Volante of Hillsboro

The findings of the re-licensure survey, conducted 06/06/23 through 06/08/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily 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 first revisit to the change of management survey of 06/08/23, conducted 01/02/24 through 01/04/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and 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 revisit to the re-licensure survey of 06/08/23, conducted 03/28/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause in order to rule out suspected abuse or neglect and failed to report the injuries as suspected abuse, when abuse could not be ruled out, to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (#2), who was identified with injuries of unknown cause. Findings include but are not limited to: Resident 2 was admitted to the facility in August 2015 with diagnoses including dementia.Review of progress notes dated 03/04/23 through 05/24/23 identified the following injuries of unknown cause:* 03/06/23 bruise to left wrist was resolved; and* 04/04/23 bruise to left wrist.There was no documented evidence the facility immediately investigated how Resident 2 sustained the bruises to the left wrist in order to rule out abuse and neglect. The facility failed to notify the local SPD office as suspected abuse when abuse and neglect was not ruled out. The surveyor requested the facility self report the two incidents to the local SPD office on 06/08/23. The facility provided verification of reporting on 06/13/23. The need to investigate injuries of unknown cause in order to rule out suspected abuse or neglect and report to the local SPD office when abuse and neglect wasn't ruled out was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant), and Staff 8 (RN Consultant) on 06/08/23. 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, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to: The facility was divided into three units that included an assisted living, memory care east and memory care west. At the time of the survey the facility was home to 25 residents. Review of the current staffing plan identified the facility staffed four universal workers during the day shift and one activities person during the day shift and no activity person during swing or night shift. During an interview with Staff 14 (Cook/Resident Care Partner) on 06/07/23, s/he stated the caregivers were responsible for resident care, medication duties, all housekeeping duties, laundry service, all meal service including, cooking, serving, feeding assistance and cleaning. Staff 14 reported "we can do activities with residents when we have time."The 06/2023 Activity Calendar was reviewed. The following scheduled activities between 06/06/23 and 06/08/23 did not occur: * 06/06/23 - Morning chat all units 8:00 am, exercise 10:00 am in assisted living, puzzle time in memory care west 10:30 am, table activities in all units 11:00 am, walking group in memory care west at 1:00 pm and movie at 2:00 pm, and painting in the assisted living at 2:30 pm. * 06/07/23 - Morning chat all units 8:00 am, exercise in assisted living at 10:00 am and jewelry making at 10:30 am, bowling in memory care east at 11:00 am, walking group in memory care west at 1:00 pm and magazine reading at 2:00 pm, and Bingo in assisted living at 2:30 pm. * 06/08/23 - Morning chat all units 8:00 am, exercise in assisted living at 10:00 am, table activities in east memory care at 10:30 am and music hour at 11:00 am, board games in assisted living at 1:00 pm, walking group in west memory care at 1:30 pm, and nail time in all units at 2:30 pm. There were no planned activities that occurred and a television played continuously in the assisted living unit. In the memory care units residents were observed in their rooms or seen wandering the halls and sitting in common areas for long periods of time. During an interview with Staff 5 (Life Engagement Manager) on 06/08/23, it was reported the facility used to have an activities assistant who worked two days a week on Sunday and Monday to give Staff 5 time off. Staff reported the caregivers have access to activity items during those days, however, they are usually busy with other duties. The lack of an activity program was discussed with Staff 1(Executive Director), Staff 5, Staff 7 (Consultant), and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were updated, were the basis for the development of the resident's service plan, available to staff and reflective of resident's care needs for 1 of 3 sampled residents (#3) whose move-in and quarterly evaluations were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.An initial move-in evaluation dated 09/23/22 was provided by the facility. An updated quarterly evaluation was requested on 06/07/23 from Staff 7 (Consultant) at 10:17 am. There was no documented evidence an evaluation had been completed after the resident moved in.The need to ensure evaluations were performed quarterly, were the basis of the resident's service plan, available to staff and reflective of resident's care needs was discussed with Staff 1 (ED), Staff 6 (Resident Services Coordinator), Staff 7 and Staff 8 (RN Consultant) on 06/08/23 at 11:20 am. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident needs, provided clear direction to staff regarding the delivery of services, and were completed initially and updated quarterly 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 was admitted to the facility in 07/2020 with diagnoses including dementia. Interviews with staff and review of the service plan, dated 10/31/22, revealed Resident 1's service plan was not updated quarterly.The need to ensure the service plans were updated at least quarterly was reviewed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.There was no documented evidence the facility completed an initial service plan and updated it quarterly. The service plan was requested on 06/07/23 from Staff 7 (Consultant) at 10:17 am. No additional documentation was received at time of survey exit.The need to ensure service plans were completed initially and quarterly was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 and Staff 8 (RN Consultant) on 06/08/23 at 11:20 am. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 08/2015 with diagnoses including dementia.Observations of the resident's room, interviews with staff, and review of the service plan, dated 10/31/22, with hand written updates on 02/15/23, identified Resident 2's service plan was not updated quarterly, was not reflective of the resident's care needs and lacked clear direction to staff in the following areas:* Weight loss and interventions;* Oxygen use, instructions and equipment maintenance;* Ambulation;* Toileting assistance; and* Evacuation status, assistive devices and support.The need to ensure the service plans were updated at least quarterly, were reflective of the residents care needs and provided clear direction to staff was reviewed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:a. Resident 2's most recent service plan lacked documentation that a Service Planning Team reviewed and participated in the development of the service plan.b. There was no documented evidence that a service plan was completed and developed by a service planning team for Resident 3.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions/interventions and/or changes were monitored at least weekly to resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 07/2020 with diagnoses including dementia.Interviews with staff, review of the service plan dated 10/31/22, temporary service plans, incident investigations and progress notes dated 04/04/23 through 06/08/23 were reviewed. The resident experienced multiple short-term changes without documented evidence resident-specific instructions or interventions were developed and communicated to staff, nor was the condition monitored at least weekly to resolution in the following areas:* 04/25/23 - cyst on left eyelid;* 04/25/23 - laceration on left finger; and* 05/03/23 - cellulitis on right leg.The need to ensure short-term changes of condition had documented evidence the condition was referred to the nurse, resident-specific instructions or interventions were developed and communicated to staff, the condition was monitored at least weekly to resolution was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease and had a history of falls. Interviews with staff, review of the initial move-in assessment dated 09/23/22, temporary service plans, incident investigations and progress notes dated 04/11/23 through 06/06/23 were reviewed. The following changes of condition lacked documented evidence interventions were identified and communicated to staff on each shift:* 05/01/23 - Bruise on left forearm; * 05/08/23 - Aggressive behavior of repeatedly pushing a locked door; and* 05/23/23 - Fall outside in the courtyard.The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff on each shift and made the interventions part of the resident's record was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 08/2015 with diagnoses including dementia.Interviews with staff, review of the service plan, dated 10/31/22, with hand written updates dated 02/15/23, temporary service plans, weight records and progress notes, dated 03/04/23 through 05/24/23, were reviewed. Resident 2 experienced multiple short-term changes of condition that lacked evidence resident-specific instructions or interventions were developed and communicated to staff, the documentation of staff instructions or interventions was made part of the resident record with weekly progress noted until the condition resolved in the following areas:* 02/03/23 - Weight loss and interventions;* 03/04/23 - ER visit, dehydration and new medication (Zofran);* 03/06/23 - bruise on left wrist;* 03/17/23 - rash under breast;* 03/17/23 - resident refused multiple medications;* 03/31/23 - emesis;* 04/04/23 - bruise on left wrist;* 04/04/23 - sharp right upper chest pain, ER visit and new diagnosis of pleurisy (fluid buildup in the lining of the lungs);* 05/03/23 - discontinued medications Lisinopril, Furosemide, and Vitamin B-12; and* 06/06/23 - discontinued scheduled Lidocaine patch for pain.The weight loss identified on 02/03/23 was assessed by an RN and included an intervention to obtain weekly weights however, the intervention was not communicated to staff. The need to ensure short-term changes of condition had resident-specific instructions or interventions developed, communicated to staff, the documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 1 of 1 sampled resident (#2) and during meal service. Findings include, but are not limited to:Observations made during the survey, 06/06/23 through 06/08/23, determined the facility failed to adhere to universal precautions for infection control in the following areas:1. Resident 2 was admitted to the facility in 08/2015 with diagnoses including dementia. Observations and interviews with staff during the survey identified s/he was unable to transfer from bed and relied on staff for incontinence care needs. On 06/07/23 at 11:20 am, the surveyor obtained permission from the resident and observed Staff 14 (Cook/Resident Care Partner) provide ADL incontinent care. During the observation, Staff 14 donned gloves without performing hand hygiene. Staff 14 failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and clean incontinent products. Staff 14 then proceeded to remove the soiled incontinent brief, cleanse the residents perineum area and applied barrier cream to the residents skin while wearing soiled gloves. Staff 14 was observed to immediately enter another resident's room to assist the resident without performing hand hygiene.The above observation was discussed with Staff 8 (RN Consultant) on 06/08/23 at 3:38 pm. She acknowledged appropriate infection control practices were not implemented.2. During the survey, from 06/06/23 through 06/08/23, multiple care staff who performed universal duties, including resident ADL care, were observed to assist with meal service. Care staff were not wearing aprons or some other barrier to prevent the potential for cross contamination when assisting with meal service. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 on 06/08/23. They acknowledged the findings.

