Brookdale Ontario

The findings of the re-licensure survey, conducted 06/25/24 through 06/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.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 re-licensure survey of 06/27/24, conducted 01/15/25 to 01/16/25, 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 004 for Home and Community Based Services Regulations.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

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse for 1 of 2 sampled residents (# 3) whose incidents were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke. The resident's Temporary Service Plan (TSP), dated 06/14/24, an incident report, progress notes dated 06/14/24 through 06/23/24, Oregon Shift Reports, and interviews with staff revealed the following: Resident 3's TSP, dated 06/14/24, directed staff to reposition him/her every two hours and PRN. A progress note relating to the 06/22/24 unwitnessed fall, stated that Resident 3 was "found on the floor yesterday morning" and that the resident was "unable to say what happened." The note goes on to report Resident 3 had "a small skin tear to [the] right foot, and a small abrasion to [his/her] left forehead."The Oregon Shift Report, dated 06/22/24, reported staff repositioned Resident 3 every three hours on the "Night Shift." And on the "Day Shift", the resident "had a fall out of bed" with "bruising on forehead, shoulder, cheek [left] side."The incident report dated 06/22/24 had no documented evidence the physical injury was not the result of abuse. On 06/27/24, Staff 3 (Health and Wellness Coordinator) stated she had not reported the above incident to the local SPD or AAA office. Survey requested the facility report the incident to the local office. On 06/27/24 at 10:48 am, verification was received of the report to the local office.The need to ensure all injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse was discussed with Staff 1 (Business Office Coordinator), Staff 3, and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) whose evaluation was reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke, hypertension, and heart disease. The Resident Evaluation and Personal Service Assessment were reviewed and revealed missing information in the following required elements: * List of medications and PRN use; * Visits to health practitioner(s), emergency room, hospital, or nursing facilities in the past year; * Vital signs if indicated by diagnoses, health problems, or medications; * Mental health issues including effective non-drug interventions; * Independent activity of daily living including transportation; and * Recent losses. The need to ensure the move-in evaluation included all required elements was reviewed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke, hypertension, and heart disease. The resident's Temporary Service Plan (TSP) dated 06/14/24, and progress notes dated 06/14/24 through 06/23/24, were reviewed. Observations of the resident, and interviews with staff were conducted. The TSP was found to lack clear caregiving instruction, which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas: * Ability to communicate needs and wants;* Right sided (dominant prior to stroke) weakness and any instructions to promote independence relating to eating, drinking, television remote, and pendent use; * Wound care; * Bed bound status; * Which services hospice provided and frequency of the services; * Monitoring an air pressure relieving mattress and who staff would contact if it was in disrepair; * Incontinent care and frequency; * Personal preference relating to straw use, small cup use, and finger foods; and * Emergency evacuation assistance. The need to ensure service plans had clear caregiving instruction, which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 1 of 6 sampled residents (# 3) whose service plans were reviewed. Findings include, but are not limited to:

2. Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke, hypertension, and heart disease. The resident's progress notes, dated 06/14/24 through 06/23/24, and MAR, dated 06/14/24 through 06/25/24, was reviewed and revealed Resident 3 missed four doses of his/her scheduled Baclofen (for muscle spasms) between 06/14/24 and 06/15/24. On 06/26/24 at 11:30 am, Staff 2 (RN) confirmed there was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until the condition resolved. The need to ensure the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until resolution was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease. The resident's progress notes, dated 04/05/24 through 06/20/24, were reviewed and identified the following changes of condition: * 04/29/24 - vomiting; * 05/21/24 - low blood pressure; and * 06/20/24 - loose stools. On 06/27/24 at 9:20 am, Staff 3 (Health and Wellness Coordinator) confirmed there was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until the condition resolved. The need to ensure the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until resolution was discussed with Staff 1 (Business Office Coordinator), Staff 3, and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition, including resident-specific instructions communicated to staff on each shift, and weekly progress noted until the condition resolved for 3 of 4 sampled residents (#s 2, 3 and 5) who had changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2023, with diagnoses including Multiple Sclerosis, congestive heart failure, and hypertension.Review of Resident 2's progress notes, dated 03/25/24 through 06/25/24, revealed the resident experienced the following changes of condition:* On 04/05/24, Resident 2 experienced an episode where s/he was nauseated, "dry heaved", and was pale. The resident also stated s/he had not had a bowel movement in five days; and* On 06/10/24, staff reported the urine in Resident 2's suprapubic catheter bag appeared "cloudy and concentrated".The facility failed to document monitoring of Resident 2's medical changes of condition, at least weekly, to resolution, and failed to determine actions or interventions needed, and communicate them to staff on each shift. On 06/27/24, the need to ensure the facility had a system for monitoring changes of condition, with weekly progress noted, to resolution, and to determine actions or interventions needed, and communicate those to staff on each shift was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator) and Staff 7 (Designee). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication specific instructions, and was initialed by staff for 2 of 3 sampled residents (#s 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted in 06//2024 with diagnoses including stroke. Resident 3's physician and prescriber orders and MAR, dated 06/01/24 through 06/25/24 was reviewed and revealed the following inaccuracies:* An entry on the MAR instructed staff to monitor him/her for being new to community from 06/14/24 through 06/18/24, three times per day. Two of the 12 entries were blank. * Another entry on the MAR directed staff to ensure bilateral pressure relieving boots were on three times a day. There was no documentation on 06/15/24 for the evening check. * An order for 0.1% atropin sulfate ophthalmic solution (for excessive secretions), directed staff to administer four drops by mouth every eight hours, PRN. The facility transcribed the amount as 1% instead of 0.1% on the MAR. * On 06/14/24, a physician wrote an order for one hydrocodone-acetaminophen tablet to be administered by mouth every four hours. On 06/15/24, a prescriber wrote a new order to reflect the administration of two tablets of the same medication given PRN every six hours. The order written on 06/14/24 was the one reflected on Resident 3's MAR. The need to ensure MARs were accurate, included medication specific instructions, and were initialed by staff was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease. The resident's 05/01/24 through 06/25/24 MARs, and progress notes, dated 04/05/24 through 06/20/24, were reviewed and revealed the following inaccuracies:* On 05/17/24, directions were added to the MAR instructing staff to "Please chart any nausea, vomiting, diarrhea. Please chart and call if any rash occurs. Please give with food." There was no direction to staff relating to who to call and what to give with food. * On 06/11/24, a multivitamin (for supplement) was added to the MAR. Staff documented the multivitamin was not available on 06/11/24, 06/12/24, 06/14/24, 06/15/24, and 06/17/24. Staff documented on 06/13/24 and 06/17/24 that the multivitamin was administered. Additionally, there was no documented evidence if the multivitamin was administered on 06/18/24. The need to ensure MARs were accurate and included medication specific instructions was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) that converted residents' evaluated care needs into staff hours to generate a facility staffing plan. Findings include, but are not limited to:On 06/26/24 at 2:57 pm, the ABST was reviewed with Staff 1 (Business Office Coordinator). Staff 1 confirmed that she was provided with a certain number of hours for staff scheduling purposes each week from their corporate office. She could not recall assigning care minutes to each resident for the corporate office to use to determine the weekly allotment. The need to implement an ABST that converted residents' evaluated needs into staff hours to generate a facility staffing plan was discussed with Staff 1 on 06/26/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. Findings include, but are not limited to:In an interview on 01/16/25, Staff 17 (ED) stated the facility's ABST (Service Alignment) had been approved by the department; however, would not be fully implemented until 01/31/25.The facility was unable to provide documented evidence that all 22 of the required ADLs were individually addressed for each resident, nor was the amount of staff time needed for each of the 22 ADL elements.On 01/16/25, the need to ensure the facility fully implemented an ABST that met the regulation was discussed with Staff 17 (ED). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 5 of 5 staff members (#s 4, 5, 9, 10, and 14) had completed the Home and Community Based Services (HCBS) training by 03/31/24, and 3 of 3 new staff (#s 9, 10, and 14) had completed pre-service infectious disease training as required. Findings include, but are not limited to: Three new staff training records were reviewed on 06/26/24. Staff 14 (CG) hired 6/22/23, Staff 9 (MT) hired 2/19/24, and Staff 10 (MT) hired 2/14/2, lacked evidence of completion of both HCBS training and of pre-service infection control and prevention in Community Based Care. Two long term staff training records were reviewed on 06/26/24. Staff 4 (Maintenance Manager) hired 10/01/21, and Staff 5 (Dining Services Coordinator) hired 10/12/21, lacked evidence of completion of HCBS training.The need to ensure staff completed the HCBS training and infectious disease prevention training was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term direct care staff, and 2 of 2 long-term non direct care staff (#s 4, 5, 8, 11, and 16) completed annual infectious disease training. Findings include, but are not limited to: Staff training records for 3 direct care and 2 non-direct care staff were reviewed on 06/26/24. Staff 4 (Maintenance Manager) hired 10/01/21, Staff 5 (Dining Services Coordinator) hired 10/12/21, Staff 8 (MT) hired 0/06/21, Staff 11 (MT) hired 01/07/21, and Staff 16 (CG) hired 08/03/21, lacked evidence they had completed annual infectious disease training as required.The need to ensure that long term direct care and non-direct care staff completed annual infectious disease training as required was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to include and document all required elements in fire drills, and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 06/26/24 identified the following:* The facility failed to relocate or evacuate residents during the monthly fire drills. Therefore, documentation was lacking regarding escape routes used, residents who resisted or failed to participate in the drills, evacuation time periods needed, and number of occupants evacuated. * There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.On 06/27/24, the need to include and document all required elements of fire drills, and to provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), Staff 4 (Maintenance Manager), and Staff 7 (Designee). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 06/26/24 identified the following: There was no documented evidence that annual training on fire safety was provided to residents.On 06/27/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), Staff 4 (Maintenance Manager), and Staff 7 (Designee). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 361.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material. Findings include, but are not limited to:The exterior of the facility was toured on 06/25/24 and 06/26/24. The following was identified: Exterior concrete pathways, including the outside of the facility and in two of the three courtyards, contained multiple drop-offs. These drop-offs created potential hazards for residents that frequently walked the pathways. The building's exterior was toured with Staff 4 (Maintenance Manager) 06/26/24. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in good repair. Findings include, but are not limited to:Observations of the facility's inner courtyard on 06/25/24 revealed two raised gardening beds that were in disrepair.The gardening bed closest to the exit doors had nails along the perimeter which were rusted with the sharp ends exposed. The gardening bed near the center of the courtyard had a supporting board from underneath the bed that was half way detached. The areas in need of repair were shown to and discussed with Staff 4 (Maintenance Manager) on 06/26/24. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:The facility was toured on 06/25/24 through 06/26/24. Interviews with staff during the survey confirmed the doors by which residents could exit the facility to the inner courtyard did not have a working alarm or other acceptable system to alert staff when residents exited the building. Staff also stated the doors in which residents could exit the facility were connected to staff's pagers and would alert staff when the doors would open. During the tour of the facility with Staff 4 (Maintenance Manager) on 06/26/24 at 11:25 am, it was confirmed that not all exit doors alerted staff's pagers when opened. The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 4 on 06/26/24. He acknowledged the findings.

