day and "Thymeless-Cooking Club" every day at 10:00 am. The thymeless-cooking club on 4/13/21 at 10:10 am consisted of a snack cart and beverages being passed out by Staff 7 (Life Enrichment Coordinator).During the survey, the primary activity observed was residents' sitting in the TV area with the TV on. At times, the residents would converse between each other and on 4/14/21 at 10:30 am, a resident, who was receiving care for lower leg wraps from an outside agency in the TV area, replied to the other residents " ...you can watch ...more exciting than watching TV ..."On 4/13/21, interview with Staff 1 (Executive Director) revealed some residents on the MCC had been taken over to the ALF side for activities but had not happened for "a year" due to Covid. Staff 1 was unable to articulate how they modified the activity calendar to ensure an activity program was in place to meet the needs of the residents.The failure to ensure an activity program was implemented to meet the needs of the residents was discussed with Staff 1 during the survey. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests and opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to:During the survey, there was a lack of unscheduled and scheduled activities that occurred for residents who were unable to self-initiate activities or the community at large. The following observations were made on 8/18/21: * Glamour time, scheduled for 8/18/21 at 9:00 am and Good News at 9:30 am did not take place;* 8/18/21 at 9:10 am, a life enrichment coordinator, provided hair service to one resident and provided one other resident nail care at 9:20 am. No other activity was observed;* During the survey, the primary activity observed included residents sitting out in the common area for long periods of time watching movies or other TV shows, wandered the halls, or remained in their rooms; and* Staff did not provide any individualized activities to residents. On 8/18/21 at 2:05 pm, Staff 17 (MT) stated the life enrichment coordinator would be off "at 1:00 pm" and covered the assisted living (ALF) side after 1:00 pm. Staff 17 continued saying it would be "extremely hard" to provide activity to residents with one caregiving staff and "frequently" activities did not happen after the life enrichment coordinator left.On 8/18/21, the failure to provide an activity program based on individual and group needs was reviewed with Staff 15 (Executive Director) during the survey. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide services to assist the residents in activities of daily living for 3 of 3 sampled residents (#s 1, 2 and 3) and unsampled residents who required oversight, cueing and supervision and assistance with bathing. Findings include, but are not limited to:a. On 4/12/21 during the evening shift the posted staff schedule of two caregiving staff was not met. Only one caregiving and a MT were observed on the unit. On 4/13/21 and 04/14/21, during the day shift, the facility did not meet the posted staff schedule of two Caregiving Staff.On 4/12/21 during the evening shift there was a period of time where there were no staff in the TV area where a group of residents were and at 3:55 pm, two staff were observed in the dining area setting the tables and obtaining beverages for the dinner meal.Resident 1, who experienced a change of condition in 12/2020 due to a hip fracture was observed on more than one occasion to appear to try to get up from a seated position. The dining room was not in direct view of the TV area. One of the female residents in the TV area stated to another resident " ...can you help [him/her] up ...?", in response to Resident 1's movement of what appeared to be trying get out his/her wheelchair. The female resident then got up and retrieved his/her walker. The resident placed it in front of Resident 1. At that time, the surveyor intervened and retrieved staff from the dining room. Resident 1 was then moved to the dining room where s/he could be observed.b. During meal observations on 4/12, 4/13 at dinner and lunch respectively, staff failed to provide consistent oversight, cueing, and encouragement with meal consumption. The one caregiving staff was not in the dining area on a consistent basis as there were residents' in their unit who required full assistance with meals. The following was noted:*Resident 3, whose plan of care identified the need for reminding and cueing to maintain adequate intake, was observed not to stay focused on his/her meals at times and was observed to watch other residents in the dining room. The resident was observed to eat less than 50 % and on one occasion, Resident 3 was observed to reach for his/her bowl of canned fruit and was unable to get anything on his/her fork. The fruit was left uneaten. *Resident 1 failed to receive consistent oversight and encouragement by staff. Resident 1 at times, would have head down and/or had pushed him/herself away from the dining room table. The resident, during the dinner meal of 4/12/21, ate 25 % or less. The resident was not offered an alternative. *On 4/12/21 Staff 9 (MT) was observed to tell an unsampled resident, who was brought to the dining room for dinner, that she would get coffee for the resident. Fifteen minutes later the resident still did not have his/her coffee and Staff 9 was at the medication cart. The resident had water and a snack at the table as s/he was waiting for the dinner meal.c. On 4/14/21 Resident 2 was scheduled to receive a bath during the day shift on that day, the resident, who Staff 8 (CG) reported, would get up "right away" and other times s/he would refuse to get out of bed in the morning. Today it was reported s/he had refused and "will try again later ..." according to Staff 8. At 9:05 am Resident 2 was observed up and dressed. When asked about when a shower would occur, Staff 8 reported "try to do it before getting the resident up ..." and due to short staff on 4/14/21 due to a no show " ...will probably pass onto next shift ..." according to Staff 8.A review of shower records revealed, for Resident 2 and 3, a lack of documented evidence that showers were received consistently. The failure to ensure oversight, cueing and assistance with ADLs was shared with Staff 1 (Executive Director). No further information was received.