Oak Lane Residential Care Facility

Based on interview and record review, it was determined the facility failed to report an injury of unknown cause to the local SPD unless an immediate investigation reasonably concluded and documented the injury was not the result of abuse for 1 of 2 sampled residents (#1) in the MCC who had injuries of unknown cause. Findings include, but are not limited to:

Resident 1 moved into the MCC in 08/2024 with diagnoses including dementia and a history of falls. The resident’s progress notes and incident reports/investigations dated 12/02/24 to 02/24/25 were reviewed, and the following was identified:

The resident experienced an unwitnessed injury fall on 01/27/25. A facility investigation was completed; however, it failed to rule out abuse. During an interview at 2:40 pm on 02/25/25, Staff 5 (Care Coordinator MCC) confirmed the investigation of the incident had not ruled out abuse. Survey requested the facility report the injury fall to the local SPD office, and confirmation was received at 10:25 am on 02/26/25.

The need to ensure injuries of unknown cause were reported to the local SPD office unless a facility investigation reasonably concluded and documented the injury was not the result of abuse was discussed with Staff 1 (Regional Director), Staff 2 (ED), and Staff 9 (Regional RN) on 02/26/25. They acknowledged the findings, and no further information was provided.

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 observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and preferences and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 5) in the MCC whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the MCC in 08/2024 with diagnoses including dementia, hypertension, and Type 2 diabetes. The resident’s service plan available to staff, dated 08/14/24, and temporary service plans, dated 12/31/24 to 02/24/25, were reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Mechanical soft diet;
* Level of assistance for toileting, dressing, and transfers;
* Mobility status;
* Assistive devices, including side rails, Hoyer lift, hospital bed, and air mattress;
* Hallucinations;
* Bathing status;
* Presence of catheter;
* Fall interventions;
* Dental status;
* Evacuation instructions; and
* Preferred activities.

The need to ensure service plans were reflective of residents’ needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 1 (Regional Director), Staff 2 (ED), and Staff 9 (Regional RN) on 02/26/25. They acknowledged the findings, and no further information was provided.

2. Resident 5 moved into the MCC in 11/2024 with diagnoses including Type 2 diabetes and dementia.

Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 02/21/25, and temporary service plans showed the service plan did not provide clear direction to staff and was not reflective of the resident's needs in the following areas:

* Non-pharmaceutical interventions for pain;
* Hyperglycemia and hypoglycemia symptoms and treatment;
* Level of assistance needed for transfers; and
* Ability to use the call system.

The need to ensure service plans were reflective of resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Regional Director), Staff 2 (ED), Staff 3 (Health Services Director/LPN), and Staff 9 (Regional RN) on 02/27/25. 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.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(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 movein 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 and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:

1. Lunch and dinner services on the residential care unit were observed on 02/25/25 and 02/26/25.

Staff were observed serving meal trays from the meal cart, knocking on doors, touching doorknobs, touching their face and hair, and placing dirty meal trays next to fresh meal trays on the cart without performing hand washing.

2. Lunch service on the memory care unit was observed on 02/25/25.

a. The community dining table was observed to have food debris from the breakfast meal and residents were observed completing a painting activity on the dirty table immediately prior to lunch service.

b. Universal care staff were observed serving food to residents without donning a protective barrier over potentially contaminated clothing.

c. Staff 17 (CG) was observed wiping her nose with her hand, touching her face and hair without performing hand washing.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (Regional Director), Staff 2 (ED), Staff 3 (Health Services Director/LPN) and Staff 9 (Regional RN) on 02/27/25. They acknowledged the findings.?

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to carry out medication orders as prescribed for 1 of 2 sampled residents (#1) in the MCC whose records were reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC in 08/2024 with diagnoses including dementia, hypertension, hypothyroidism, and Type 2 diabetes.

The resident’s 02/01/25 to 02/24/25 MAR and “Administration” notes and current physician orders were reviewed. The following was identified:

The resident had the following orders:

Staff documented the medications were not administered due to the medications not being available as follows:

* Aspirin, on 12 occasions;
* Levothyroxine, on 12 occasions; and
* Metformin, on 25 occasions.

Staff 9 (Regional RN) stated at 10:20 am on 02/26/25 that the resident’s pharmacy had sent the refill requests to the wrong provider, and MCC staff had not made the nurse aware of the medications not being filled.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Regional Director), Staff 2 (ED), and Staff 9 on 02/26/25. They acknowledged the findings, and no further information was provided.

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

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for 46 of 54 residents. Findings include, but are not limited to:

During the acuity interview at 1:30 pm on 02/24/25, Staff 1 (Regional Director) confirmed the facility census was at 54 residents.

The facility’s ABST data and posted staffing plan were reviewed at 1:30 pm on 02/26/25. The ABST data for 46 of 54 residents did not show documented evidence of being updated at least quarterly.