Based on interview, and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 1 of 4 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to:Resident 2's 05/01/23 through 06/05/23 MARs and signed physician orders, dated 05/05/23, were reviewed during the survey. The following inaccuracies were identified:a. Resident 2 was prescribed Hydrocodone, as needed, for pain.During an interview with Staff 8 (RN Consultant) on 06/08/23 at 2:35 pm it was reported the pharmacy didn't have an active order therefore, the medication was not delivered to the facility and the medication was not removed from the MAR. b. Resident 2 was prescribed continuous oxygen 2 LPM (liters per minute). The order was not transcribed onto the MAR and the facility failed to document administration of the treatment. c. Resident 2 was prescribed zinc oxide barrier cream to be applied after each incontinent episode. The facility staff failed to document on the 05/01/23 through 06/05/23 MARs the barrier cream was being applied during the incontinent changes. The need to ensure MAR's were accurate was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 on 06/08/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication specific instructions, and had resident-specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 7, 8, and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 moved into the facility in 08/2023 with diagnoses including Parkinson's disease.Resident 7's MAR dated 12/01/23 through 01/01/24 was reviewed during survey and revealed the following:a. The following PRN medications prescribed for constipation lacked resident-specific parameters and instructions to staff:* Bisacodyl 10 mg suppository;* Phosphate/saline enema;* Milk of Magnesia 400 mg/5 mL; and* Polyethylene glycol 3350 powder.In an interview with Staff 11 (MT/CG) on 01/03/24 at 1:30 pm, she confirmed the PRN bowel medications lacked resident-specific parameters and instructions in the electronic MAR.b. The MAR was blank for the following medications on 12/30/23:* Acetaminophen 500 mg (for pain);* Carbidopa-levodopa 25 mg/100 mg (for Parkinson's disease);* Docusate/senna 25 mg/100 mg (for bowel care);* Gabapentin 300 mg (an anticonvulsant);* Lidocaine 5% patch (for pain);* Pramipexole 0.5 mg (for Parkinson's disease);* Propranolol 20 mg (for high blood pressure);* Quetiapine 25 mg (a psychotropic); and* Rivastigmine 1.5 mg (for dementia).On 01/03/24 at 1:30 pm, the surveyor and Staff 11 (MT/CG) reviewed the MAR and checked the medication cart. Staff 11 verified the medications had been administered, but staff failed to document on the MAR.The need to ensure MARs were accurate and PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 2 (ED) and Staff 20 (RN) on 01/04/23. They acknowledged the findings.
2. Resident 8 was admitted to the facility in 12/2023 with diagnoses including dementia and type 2 diabetes mellitus with use of insulin.Resident 8's MAR from 12/28/23 through 01/02/24 and physician orders were reviewed and revealed the MAR lacked specific instructions for administration of the insulin glargine 100U/ml pen (to control blood glucose level).The medication record had the following instructions for insulin glargine administration:"Inject 50 units subcutaneously daily at bedtime. Use 2 units to prime prior to each administration." Injecting insulin glargine in accordance with the specific instructions on the MAR would result in 48 units being administered, which was not in accordance with the physician order. On 01/03/24 at 4:00 pm, Staff 25 (MT/CG) demonstrated to the surveyor how to prepare and administer the proper dose of insulin glargine by following the facility written instructions located in the Nursing Delegation binder. The need to ensure MARs were accurate and contained medication specific instructions was reviewed with Staff 2 (ED) and Staff 20 (RN) on 01/04/24. They acknowledged the findings. No further information was provided.
3. Resident 10 moved into the facility in 03/2021 with diagnoses including dementia and constipation.Resident 10's MAR dated 12/01/23 through 01/02/24 was reviewed during survey and revealed the following:a. Two PRN medications, Diclofenac 1 % gel and Tramadol 50 mg tablet were prescribed for hip pain. The MAR lacked resident-specific parameters and instructions to staff. Both PRN medications were administered on multiple occasions during the review period.In an interview with Staff 26 (MT/CG) on 01/03/24 at 9:21 am, she confirmed the PRN pain medications lacked resident-specific parameters and instructions in the electronic MAR.b. The MAR was blank on scheduled Acetaminophen 1000 mg (for pain) medication on 12/01/23 and 12/18/23.On 01/03/24 at 9:28 am, the surveyor and Staff 3 (Resident Services Coordinator) reviewed the MAR and checked the medication cart. Staff 3 verified the medications had been administered, but staff failed to document on the MAR.The need to ensure MARs were accurate and PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 2 (ED) on 01/03/24 at 11:10 am. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST), no less than quarterly for all residents and address all the activities of daily living (ADLs) for each resident, including the amount of staff time needed to provide care. Findings include, but are not limited to:A review of the ABST being used by the facility and an interview with Staff 1 (Executive Director) on 06/07/23 identified the following:* The facility had not completed quarterly updates of the ABST tool for residents residing in the "west memory care unit"; and* During interviews with staff and observations of resident care, the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care.The need to ensure all time needed for providing ADL care to residents was accurate and all residents were updated in the ABST tool, at least quarterly, was reviewed with Staff 1 on 06/07/23 and 06/08/23. No additional information was provided.