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations were completed prior to move-in, contained all elements and were part of the resident's record for 2 of 2 sampled residents (#s 2 and 3) whose move-in evaluations were reviewed. Findings include, but not limited to:1. Resident 3, who had resided on the ALF side, was moved to the Residential Care Facility, a memory care endorsed unit and a different license on 2/11/21. There was no documented evidence a new move-in evaluation was completed prior to the move-in. 2. Resident 2 was admitted to the facility in 7/2020. The move-in evaluation was not in the resident's chart during the survey. It was later located in purged files by Staff 2 (RN). The requirement of initial move-in evaluations to be retained in the resident's record up to 24 months was reviewed at that time.3. A review of the move-evaluations utilized by the facility revealed not all elements were addressed including:* Personality, including how the person copes with change or challenging situations;* Pain non-pharmaceutical interventions, including how a person expresses pain or discomfort; and* Environmental factors that impact the resident's behavior including, but not limited to:(A) Noise. (B) Lighting. (C) Room temperature; and* Recent losses. Move in evaluations were reviewed and discussed with Staff 1 (Executive Director) during the survey. No further information was received.

2. Resident 5, who had resided on the ALF side, was moved to the Residential Care Facility, a memory care endorsed unit and a different license on 7/15/21. There was no documented evidence a new move-in evaluation was completed prior to the move-in. Move in evaluations were reviewed and discussed with Staff 15 (Executive Director) during the survey. No further information was received.
Based on interview and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements and provided sufficient information to develop an initial service plan, for 2 of 2 sampled residents (#s 4 and 5) who were recently admitted to the facility. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in July of 2021 with diagnoses including dementia.Review of Resident 4's initial evaluation dated 6/9/2021 revealed the following missing elements:* History of treatment of mental health;* Effective non-drug interventions for mental health;* Pharmaceutical and non-pharmaceutical interventions for pain; and* Recent losses.The need to ensure the initial evaluation contained all required elements and included sufficient information to develop an initial service plan was discussed with Staff 15 (Executive Director) and Staff 16 (LPN) on 8/18/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, were person centered, updated and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plan was reviewed. Findings include, but are not limited to:1. Resident 1's record revealed the resident had recurring incidents of being found on the floor and had a history of weight loss. The resident's service plan that was not reflective, provided clear caregiving instructions or followed in the following areas:* Fall interventions;* Noted hip incision. Incision was noted healed in 3/2021;* Noted with behaviors including resistance to care, and to have anxiety. Further caregiving instructions on approach, description of anxiety including possible antecedents lacking;* Instructed staff to take resident on a "walk" under toileting schedule. Resident was observed up in a wheelchair during all days of the survey;* No information on the service plan regarding a male friend who was observed to visit on 4/13/21 and he/she reported to visit at least once a week and had known each "over 20 years"; * Frequency of outside services visits and responsibilities (i.e. bathing, skin); and* Identify the resident, under meals, " ...may require cueing and reminding ..." and " ...may need assistance with adding cream to coffee ...." The resident was not observed to receive consistent oversight during meals and no coffee was observed to be provided on 4/14/21 during breakfast.2. Resident 2 was identified by staff during the survey as having good days and bad days and refused care at times. It was also revealed during the survey the resident experienced sleep disturbances at night according to Staff 1 (Executive Director).The resident's plan of care failed to be reflective and provided clear caregiving instructions in the following areas:* Identified with a history or current behavior including "disruptive ...aggressive ...inappropriate behavior ..." There was no further description of the behaviors, staff interventions to manage or minimize behaviors was missing;* Identified to "...resist care at times ..." No further caregiving instructions on how to approach;* Noted "...wakes up throughout the night ..." Clear caregiving instructions on how to redirect and how it may impact morning care and/or refusal to get up in the morning was not identified in the plan of care; and* Failed to identify the resident's ability, at times, to report the need to use the restroom.3. Resident 3's service plan failed to be reflective, updated or followed in the following areas:* Failed to be reflective of the resident's change in ambulation and needing staff assistance with transfers;* Had "occasional anxiety." There was no further description of the resident's anxiety, staff approach and possible antecedents; and* Identified the resident "may need reminding/cueing to maintain adequate intake ..." Resident failed to receive consistent oversight by staff during meal observations.The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (Executive Director). No further information was provided.