During an interview on 02/26/25 at 2:30 pm, Staff 4 (Social Services Director) stated the facility process for updating the ABST included to update it at the same time the service plan was being updated and/or with significant changes of condition. No additional documentation was provided to show the ABST for the above residents had been updated at least quarterly.

The need to ensure residents’ ABST was updated no less than quarterly was discussed with Staff 1 (Regional Director), Staff 2 (ED), Staff 3 (Health Services Director/LPN) and Staff 9 (Regional RN) on 02/27/25. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - 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 observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were safely stored in a locked storage and exterior pathways were maintained in good repair. Findings include, but are not limited to:

During a tour of the facility on 02/24/25 at 2:00 pm, the following was identified:

* Cleaning chemicals and disinfectants were found unlocked in cabinets under the sink and counter in the kitchenette of the memory care unit. The kitchenette area was easily accessible to residents;

* The exterior pathways and accesses to the facility had multiple cracked and uneven concrete areas. There were multiple drop-offs of one to two inches along pathway edges. A concrete path between buildings had a drop-off of up to four inches measured from the pathway’s edge to the asphalt. The drop-offs created a potential tripping and fall hazard for residents; and

* There was an accumulation of yard debris and miscellaneous refuse around the exterior of the building.

The need to ensure chemicals were kept in a locked storage and exterior pathways were maintained in good repair was shown to and discussed with Staff 1 (Regional Director) and Staff 2 (ED) on 02/26/25. They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:
?Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were safely stored in locked storage and exterior pathways were maintained in good repair. Findings include, but are not limited to:

The facility continues to be out of compliance in the area of general building exterior; however, they have requested and were approved for an extension to their allegation of compliance date of 09/28/25.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

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

Observations of the facility on 02/24/25 through 02/26/25 showed the following areas were in need of cleaning and/or repair:

* Carpet throughout the facility including resident rooms, had dark stains of varying sizes and showed significant signs of wear and tear;

* Doors and door frames throughout the facility, including resident rooms on the west and east sides, were gouged, scraped, and damaged;

* The doors to the laundry rooms had been removed;

* Dining room chairs and tables were scraped, dinged, and chipped;

* The memory care unit common-use bathroom had discolored and missing caulking around the toilet base and shower area; and

* There was a consistently pervasive odor of urine throughout the memory care unit.

The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Regional Director) and Staff 2 (ED) on 02/26/25. 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 the environment was maintained in clean and good repair. Findings include, but are not limited to:

The facility continues to be out of compliance in the area of environment; however, they requested and were approved for an extension to their allegation of compliance date of 09/28/25.

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 exit doors were equipped with a functional alarm for security purposes and to alert staff when residents exited the facility and failed to provide a call system that connected resident units to the care staff or staff pagers on the memory care unit and that a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors. Findings include, but are not limited to:

A tour of the facility on 02/24/25 identified the following:
* Exit doors, including the doors to the secured courtyard of the memory care unit, lacked an operational alarming device or other acceptable system to alert staff when residents exited the building;

* There were no manually operated emergency call systems in any of the common-use bathrooms used by residents and visitors; and

* There was no call system in place to connect resident units to the care staff or staff pagers in the memory care unit. Observations made of the memory care unit during the survey and interviews with staff indicated residents were routinely checked on every one to two hours by staff due to the lack of a call system.
During a walkthrough of the facility on 02/26/25 at 1:15 pm, Staff 1 (Regional Director) and Staff 2 (ED) verified that the exit door alarms were inoperable and acknowledged that there were no call systems in the memory care and common-use bathrooms used by residents and visitors. Staff 1 reported that the facility had already contacted a call system company and that they would be at the facility the following week for installation.

The need to ensure exit doors were equipped with a functional alarm for security purposes and to alert staff when residents exited the facility, and that the memory care had a call system, including providing a manually operated emergency call system in all the common-use bathrooms used by residents and visitors was reiterated to Staff 1 and Staff 2 on 02/27/25.

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OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

(11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with a functional alarm for security purposes and to alert staff when residents exited the facility and failed to provide a call system that connected resident units to the care staff or staff pagers on the memory care unit and that a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors. Findings include but are not limited to:

The facility continues to be out of compliance in the areas of call systems and exit door alarms, however, they requested and were approved for an extension to their allegation of compliance date of 09/28/25.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

(11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident 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 C231, C295, C363, C510, C513, C555.

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 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 C510, C513, and C555.

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 observation, interview, and record review, it was determined the facility failed to ensure health services were consistently provided in accordance with the licensing rules of the facility. Findings include, but are not limited to:

Refer to C260, C303.

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 interview and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 1 and 5) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:
Service plans for Residents 1 and 5 were reviewed during survey. Each of the service plans included some food preferences but lacked individualized hydration information and staff instructions related to meeting resident-specific nutrition and hydration needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Regional Director), Staff 2 (ED), Staff 3 (Health Services Director/LPN), and Staff 9 (Regional RN) on 02/27/25. 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 behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service or care plan for 2 of 2 sampled residents (#s 1 and 5) in the MCC whose records were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 11/2024 with diagnoses including ADHD, dementia, anxiety and bi-polar disorder.