Based on interview and record review, it was determined the facility failed to document all required elements of fire drill documentation, and provide fire and life safety instruction to staff on alternate months per the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records dated 01/2023 through 05/2023 were reviewed on 06/07/23. The following was identified:1. Fire drill documentation did not include the following required elements:* Problems encountered, comments relating to residents who resisted or failed to participate in the drills.2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months. The need to follow OFC requirements pertaining to fire drills, documentation, and staff training was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 06/07/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following was identified:*The facility lacked documentation of annual fire and life safety training provided to residents.The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 06/07/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their change of management survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 310 and C 530.

Based on observation and interview, it was determined the facility failed to provide handrails at one or both sides of resident-use corridors. Findings include, but are not limited to:The interior of the building was toured on 06/07/23. The corridors of the main entrance leading to the common area and the corridor leading to the "east memory care unit" were observed without a handrail on at least one side of the corridor.On 06/07/23, the need to ensure handrails were installed along resident use corridors was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:Observations made on 06/06/23 and 06/07/23 revealed the following areas needed cleaning or repair:1. In the "East Memory Care Unit":* Multiple chairs in the living room/tv area had peeling fabric and worn leather, exposing the fibers underneath. There were food particles and trash in the cup holders;* A section of baseboard was missing on the wall near the unit entrance/exit; and* Multiple window screens along the east side of the building were torn and had holes along the bottom perimeter of the screens.2. In the "Open Unit": * There was a missing electrical wall plate near the TV in the common area living room.The environment was toured on 06/07/23 with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed with Staff 1 and Staff 4. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure laundry facilities were located to allow for resident use, washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing, and ensure the separate storage and handling of soiled linens and soiled clothing. Findings include, but are not limited to:The three facility laundry rooms were observed on each unit on 06/06/23 and 06/07/23. The were observed: a. The facility had both commercial and residential type washers. During an interview on 06/07/23, Staff 4 (Maintenance Director) stated there was no way to determined the rinse temperature. The detergent the facility used did not include a disinfecting agent to use on soiled linens.b. During an interview on 06/08/23 with unsampled residents on the "Open Unit", residents stated there were no laundry facilities available if they chose to do their own laundry. Staff 1 (Executive Director) stated there were no residents currently requesting to do their own laundry and acknowledged no process had been identified for them to do so.c. During an interview on 06/06/23, Staff 10 (Resident Care Partner) stated soiled linens were washed in the laundry facilities in the "West Memory Care Unit". There was no separate area in the west unit for handling soiled linens and clothing. In an interview on 06/07/23, Staff 1 and Staff 4 acknowledged the facility was lacking a process for soiled linen processing.The need to ensure soiled laundry was properly disinfected, a resident laundry room was available for resident use, and the facility was following a soiled linen process was discussed with Staff 1 and Staff 4 on 06/07/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing, and ensure the separate storage and handling of soiled linens to preclude potential for contamination of clean linens and clothing. This is a repeat citation. Findings include, but are not limited to:Facility laundry rooms were observed