2. Reviewing Resident 7's service plan, dated 5/26/21, subsequent temporary service plans and clinical records revealed Resident 7 experienced an increase in verbal and physical behaviors and was involved in multiple resident-to-resident altercations. There was no temporary service plan or interventions to instruct staff on how to redirect him/her when the resident expressed negative behaviors.The need to ensure the resident service plans were reflective of current health status and provided specific instruction to staff was discussed with Staff 15 (Executive Director) on 8/18/21. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, provided clear direction to staff and were updated within 30 days of admission for 2 of 4 sampled residents (#s 4 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 4's most current service plan dated 7/13/21 revealed the following:The service plan indicated the review date to update the service plan was 8/12/21. Interview with Staff 16 (LPN) on 8/18/21 determined she did not update the service plan within the 30 day period. On 8/11/21, Resident 4 was involved in a resident to resident altercation. There was no update to Resident 4's service plan or a temporary service plan instructing staff on how to redirect him/her to prevent further altercations. Resident 4 experienced an increase in verbal and physical behaviors. There were no temporary service plan updates to inform staff of his/her current health status.The need to ensure service plans were reflective of the resident's current health status, provided clear direction to staff and updated timely was discussed with Staff 15 (Executive Director) and Staff 16 (LPN) on 8/18/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of conditions were evaluated and referred to the RN, failed to ensure short term changes were evaluated, specific resident interventions determined and documented and the condition monitored with weekly progress until resolved for 3 of 3 sampled residents (#s 1, 2 and 3) and failed to evaluate and monitor service planned interventions for 1 of 1 sampled resident (#1) who had repeated falls. The failure to evaluate, monitor interventions to minimize falls placed Resident 1 at continued risk for falls with injuries. Findings include, but are not limited to:1a. Resident 1 was admitted to the facility in 6/2017 and was at risk for falls following a hip fracture sustained in 12/2020. The resident returned from skilled nursing, following the fracture, on 1/7/21. The use of a "fall matt" was identified after being re-admitted to the facility on 1/12/21.According to progress notes and incident reports the resident had seven incidents, from 1/18 through 4/10/21, of being found on the floor. One of the incidents, 2/16/21, that occurred during nights, was not located. The resident was noted to have redness to his/her head and bruising to outer hand on that incident.Three of the incidents occurred during the morning hours between 9:00 a.m. and 11:00 a.m., two other incidents occurred at nights between 4:30 a.m. and 5:30 a.m. There was no documented evidence the facility had determined a pattern to the incidents at any time.Follow up actions to the incidents noted the following interventions including: continued frequent safety checks (frequency of those checks were not determined); to toilet prior to bed and/or nap time; and to place in common area to increase supervision.There was no documented evidence the interventions were evaluated after each incident to determine if in place and effective. The last time toileted, when checked and/or in area with increased supervision was not reviewed after each incident and the plan of care was not updated after each incident to instruct staff on new fall interventions. Observation during the survey, the resident was observed to have a fall matt in his/her room under the bed. The resident was observed to receive toileting assistance during the day. On 4/12/21 during the evening shift there was a period of time where the resident was not in direct line of staff and the surveyor had to intervene as the resident was attempting to get out of wheelchair unassisted.The failure to evaluate, monitor interventions after each incident placed the resident for continued risk for falls with potential for moderate harm was discussed with Staff 1 (Executive Director) during the survey. No further information was received.b. Resident 1 returned with an incision to his/her left hip on 1/7/21. Treatment to the area was noted, however, there was no documented evidence facility staff consistently monitored the area weekly until resolved. On 3/17/21 an outside provider noted the area had resolved.c. On 2/18 and 4/2/21 the resident had an increase to his/her routine antipsychotic medication and narcotic pain medication respectively. There was no documented evidence an evaluation of the resident's status, resident specific interventions determined and the resident was monitored weekly until resolution had been completed at the time of the medication change.2. Resident 2 was sent out the ER on 12/12/21 due to complaints of abdominal pain. The resident returned the same day with a diagnosis of constipation and dehydration. The resident was placed on alert when he/she returned however, there was no documented evidence an evaluation of the resident's status including resident specific interventions were determined and status monitored until resolution.The failure to refer to the RN following a significant change of condition and to evaluate and monitor short term changes of condition and monitor until resolution was reviewed with the Staff 1 (ED) during the survey. No further information was received.3. Resident 1, 2 and 3 experienced a significant changes of condition related to weight loss, change in ambulation status and there was no documented evidence the areas where evaluated and referred to the RN for assessment. Refer to C 280 example 1, 2 and 3.