A review of the resident's service plan dated 02/21/25 identified the resident had a diagnosis of anxiety and would assume the worst of things and would panic until staff sat with them and staff to ensure them that everything was okay.

The service plan instructed staff of the following:

* Avoid confrontation;
* Do not argue;
* Try to identify feelings being expressed. “When [the resident] feels accepted; it does not matter what [s/he] is trying to say;
* Cue the resident prior to care delivery, use one step directions and a slow pace; and
* Calling their spouse helps calm them down.

The service plan stated that “[the resident] had attempted to hurt [themselves] by breaking a glass picture frame and cutting [their] arm. “[The resident] was sent to the ER and was placed on suicide watch for over a week and was able to come back to [the] facility with new medications that [the resident] says works good for [them].

Resident 5’s current service plan dated 02/21/25 provided some information related to the resident's behaviors; however, the facility had not completed a service plan which included an individualized behavior plan.

During an interview with Staff 1 (Regional Director) at 12:30 pm, Staff 1 acknowledged Resident 5 did not have an individual behavioral plan and stated the facility would be working with the resident’s outside service provider to develop a plan.

The need to develop individualized behavior plans for residents with behavioral symptoms that negatively impacted the resident or others in the community was discussed with Staff 1 (Regional Director), Staff 2 (ED), and Staff 9 (Regional RN) on 02/27/25. They acknowledged the findings.

2. Resident 1 moved into the MCC in 08/2024 with diagnoses including dementia and a history of falls. The resident’s 02/12/25 quarterly evaluation, 08/14/24 service plan, and progress notes from 12/02/24 to 02/24/25 were reviewed, and the following was identified:

* A 12/02/24 progress note stated, “when we try to get [him/her] out of bed or sit [him/her] up to eat [s/he] yells in pain until we lower [him/her] back down and leave [him/her] be”;
* A 01/09/25 progress note stated, “staff received call in regard to resident’s refusal of catheter changes”;
* A 02/03/25 progress note stated, “Resident has been leaning off towards the left side of the bed often today and refuses to be moved or repositioned with pillows”; and
* A 02/21/25 progress note stated, “[Resident 1] was having some [complaints of] pain to [his/her] toes and we had set up a podiatry [appointment] for [him/her] to go on 02/19. Come that day staff tried for a good hour and [Resident 1] kept saying [s/he] didn’t want to go anywhere.”

There was no documented evidence the behaviors were evaluated and included on the resident’s service plan.

The need to ensure behaviors which negatively impacted the resident were evaluated and included on the service or care plan was discussed with Staff 1 (Regional Director), Staff 2 (ED), and Staff 9 (Regional RN) on 02/26/25. They acknowledged the findings, and no further information was provided.

OAR 411-057-0160(e) Behavior

(e) Behavioral symptoms which negatively impact the resident and others in the community must be evaluated and included on the service or care plan. The memory care community must initiate and coordinate outside consultation or acute care when indicated.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 06/03/24, 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 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.
The findings of the revisit to the kitchen inspection of 06/03/24, conducted 09/09/24, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The kitchen was toured with Staff 2 (Kitchen Manager) on 06/03/24. Observations of the facility's kitchen, food storage areas, food preparation, and food service on 06/03/24 revealed:* Splatters, spills, stains, and debris noted on: - Hand washing sink; - Can opener blade and casing; - Wire rack storage shelves in walk-in refrigerator, walk in freezer, and throughout the kitchen; - Open shelving throughout the kitchen; - Walls throughout the kitchen; - Floors in walk-in refrigerator, walk-in freezer, throughout the kitchen, cove base, and drains; - The dishwashing area walls, floors, and equipment; - Both sides of the range, grill, and oven; - Standing mixer; - Carts; - Free standing air conditioner; - Interior of drawers in main kitchen and Memory Care dining room; and - Cabinet fronts in the Memory Care dining room. * Walls, shelving, flooring, and cove base through the kitchen was damaged, creating un-cleanable surfaces. * The plastic cutting board attached to the steam table were deeply scored and stained black.* There was an approximately 2 foot wooden cutting board attached to the steam table. * Dish racks were stored directly on the floor.* A soiled cloth was observed stored over the clean flatware bin.* There were undated and unlabeled foods in the walk in refrigerator and reach in refrigerator in the Memory Care dining room.* Packaged foods were not dated when opened.* There were expired food items in the walk in refrigerator.The kitchen was reviewed with Staff 1 (Executive Director) and Staff 2 on 06/03/24. 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 240.