on the East Unit, West Unit and Open Unit from 01/02/24 through 01/04/24. The following deficiencies were identified: 1. Facility policy for soiled linens and clothing stated items were to be bagged, brought to the East Unit laundry room, any debris rinsed in the flushing rim clinical sink, placed in the washing machine, and washed using laundry detergent and the chemical disinfectant provided by the facility. The facility washing machines did not offer a minimum rinse temperature of 140 degrees F.Interviews during the survey identified the following inconsistencies with the process for rinsing soiled linens and using a chemical disinfectant:a. Staff 10, 11, 19 and 22 (CG's) stated they used laundry detergent but did not say they used the chemical disinfectant.b. Staff 14 (CG) stated soiled linens were rinsed off in residents' private bathroom toilets. c. Staff 26 (CG) stated the utility sink was used, not the flushing rim clinical sink, to rinse soiled items. 2. The facility stored clean bedding/linens, reusable bed pads and plastic hangers in the East Unit laundry room in close proximity to the flushing rim clinical sink used for pre-rinsing soiled laundry.The need to ensure soiled laundry was properly disinfected and the facility was storing clean laundry separately from where soiled laundry was processed was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 01/04/24. They acknowledged staff were not consistently following the facility process for laundering soiled items and agreed to relocate the clean linen storage.

Based on observation and interview, it was determined the facility failed to ensure that a manually operated emergency call system was provided in each toilet facility used by residents and visitors. Findings include, but are not limited to:The facility was toured on 06/07/23 with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). A restroom located in the "Open Unit," used by residents and visitors, did not have a manually operated emergency call device.The need to provide a manually operated emergency call system in all toilet and bathing facilities used by residents and visitors was discussed with Staff 1 and Staff 4. They acknowledged the findings.

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 231, C 242, C 295, C 361, C 420, C 422, C 511, C 513, C 530 and C 555.
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 C 530.

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed, demonstrated competency in assigned duties within 30 days of hire for 3 of 3 newly hired direct care staff (#s 15, 16 and 17) , and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics for 2 of 3 long-term direct care staff (#s 18 and 19) . Findings include, but are not limited to:Staff training records were reviewed with Staff 2 (Business Office Manager) and Staff 6 (Resident Services Coordinator) on 06/06/23 and 06/08/23. 1. Training records for Staff 15 (MT/Resident Care Partner), Staff 16 (Resident Care Partner), and Staff 17 (Resident Care Partner), hired 04/19/23, 04/04/23, and 03/21/23 respectively, identified the following:a. Staff 15, 16 and 17 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:* Resident rights and values of community based care;* Abuse reporting requirements;* Fire safety and emergency procedures; and* Infectious disease prevention.b. Staff 15, 16 and 17 lacked documented evidence pre-service dementia training was completed prior to independently providing care and services to residents. c. Staff 15, 16 and 17 lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in the following required areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions which require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation; and* Other duties as applicable, including safe medication and treatment administration. 2. Staff 18 (Resident Care Partner) and Staff 19 (Resident Care Partner), hired 05/01/10 and 05/31/19 respectively, lacked documented evidence of completion of 16 hours of annual in-service training which included at least six hours of dementia care training annually from 05/2022 to 05/2023. The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Executive Director) and Staff 2 on 06/08/23. They acknowledged the findings.

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 252, C 260, C 262, C270 and C 310.
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 310.