2. Resident 7 was admitted to the facility in 2017 with diagnoses including dementia. Resident 7's clinical records were reviewed during the survey and the followings were noted:* 6/29/21: Involved in resident to resident altercation;* 7/15/21: Started a new medication, depakote (to treat seizure), for mood stability;* 7/16/21: Decreased dose of thyroid medication;* 7/24/21, 7/27/21 and 7/28/21: Involved in resident to resident altercation and increased behaviors and pacing;* 8/6/21: Returned from hospital/emergency department visit;* 8/6/21: Use of anti-biotic to treat urinary tract infection; and* 8/6/21: Had a fall.There was no documented evidence that the resident's short-term changes of condition were evaluated and monitored to resolution. On 8/18/21, the above information was discussed with Staff 15 (Executive Director). Staff 15 acknowledged the findings.
3. Resident 4 was admitted to the facility in 7/2021.A review of the resident's clinical records, 7/13/21 through 8/17/21, indicated the following changes of condition had not been reviewed by the facility or monitored to resolution: *There was no evidence the facility had monitored the resident after initial move in regarding his/her adjustment to a new living environment; and*Resident 4 had multiple medications discontinued in 7/2021 and s/he was not monitored at least weekly for side effects of medication changes.The need to ensure changes of condition were reviewed and monitored at least weekly until resolution was discussed with Staff 15 (Executive Director) and Staff 16 (LPN) on 8/18/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to evaluate, determine further action and monitor the resident's condition until resolution for 3 of 3 sampled residents (#s 4, 6 and 7) who experienced short term changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility on 9/23/20 with diagnoses including dementia. A review of the resident's clinical records, 6/13/21 through 8/17/21, indicated the following changes of condition had not been monitored to resolution: *6/25/21: Resident 6 was involved in an altercation with another resident, sustaining injury;*7/22/21: Return from the emergency department with a diagnosis of UTI with a new antibiotic;*7/29/21: Grief and loss related to the loss of a pet;*8/5/21: Gabapentin (for osteoarthritis) was decreased; and*8/11/21: Resident 6 was involved in an altercation with another resident, sustaining injury. The need to monitor the resident's status until resolution was discussed with Staff 15 (Executive Director) and Staff 16 (LPN) on 8/18/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for a significant change of condition for 3 of 3 sampled residents (#1, 2 and 3) who experienced a change in condition. Findings include but are not limited to:1. Resident 1 sustained a hip fracture in 12/2020 and returned to the facility from Skilled Care in 1/2021 and was admitted to hospice. The resident had experienced weight decline from the previous month that constituted a change of condition. Although the hip fracture was noted by the RN, the RN failed to thoroughly assess the resident's significant changes in the area of weight loss and pain and the service plan failed to be reflective of those changes.In March 2021, Resident 1 experienced a weight decline in one month (8 %) that met the definition of a significant change. There was no documented evidence the RN completed a change of condition related to the weight loss. The following month, April 2021 the resident's weight revealed a four pound weight increase.The resident was observed to receive a regular diet and a puree diet, and according to Staff 3 (Memory Care Director) the puree diet was "PRN" because s/he had been observed to pocket food at times. The resident fluctuated in her/his intake during the survey and received inconsistent oversight and cueing with her/his meals. When provided full assistance with his/her morning snack s/he was observed to eat all the pudding and most of his/her drink. During one meal breakfast, when s/he received pureed food s/he ate two bowls of food independently.There was no documented evidence a RN assessment was completed to address the weight loss in March 2021.The failure to ensure a change of condition was completed was discussed with Staff 1 (Executive Director). No further information was received.2. Resident 3 was identified by Staff 4 (MT), during the acuity interview on 4/12/21, as having a change in condition related to change in ambulation and transfer status.Observation of the resident, during the survey, revealed the resident required assistance of transfers by one staff person and was not observed to ambulate. A wheelchair was his/her primary locomotion. According to Staff 6 (CG) the resident had been walking with a walker with staff assistance and then "stopped" walking.The resident's plan of care at the time of the survey revealed the resident was "independent with mobility/ambulation ...uses a cane for stability ..." and " ...does not require assistance with transferring ..."The resident experienced a change of condition and there was no documented evidence an RN assessment was completed. In interview with Staff 2 (RN) on 4/13.21 at 4:00 p.m. verified he had not been notified of the change and so an assessment was not completed. 