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 a facility monitoring inspection conducted on 11/02/2022. 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

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 10/6/2022. 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 record review, it was determined the facility is not implementing a daily program of social and recreational activities. Findings include but are not limited to:In an interview on 10/6/2022, Staff #1 (S1) reported h/she was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator. During S1's absence, facility staffing was reduced and the activities director quit. S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found and is in the process of hiring new staff to include a full time activity director.Record review on 10/6/2022 of the facility's activity schedule revealed social and recreational activities for the Memory Care Unit are not scheduled daily, but around the receptionist's work schedule until a replacement is hired. Scheduled activities are 2-3 times per week, not daily.On 10/6/2022, S1 acknowledged the findings.Plan of Correction:S1 has been back to work for three days and is in the process of hiring a full time activity director.

Based on interview and record review, it was determined the facility is not staffed adequately to respond to call lights within a reasonable amount of time. Findings include but are not limited to:In an interview on 10/6/2022, Staff #1 (S1) reported h/she was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator. During S1's absence, facility staffing was reduced, several caregivers quit along with some of their long term management team and shifts were not being covered. S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found.Record review on 10/6/2022 of Resident #1-3's Medication Administration Records and progress notes for Aug-Sept 2022 revealed Medications were not being administered as prescribed.Record review on 10/6/2022 of the facility's Medication Administration Policy revealed staff were not following procedures for administering scheduled medications within a two hour window. In separate interviews on 10/6/2022, Staff #3-5 reported the facility has been severely short staffed over the past two months. Care staff would call out or not show up for shifts leaving only one caregiver on shift on multiple occasions. During this time, medications were not administered as scheduled or timely.On 10/6/2022, S1 acknowledged the findings.Plan of Correction:S1 has been back to work for three days, Staffing Agencies are now in place to supplement staffing and they are actively hiring.

Based on interview and record review, it was determined the facility is not staffed adequately to respond to call lights within a reasonable amount of time. Findings include but are not limited to:In an interview on 10/6/2022, Staff #1 (S1) reported h/she was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator. During S1's absence, facility staffing was reduced, several caregivers quit along with some of their long term management team, and shifts were not being covered. S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found.Record review on 10/6/2022 of the facility's call light logs for 9/5-9/10/22 revealed call light response times in excess of 30-90 minutes in length.In separate interviews on 10/6/2022, Staff #3-5 reported the facility has been severely short staffed while S2 was working as the Interim Administrator. Staff would call out or not show up for shifts, leaving only one caregiver on shift on multiple occasions. Staff would try to contact S2 via phone to no avail. During this time, medications were not administered as scheduled or timely.On 10/6/2022, S1 acknowledged the findings.Plan of Correction:S1 has been back to work for three days, Staffing Agencies are now in place to supplement staffing and S1 is actively hiring.

Based on interview and record review it was determined the facility is not updating their Acuity Based Staffing Tool (ABST). Findings include but are not limited to:In an interview on 10/6/2022, Staff #1 (S1) reported the following:*S1 was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator. *Prior to S1's absence, the facility was implementing and updating their ABST tool (DHS tool). *During S1's absence, facility staffing was reduced, several caregivers quit along with some of their long term management team and shifts were not being covered. *S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found. *S1 stated that the ABST has not been updated during h/her absence.Record review on 10/6/2022 of the facility's ABST data revealed residents who were no longer at the facility were still included in ABST data and new residents admitted since August 2022 had not been entered into the ABST. On 10/6/2022, S1 acknowledged the findings.Plan of Correction:S1 has been back to work for three days and is in the process of doing a thorough review of resident care needs to ensure the accuracy of their ABST. S1 completed the reconciliation of resident numbers in their ABST in Compliance Specialist's (CS) presence on 10/6/2022.

The findings of the re-licensure survey, conducted 5/3/21 through 5/5/21, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.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 revisit to the re-licensure survey of 5/5/21, conducted 10/11/21 to 10/12/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in residents' evaluations for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed and 1 of 1 sampled resident (#1) who lacked a thorough smoking evaluation. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in March 2021 with diagnoses including failure to thrive.Resident 5's move-in evaluation, dated 3/16/21 was reviewed. There was no documented evidence the following required elements were addressed prior to move-in:* Personality, including how the person copes with change or challenging situations;* Communication and sensory, including speech and ability to understand and be understood;* Nutrition habits, fluid preferences and weight if indicated;* List of treatments, including type, frequency and level of assistance needed;* Complex medication regimen;* History of dehydration;* Recent losses; and* Environmental factors that impact the resident's behavior, including, but not limited to noise, lighting and room temperature.The facility's failure to address all required elements prior to resident's admission to the facility was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2 (Resident Care Manager) on 5/4/21. They acknowledged the findings.
2. Resident 1 was identified during the acuity interview as a smoker. During the survey, the resident was observed smoking outside on the patio.Review of the resident's records showed the quarterly evaluation, dated 2/2/21, lacked documented evidence that an evaluation was conducted to determine the resident's current ability to safely smoke independently.On 5/5/21 the need to evaluate the resident's ability to safely smoke independently was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2 (Resident Care Manager). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 7/2019 with diagnoses including dementia with behaviors. The most recent service plan, dated 12/19/20, and temporary service plans were reviewed. The following areas were not current and did not provide clear caregiving instruction: * Outside services; * Spouse's visitation schedule; * Behavior interventions for care; * Glasses; * Bathing assistance; * Transfer assistance; * How the resident ate meals; * Meal assistance from staff; and * Housekeeping relating to mopping the resident's restroom PRN. During an interview on 5/4/21 at 1:25 pm, Staff 19 (CG) reported what services she provided to Resident 4 and stated the service plan information she had access to was outdated and not reflective of the resident's current needs.The failure to ensure service plans were updated to provide clear caregiving instruction was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2 (Resident Care Manager) on 5/5/21. No further information was received.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, were updated and provided clear directions regarding delivery of services for 2 of 4 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include but are not limited to: 1. Resident 3's initial service plan, dated 3/1/21, was reviewed and was not updated within the required 30 days from move-in, was not reflective of the resident's current status and care needs, and lacked clear directions for staff in the following areas:* Transfer status and assistance needed;* Mobility status; * Shower schedule; * Prolapsed bladder; * Skin conditions; * Treatments;* Pain and use of pain medication; and * Behaviors.The need to ensure service plans were reflective of the resident's current status and care needs, were updated and provided clear directions regarding delivery of services was discussed with Staff 2 (Resident Care Manager) on 5/5/21. She acknowledged the findings.