Based on interview, and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled memory care residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to:a. Resident 1 and 3's "The Story of a Lifetime" form offered some historical information about the resident's previous interests, hobbies, and occupations; however, the facility failed to evaluate 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* Identification of activities for behavioral interventions.b. Resident 1 and 3 lacked an individualized activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities. In an interview on 06/08/23 at 9:45 am, Staff 5 (Life Engagement Manager), stated she was the only activity person and reported she was not involved in the service planning meetings.The need to ensure an individualized activity plan was developed for each resident based on their activity evaluation was reviewed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident or others in the community and include them on the service plan for 1 of 2 sampled residents (#3) with documented behaviors. Findings include, but are not limited to:Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.Resident 3's record documented behaviors including exit seeking, agitation, restlessness and aggression.Review of the record indicated Resident 3 exhibited exit seeking behaviors in which s/he would push against a heavy door to attempt to exit and the door would shut on his/her forearms, which resulted in bruising. Triggers for some of the behaviors included time of day and when spouse would leave the building after visiting Resident 3. There was no documented evidence the facility had completed a service plan which included an individualized behavior plan. On 06/08/23 at 11:25 am, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure fencing surrounding the perimeter of the outdoor recreation area was no less than six feet in height and designed to prevent resident elopement. Findings include, but are not limited to:A tour of the outdoor recreation areas of the "West Memory Care Unit" on 06/07/23 revealed the fencing around the perimeter of the exterior patios was less than six feet in height in multiple areas due to uneven ground. The fence was loose and flexed several inches when pushed on.The outdoor recreation area was toured on 06/07/23 with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). The need to ensure outdoor fencing was no less than six feet in height and designed to prevent resident elopement was discussed with Staff 1 and Staff 4. They acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 03/30/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified: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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 7/29/2022 and 7/30/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified: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

Based on interview and observation it was confirmed that the facility failed to maintain equipment in good repair and failed to provide heating and ventilation systems capable of maintaining 70 degrees Fahrenheit. Findings include but not limited to: During an unannounced site visit on 07/29/2022 the Compliance Specialist (CS) interviewed Staff #1 (S1) and Staff 2 (S2) regarding the maintenance of equipment designed to keep the facility at a reasonable temperature. S1-3 and R1-3 stated the air conditioner has been out of order since 07/25/2022. CS and S1 used a facility thermometer to take the ambient room temperature of R1s room and it indicated 89 degrees Fahrenheit. CS observed the hall thermostat reading 87 degrees. S1 stated that the facility is offering water, popsicles and personal fans to residents. CS observed a total of 18 cooling devices including three large portable AC units, 3 industrial sized fans throughout the facility, 2 turbo fans and several personal fans'.During an unannounced visit on 07/30/2022, the CS observed two commercially rented portable AC units at the facility. The CS observed S1 programming the units for blowing cool air into the facility. The CS observed large 12-inch hoses coming through the window and placed in the hallway to begin the process of cooling the facility.Facility Plan of Correction:Facility stated that bids are being reviewed to contract with a cooling maintenance company as soon as possible to ensure the heating and cooling equipment is operational and functioning properly.

Based on interview and observation it was confirmed that the facility failed to maintain equipment in good repair and failed to provide heating and ventilation systems capable of maintaining 70 degrees Fahrenheit. Findings include but not limited to: During an unannounced site visit on 07/29/2022 the Compliance Specialist (CS) interviewed Staff #1 (S1) and Staff 2 (S2) regarding the maintenance of equipment designed to keep the facility at a reasonable temperature. S1-3 and R1-3 stated the air conditioner has been out of order since 07/25/2022. CS and S1 used a facility thermometer to take the ambient room temperature of R1s room and it indicated 89 degrees Fahrenheit. CS observed the hall thermostat reading 87 degrees. S1 stated that the facility is offering water, popsicles and personal fans to residents. CS observed a total of 18 cooling devices including three large portable AC units, 3 industrial sized fans throughout the facility, 2 turbo fans and several personal fans'.During an unannounced visit on 07/30/2022, the CS observed two commercially rented portable AC units at the facility. The CS observed S1 programming the units for blowing cool air into the facility. The CS observed large 12-inch hoses coming through the window and placed in the hallway to begin the process of cooling the facility.Facility Plan of Correction:Facility stated that bids are being reviewed to contract with a cooling maintenance company as soon as possible to ensure the heating and cooling equipment is operational and functioning properly.