3. Resident 2, who was observed to eat independently, was noted to have had a significant weight loss in one month (March 2021) constituting a change in condition. There was no documented evidence a change in condition assessment was completed by the facility RN. That was verified by Staff 2 during the survey. The lack of documented evidence of significant change assessments being completed was reviewed with Staff 1 (Executive Director) during the survey. No further information was received.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers for 2 of 2 sampled residents (#s 1 and 2) who received outside services. Findings include, but are not limited to: 1. Resident 1 was admitted to hospice in 1/2021 and according to Staff 2 (RN) had a hip incision that hospice had been providing oversight of the area. Facility staff, according to treatment records, were providing treatment to the area. When asked about documentation left by the hospice RN, who according to Staff 2 came in once a week, revealed minimal or no documentation of their visits including oversight of the incision.2. A review of Resident 2's record revealed s/he had received outside services in 11/2020 through 12/11/2020. The visits centered on keeping the resident awake during the day, diversion activities for behavior and identified items that engaged the resident including hunting magazines, music (i.e. beach boys) that improved resident's mood and lastly a "fidget board for distraction" was going to be obtained. There was no documented evidence the recommendations were followed up and initiated. The resident's current plan of care failed to address any of the recommendations. The failure to coordinate with outside services including obtaining visit notes and following up on recommendations was reviewed with Staff 1 (Executive Director) during the survey. No further information was received.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:1. During the survey, the facility had five residents who were on hospice, three of which were bedfast and required staff assistance with meal intake. It was also noted in the ADL log sheet that 10 of the 18 residents required staff assistance with incontinence management (greater than 50 %). There were two residents identified by staff who required two-person assistance for transfers.2. The posted staff scheduled revealed:*Days/Evenings 1 MT, 2 Caregiving staff; and*Nocturnal 1 MT, 1 Caregiving staff.3. An anonymous complaint prior to survey revealed staff from the MCC were pulled to the ALF side to cover staffing at times. At the time of the survey the following was observed and interviews revealed: *On 4/12/21 during the swing shift Staff 6 who was scheduled to work on the MCC unit was observed to be pulled and to work on the ALF leaving the MCC to one caregiving staff and one MT (Medication Technician);*On 4/12/21 Staff 5 (CG) reported staff were pulled to work the ALF side frequently to cover staff who quit and/or were on vacation;*On 4/13/21 and 4/14/21 during the dayshift the facility was short one staff and Staff 7 (Life Enrichment) was observed to assist with meal intake of one of the hospice residents. The dining room lacked a caregiver to provide oversight and cueing during meal times; *On 4/14/21 during the day shift the facility was short one staff due to a "no show". Resident 2 who had a scheduled shower during the dayshift was reported to be passed onto the evening shift to do the shower related to short staff; and*Lack of an activity program during the day and evening shift.Refer to C242 and C243.4. Time clock records were requested, reviewed and compared to the facility's posted schedule for 04/01-4/12/21 and revealed: *Day shift was short one staff five days out of 12 or 40 % of the time;*Evening shift was short one staff five days out of the 12 or 40 % of the time; and*Nocturnal shift was short one staff, leaving one staff on nights seven days out of the 12 or 58 % of the time. The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents' was shared with Staff 1 (Executive Director) during the survey. No further information was received.
Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to:1. During the survey, the facility had five residents who were on hospice, three of which required staff assistance with meal intake. There were three residents identified by staff who required two-person assistance for transfers.2. Memory Care staffing schedule revealed:*Days/Evenings 1 MT, 2 Caregiving staff; and*Nocturnal 1 MT, 1 Caregiving staff.3. At the time of the survey the following was observed and interviews revealed: * Lack of an activity program during the day and evening shift. Refer to C 242.* Staff 17 (MT) stated usually they were "short staffed" and most of the time had 1 CG and 1 MT. In addition, Staff 17 stated at times, there was 1 MT and 1 CG at night to cover both ALF and MCC side. Staff 17 Stated someday "if we are lucky" we have 2 CGs and 1 MT.

* Staff 21 (MT/CG) on 8/18/21 said that he/she felt overwhelmed, and sometimes was able to complete his/her duties depending on who he/she was working with. For the last few weeks there was 1 CG and 1 MT on duty per shift, and stated the ratio observed by the surveyor was higher than normal. Staff 21 also stated that the overnight shift sometimes only had 1 MT. * Staff 16 (LPN) on 8/18/21 when discussing missing paperwork stated "with being short staffed a lot might be missed. It's not intentional but some has been missed." The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents' was shared with Staff 15 (Executive Director) during the survey. No further information was received.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month according to the Oregon Fire Code (OFC) and failed to provide fire and life safety training to staff on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety records for October 2020 - March 2021 were reviewed and identified the following deficiencies: a. The facility failed to provide documented evidence fire and life safety instruction to staff was completed on alternating months from the fire drills; andb. The facility failed to complete fire drills on alternating months and because the facility was not relocating residents, lacked the following components:* Fire drills conducted and recorded every other month at different times of the day;* Location of simulated fire origin;* Alternate escape routes were used; * Problems encountered with residents who resisted or failed to participate in drills;* Evacuation time period needed; * Staff members on duty and who participated; and* Number of occupants evacuated.The need to ensure the facility was in compliance with all required fire drill and fire and life safety requirements was discussed with Staff 1 (Executive Director) on 4/14/21 and Staff 14 (Maintenance Director) on 4/13/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months and include required components on fire drill records. This is a repeat citation. Findings include, but are not limited to:Fire and life safety records, reviewed between 6/13/21 - 8/17/21, revealed the following:* Fire and life safety instruction was not consistently provided to staff on alternating months; and* Fire drill records were not kept for the MCC.In an interview on 8/18/21 at 12:40 pm, Staff 14 (Plant Operations Director) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months and stated there were not separate fire drills for the MCC. Fire and life safety training and documentation was discussed with Staff 15 (Executive Director) and Staff 16 (LPN) on 8/18/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C160, C 242, C 252, C 260, C270, C 360, C 420 and Z 164.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:On 4/13/21, observation during the survey revealed an electric fireplace was on and located in the living room where residents congregated. The glass face of the unit was cool to the touch but the upper metal aspect of the unit was hot to the touch. The surface temperature was measured and exceeded 140 degrees. The fireplace was later turned off and remained off during the survey.Staff 1 (Executive Director) was informed of the increased temperature and acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit.

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 C160, C231, C240, C360, C420 and C540.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C160, C 360 and C 420.