2. Resident 3 was admitted to the Memory Care Unit in March 2021. Review of Resident 3's progress notes and temporary service plans indicated the following changes of condition:* 3/8/21 - Areas of severe dry skin on the back of legs; * 3/9/21 - Areas of the severe dry skin had opened; * 3/11/21 - Open sores on the back of the legs; * 3/12/21 - An open blister near the resident's right foot; * 3/18/21 - Right leg was red and the resident was experiencing extreme pain in that leg; * 4/2/21 - A fall with injury that resulted in an ER visit; and * 4/5/21 - The resident's shins were red and swollen and the blisters on legs were weeping.On 4/27/21, the facility received a physician order for staff to perform daily wound care to Resident 3's right lower leg. In an interview on 5/3/21 at 3:05 pm, Staff 17 (MT) stated the morning shift was responsible for the resident's wound care. An interview on 5/4/21 at 9:10 am, Staff 15 (MT) and Staff 19 (CG) both reported wound care was done on the evening shift. The surveyor and Staff 17 observed Resident 3's right lower leg on 5/4/21 at 4:00 pm. The resident's leg was swollen and red. Resident 3 stated no one had changed the bandage on the leg or looked at it for two weeks. Staff 17 reported she was not sure, but thought the bandage had been on for at least a week. During an interview on 5/5/21 at 11:00 am with Staff 2 (Resident Care Manger) confirmed the wound care treatment order had not been implemented until 5/4/21. There was no documented evidence the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored the above documented changes of condition to resolution. The need to ensure the facility evaluated, determined and documented what actions or interventions were needed for changes of conditions and to monitor the effectiveness of interventions was reviewed with Staff 2 on 5/5/21. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to identify and evaluate changes of condition, determine what interventions were needed and monitor the conditions to resolution for 2 of 4 sampled residents (#s 1 and 3) who experienced changes of condition. Findings include, but are not limited to:1. Review of the Resident 1's records from 2/2/21 to 5/3/21 identified the following issues:a. Resident 1 fell on 4/10/21, resulting in a right arm fracture, skin abrasions on face and knees, and bruises to arms, legs and hands. There was no documented evidence the service plan was updated to provide instructions to staff and the injuries were monitored to resolution.b. The resident was monitored for several medications changes. The facility failed to document when the condition was resolved.c. Several temporary or interim service plans lacked resident-specific instructions for staff regarding medication changes, skin issues, and when to notify the nurse.On 5/5/21 the need to evaluate changes of condition, determine interventions needed and monitor the changes to resolution was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2 (Resident Care Manager). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 2015 with diagnoses including myasthenia gravis (neuromuscular disease) and failure to thrive. Review of Residents 2's weight records revealed the following:* On 2/3/21 - 127 pounds; * On 3/4/21 - 116 pounds;* On 4/4/21 - 86 pounds; and* On 5/4/21 - 100 pounds.From 2/3/21 to 3/4/21 Resident 2 experienced a severe weight loss of 11 pounds, or 8.6% total body loss in one month. From 3/4/21 to 4/4/21 the resident experienced an additional severe weight loss of 30 pounds, or 26% total body loss in one month. From 4/4/21 to 5/4/21 Resident 2 experienced a severe weight gain of 14 pounds, or 14% total body weight gain in one month. The severe weight loss and gain constituted a significant change of condition.There was no documented RN assessments of Resident 2's severe weight losses. Resident 2 was admitted to hospice on 4/9/21 for failure to thrive secondary to myasthenia gravis and severe weight loss.During an interview on 5/4/21 at 11:00 am, Staff 20 (MT) reported that Resident 2 ate independently in his/her room. She said s/he was eating better recently, receiving protein shakes with all meals, more snacks and soft foods. The lack of a significant change of condition RN assessment for severe weight loss was discussed with Staff 1 (RN - Vice President of Operations) on 5/5/21. She acknowledged the findings.
3. Resident 3 was admitted to the Memory Care Unit in March 2021. Resident 3's progress notes, dated 2/1/21 through 4/29/21, identified skin issues on the resident's lower legs that had developed into open areas, resulting in a wound. These open areas constituted a significant change of condition for the resident for which an assessment by the facility RN was required. There was no documented evidence the RN completed a significant change of condition assessment for the open areas on the resident's legs to include findings, resident status, and interventions made as a result of the assessment. The lack of an RN assessment regarding Resident 3's significant change of condition was reviewed with Staff 2 (Resident Care Manager) on 5/5/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for all residents who experienced a significant change of condition, which included findings, resident status and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced significant changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in June 2020 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure and type 2 diabetes mellitus. Review of Resident 1's progress notes and incident reports indicated Resident 1 fell on 4/10/21, resulting in a right arm fracture. This represented a significant change of condition for the resident. There was no documented evidence the facility RN performed an assessment of the resident's significant change of condition, and reviewed updates to the service plan within 48 hours.On 5/5/21 the need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2 (Resident Care Manager). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate system for tracking controlled substances, for 1 of 1 sampled resident (#1) who was prescribed PRN narcotic pain medications. Findings include, but are not limited to:Resident 1 was prescribed PRN hydrocodone and PRN oxycodone, both to treat the resident's chronic pain condition. Resident 1's MAR was reviewed between 4/1/21 and 4/30/21. The following discrepancies related to administration of controlled substances were identified:a. One staff repeatedly failed to document the time a narcotic medication was removed from locked storage on the Narcotic Disposition log, documenting only "am" for medications removed during the morning shift.b. The Controlled Substance Disposition Record indicated 1 oxycodone tablet was removed from locked storage on 4/6/21, 4/9/21, 4/11/21, 4/13/21 and 4/19/21, however, there was no documentation on Resident 1's MAR that the medications were administered.The facility's failure to maintain an accurate system for tracking controlled substances was reviewed with Staff 2 (Resident Care Manager) on 5/5/21. She acknowledged the discrepancies with the narcotic log and Resident 1's MAR.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 7/2019 with diagnoses including dementia with behaviors. The resident's April 1 through May 3, 2021 MARs and physician orders were reviewed. Resident 4 had a buprenorphine patch (for pain) that was not administered four times in April 2021 due to the medication not being available to staff. The failure to ensure physician's orders were followed was reviewed with Staff 1 (RN - Vice President of Operations) on 5/4/21. She acknowledged the findings.
2. Resident 3 was admitted to the Memory Care Unit in March 2021 with diagnoses including dementia and chronic kidney disease. Resident 3's 4/1/21 through 5/3/21 MARs and current physician orders were reviewed and identified the following:a. The following medications documented on the MARs lacked signed physician's orders:* Levothyroxine (for hypothyroidism); and* Furosemide (for edema). b. A physician's order for triamcinolone topical cream (for skin irritation) was not carried out as prescribed multiple times due to medication not being available for staff to administer. c. A physician order dated 4/27/21 instructed staff to perform daily wound care on Resident 3's right leg. There was no documented evidence the order was transcribed onto the MAR and implemented.The need to ensure the facility obtained signed physician orders for all medications and orders were carried out as prescribed was discussed with Staff 1 (RN - Vice President of Operations ) and Staff 2 (Resident Care Manager) on 5/5/21. They acknowledged the findings.
3. Resident 1 was admitted to the facility in June 2020 with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease. Review of the resident's MAR and physician orders indicated the following deficiencies:a. The signed physician orders, dated 2/24/21, included alprazolam (for anxiety) and ipratromium-albuterol duonebulizer (for difficulty breathing) PRN every four hours. These medications were not included on Resident 1's MARs for April 2021 and May 2021, and there were no orders in the resident's record to discontinue the medications.b. PRN hydrocodone (for pain) parameters were not followed as ordered (every eight hours) on the following dates: 4/1/21, 4/3/21, 4/4/21, 4/7/21, 4/8/21, 4/12/21, 4/15/21, 4/18/21.c. PRN cyclobenzaprine (for muscle spasms) was not administered as ordered on 4/1/21 and 4/3/21. The order stated "twice daily as needed". The medication was given three times on both of these dates.d. PRN ondansetron (for nausea) was not administered as ordered on 4/17/21. The order stated "once every 12 hours as needed." Dosages of this medication were given eight hours apart on this date.On 5/5/21 the need to ensure all orders from a physician or other legally recognized prescriber were documented in the resident's MARs and carried out as prescribed was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2 (Resident Care Manager). They acknowledged the findings.