Based on interview and record review, it was determined the facility administrator failed to acquire at least 10 hours of Continuing Education Credits (CEU's) related to the care of individuals with dementia over the last year. Findings include, but are not limited to:During the survey, there was no documented evidence that Staff 1 (Executive Director), who had an exception to be Administrator over the ALF and MCC, had acquired 10 hours of her 20 CEU requirements in the care of individuals with dementia in the Year 2019-2020. The requirement was reviewed with Staff 1. No further information was received.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired employees (#s 10 and 11) completed all required pre-service training prior to providing care and services independently. Findings include, but are not limited to:Training records were reviewed with Staff 12 (Business Office Manager) on 4/14/21. Staff 10 (CG) and Staff 11 (CG) were hired on 1/17/21 and 3/2/21, respectively. The following deficiencies were identified:* Though both staff were determined to have demonstrated satisfactory performance in any duty they were assigned and were working independently at the time of the survey, Staff 12 acknowledged neither Staff 10 or Staff 11 had completed training in the following required subject areas:* Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.* Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: Identify and address pain, provide food and fluids, prevent wandering and elopement and use a person-centered approach.* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.).* Family support and the role the family may have in the care of the resident.* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.* The use of supportive devices with restraining qualities in memory care communities.The need to ensure all required pre-service training was completed prior to working independently was reviewed with Staff 12 and Staff 1 (Executive Director) on 4/14/21. They acknowledged the findings.

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 C242, C243, C252, C260, C270, C280 and C290.

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. This is a repeat citation. Findings include, but are not limited to:Refer to C 242, C 252, C 260 and C 270.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutritional and hydration plans for each resident was developed and included in residents' service plans, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 who was observed to receive a puree diet at some meals was not addressed in his/her service plan, and had a history of weight loss. There was no individual nutrition and hydration plan outlined in his/her service plan.2. Resident 2 had a history of weight loss and a diagnosis of dehydration in 12/2020 and there was no individual nutritional and hydration outlined in his/her service plan. 3. Resident 3 was identified on his/her plan of care for staff to offer supplement drinks. The drinks were not observed to be offered during the survey and according to Staff 3 (Memory Care Director) believed it wasn't implemented due to no physician orders for the supplement. There was no further information on the resident's service plan regarding his/her nutritional needs.4. During the survey, staff were observed to clear plates and beverages after meals observed on 4/13 (breakfast, lunch) and 4/14/21 (breakfast) without oversight and cueing to finish drinks. Some residents were observed with full cups of fluids being disposed of at the end of meal without encouragement to drink more. On 4/13/21 at 4:30 pm, during the dinner meal, an outside visitor was observed to tell a caregiving staff that a resident was requesting more juice which at that time staff filled the resident's cup.The lack of an individualized nutritional and hydration plan on the service plan and failure to provide oversight and cueing to drink fluids was discussed with Staff 1 (Executive Director) on 4/14/21 in the morning at 11:30 a.m. No further information was received.

Based on observation, interview and record review, it was determined the facility failed to develop individualized activity plans based on an evaluation for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 and 3 failed to have service plans that addressed an activity plan based on the residents' current preferences, abilities and skills, emotional/social needs and patterns or activities to use as behavioral interventions. 2. Resident 1 had a service plan that identified the resident "enjoys going for rides ..." and "small groups ..." There was no further information on "small group" activities. On 4/14/21, Resident 1 was not observed to go on a van ride that was offered and according to Staff 3 (Memory Care Director) indicated there may not have been enough room on the van and that the resident's tolerance for rides had decreased due to his/her hip fracture.There was no documented evidence a re-evaluation of the resident's activity plan had been completed to meet the resident's current psychosocial and physical limitations.The failure to ensure an evaluation of the residents' current abilities in order to develop an individualized activity plan and failure to implement a plan was discussed with Staff 1 (Executive Director) during the survey. No further information was received.3. During the survey, there was a lack of unscheduled and scheduled activities that occurred for residents who were unable to self-initiate activities on their own. Refer to C 242.
2. Resident 5, who had resided on the ALF side, was moved to the Residential Care Facility, a memory care endorsed unit on 7/15/21. Resident 5's current service plan, dated 7/27/21 indicated the resident "does not require assistance with activities ...resident requires frequent verbal reminders and may need physical assistance." There was no documented evidence a re-evaluation of the resident's activity plan had been completed to meet the resident's current psychosocial and physical abilities and skills.The failure to ensure an evaluation of the residents' current abilities in order to develop an individualized activity plan and failure to implement a plan was discussed with Staff 15 (Executive Director) during the survey. No further information was received.
Based on observation, interview and record review, 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 and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 4 sampled residents (#s 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Though Resident 4's service plan offered some information about the resident's interests, the facility had not fully evaluated the resident's: * Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.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 resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation was discussed with Staff 15 (Executive Director) and Staff 16 (LPN) on 8/18/21. They acknowledged the findings.