2. Resident 4's 4/1/21 through 5/3/21 MARs were reviewed. The facility failed to provide documented evidence Resident 4's physician was notified relating to the following refusals:* 4/23/21 - acetaminophen and oxycodone;* 4/27/21 - lorazepam;* 4/30/21 - acetaminophen, oxycodone, diclofenac sodium gel, furosemide, memantine, myrbetriq, omeprazole and potassium; and* 5/1/21 - oxycodone. The need to notify the physician when a resident refused to consent to an order was discussed with Staff 1 (RN - Vice President of Operations) on 5/5/21. No additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure the physician was notified when a resident refused consent to an order for 2 of 2 sampled residents (#s 1 and 4) who refused medications. Findings include, but are not limited to:1. Review of Resident 1's MAR, dated 4/1/21 to 4/30/21, indicated the resident refused each of the following medications multiple times: * Alendronate (for bone health);* Diclofenac sodium gel (for arthritis); and* Miralax (for bowel care).There was no documented evidence the facility notified the resident's physician following these medication refusals.On 5/5/21 the need for notification of a resident's physician following refusal to consent to an order was discussed with Staff 1 (RN - Vice President of Operation) and Staff 2 (Resident Care Manager). They acknowledged the findings.

2. Resident 4 was admitted to the Memory Care Unit in 7/2019 with diagnoses including dementia with behaviors. Resident 4's 4/1/21 through 5/3/21 2021 MARs were reviewed during the survey and identified the following: * The reason for use was inaccurate for the ciclopirox solution (used to treat fungal infections); * Two out of four PRN bowel medications lacked clear parameters as to the order in which unlicensed staff were to administer the medications; and* There were no directions to unlicensed staff on where to apply the diclofenac gel (for pain). The need to ensure MARs were accurate and contained resident-specific parameters for use was discussed with Staff 1 (RN - Vice President of Operations) on 5/5/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, contained accurate reasons for use, and included resident-specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3's 4/1/21 through 5/3/21 MARs were reviewed and identified the following:* Multiple medications lacked accurate reasons for use; * Two PRN pain medications lacked resident-specific parameters and instruction for unlicensed staff regarding administration; * Triamcinolone (used for itching) lacked specific instructions for unlicensed staff for application of the cream; and* There were duplicate orders for furosemide (for edema) and potassium (for a supplement). The need to ensure MARs were accurate and contained resident specific parameters for use was discussed with Staff 1 (RN - Vice President of Operations) on 5/5/21. She acknowledged the findings.
3. Review of Resident 1's MAR, dated 4/1/21 to 4/30/21, identified the following deficiencies:* The MAR lacked reasons for use for alendronate (for bone health) and pregabalin (for nerve pain);* The MAR lacked parameters for the order of use of multiple PRN medications for pain, bowel care and nausea; and* The MAR lacked documentation of the amounts of sliding scale insulin administered between 4/1/21 and 4/15/21.On 5/5/21 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2 (Resident Care Manager). They acknowledged the findings.

Based on interview and record review, it was determined 2 of 2 sampled newly-hired direct care staff (#s 8 and 11) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 5/4/21 with Staff 2 (Resident Care Manager). Staff 8 (CG) and Staff 11 (CG), hired on 1/14/21 and 3/4/21, respectively, lacked documentation of the required First Aid and abdominal thrust training.The need to ensure all training was completed within required time frames was discussed with Staff 1 (RN - Vice President of Operations) and Staff 2. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and life safety instruction to staff on alternating months. Findings include, but are not limited to:Fire and life safety records, reviewed on 5/3/21, revealed the following:There was no documented evidence that fire drills were conducted every other month or that fire and life safety instruction was provided to staff on alternating months after 9/28/20 until 3/30/21.In an interview on 5/3/21 at 4:15 pm, Staff 1 (RN - Vice President of Operations) acknowledged the facility failed to conduct fire drills and fire and life safety instruction to staff as required.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways and accesses to the RCF common-use areas were maintained in good repair and the outdoor perimeter fencing was not secured to prevent exit. Findings include, but are not limited to:The exterior of the facility was toured on 5/3/21 at approximately 12:30 pm. The following were identified:a. A section of asphalt in the courtyard between the main RCF building and the independent living building was damaged from a tree root, representing a tripping hazard.b. There were drop-offs along the concrete patio of up to one and one-half inches measured from the concrete to the grass surface in the interior courtyard near the reception area. This created a potential fall hazard.c. The facility had chain-link fencing and gates that enclosed the courtyard between the main RCF building and the independent living building, and that enclosed the property on the northeast and southeast sides of the independent living building. The gates to these areas were locked with a keyed knob-type handle, which would prevent building occupants from exiting in the event of a fire or other emergency.The exterior areas were reviewed with Staff 2 (Resident Care Manager) and Staff 18 (Maintenance) on 5/5/21 at 8:40 am. They acknowledged the walkways and gate locks needed to be addressed.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:The interior of the facility was toured on 5/3/21 at approximately 12:30 pm. The following were identified:* There were small dead winged bugs on the baseboard heater in the hallway across from the reception area;* Sections of the handrails between resident rooms 4 and 6 and rooms 8 and 10 were splintered and very rough to the touch;* There was a large (approximately 30 inches square) section of carpeting missing in the medication room hallway;* Several hallway arm chairs and benches were soiled;* There was a dark spot on the carpet in the MCC hallway near the medication room; and* There was a urine odor in the shower room across from resident room M4 on the MCC unit.The interior areas were reviewed with Staff 2 (Resident Care Manager) and Staff 18 (Maintenance) on 5/5/21 at 8:40 am. They acknowledged the findings.

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 (F) when they are installed in locations that are subject to incidental contact by individuals. Findings include, but are not limited to:The interior of the RCF was toured on 5/3/21 at approximately 12:30 pm. The surveyor observed a long baseboard heater in the hallway across from the reception area which was a location where a resident could come in incidental contact with it. The heater was on and felt hot to the touch. The surface temperature of the heater was in excess of 160 degrees F when measured with the surveyor's digital thermometer. There were similar baseboard heaters installed under the window in each resident's room. A random room (room 108) was selected and, when turned on, the surface of the heater was in excess of 140 degrees F.The baseboard heaters were discussed with Staff 2 (Resident Care Manager) on 5/5/21. She acknowledged the need to address the risks associated with the heaters.

Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in resident rooms within a range of 110 - 120 degrees Fahrenheit (F). Findings include, but are not limited to:On 5/4/21 at approximately 1:15 pm, water temperatures in two public bathrooms and two vacant resident rooms were measured using the surveyor's digital thermometer. The water temperatures were outside the required temperature range as follows:* Public restroom in front of building: 106 degrees F;* Public restroom across from room 108: 125.6 degrees F;* Room 22: 126 degrees F; and* Room 7: 127 degrees F.On 5/5/21, Staff 2 (Resident Care Manager) and Staff 18 (Maintenance) were informed of the water temperatures. Staff 18 began making adjustments to the temperature controls and the water temperatures began to drop.

Based on observation and interview, it was determined the facility lacked a working exit door alarm or other acceptable system for security purposes and to alert staff when residents left the RCF. Findings include, but are not limited to:The interior of the facility was toured on 5/3/21 at approximately 12:30 pm. When exit doors were opened, there was no alarm noted.In an interview on 5/5/21, Staff 2 (Resident Care Manager) acknowledged that, though there were individual alarms on all the exit doors except those leading to the front interior courtyard, the alarms were not all working.

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 C372, C420, C510, C513, C540, C545 and C555.

Based on interview and record review, it was determined the facility failed to ensure staff completed all required pre-service orientation and dementia training for 4 of 4 staff (#s 6, 8, 10 and 12) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed on 5/4/21.Staff 6 (CG) hired 4/23/21, Staff 8 (CG) hired 1/14/21, Staff 10 (Dietary Aide) hired 2/11/21, and Staff 12 (CG) hired 4/12/21 lacked documentation of completing pre-service training within the required time frames in one or more of the following areas:* Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures;* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensure safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being;* Family support and the role 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;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 (RN - Vice President of Operations) on 5/5/21. She 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 C252, C260, C270, C280, C302, C303, C305 and C310.

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 and updated for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the Memory Care Unit on 7/2019 with diagnosis including dementia with behaviors.a. There was no documented evidence a re-evaluation of the resident's initial activity plan had been completed to meet the resident's current psychosocial and physical limitations. The current activity plan failed to address the resident's current preferences, abilities, skills, and emotional/social needs and patterns. b. Per observation on the unit, there was a lack of unscheduled and scheduled activities occurring for residents who were unable to self-initiate activities on their own. The failure to ensure an evaluation of the residents' current abilities in order to develop an individualized activity plan, failure to implement the plan and provide unscheduled and scheduled activities was discussed with Staff 1 (RN - Vice President of Operations) and Staff 21 (Activities Director) on 5/4/21. They acknowledged the findings.
2. Resident 3's service plan, new move-in evaluation and temporary service plans were reviewed. a. The facility failed to evaluate the resident upon move-in to the Memory Care Unit in 3/2021. There was no documented evidence of a person centered activity plan based on the resident's current preferences, abilities and skills, emotional/social needs and patterns and there was no specific activity plan which detailed what, when and how often staff should offer and assist the resident with structured and individualized activities. b. Per observation on the unit, there was a lack of unscheduled and scheduled activities occurring for residents who were unable to self-initiate activities on their own. 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 individualized activity plans were developed and updated was reviewed with Staff 1 (RN - Vice President of Operations), Staff 2 (Resident Care Manager) and Staff 21 (Activities Director) on 5/5/21. They acknowledged the findings.