The findings of the kitchen inspection, conducted 08/01/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first re-visit to the kitchen inspection of 08/01/23, conducted 08/31/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to ensure 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 (Dining Services Coordinator). Observations of the facility's kitchen, food storage areas, food preparation, and food service on 08/01/23 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; - Door handle and door of walk-in refrigerator; - Open stainless-steel shelving throughout the kitchen; - Walls throughout the kitchen; - Floors in walk-in refrigerator, walk-in freezer, throughout the kitchen, tile cove base, and drains; - The dishwashing area walls, floors, and equipment; - Both sides and the interior of the range, grill, and oven; - Standing mixer; - Food delivery carts; and - Cages of fans blowing in walk in refrigerator and freezer.* There was no small diameter thermometer to measure the temperature of thin foods.* There was no evidence food temperatures were monitored on the steam table.* The cutting boards attached to the steam table were deeply scored and stained black. * Dish racks were stored directly on the floor.* The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million, the solution was tested, and at the correct level.* There was no evidence the low temperature dish sanitizer machine was monitored to ensure the chorine was at the correct levels and the machine was reaching the required temperature. The machine was tested and the bleach solution was not between 50 and 110 part per million. The temperature gauge appeared to be not operational. Ecolab was immediately contacted and scheduled to service the machine on 08/01/23.The kitchen was reviewed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

The findings of the kitchen inspection, conducted 10/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 10/24/22, conducted 02/15/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 10/24/22 at 3:50 pm, the facility kitchen was observed to need cleaning and repair in the following areas:a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:* Wall behind dish machine;* Between floor tiles in dish machine area;* Caulking on wall behind sink in dish machine area;* Floor perimeter, underneath appliances, and top of tile cove base;* Metal pipe to right of entrance door;* Oven interiors;* Microwave interior;* Wall to right of coffee station;* White floor drains throughout kitchen;* Around faucet and basin of hand wash sink;* Wall to left of entry to dry storage room; and * Grease trap.b. The following areas needed repair:* Grout missing between several floor tiles in dish machine area;* Peeling caulking in dish machine area;* The ceiling above the ice machine had an approximate 1X2 foot area with peeling paint;* The wall next to the hand wash sink had an approximate 2X6 inch scrape; and * The dry storage door had an approximate 2X2 inch hole on the interior.The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) and Staff 2 (Executive Kitchen Manager) during interviews on 10/24/22. The findings were acknowledged.

The findings of the re-licensure survey conducted 7/26/21 through 7/29/21 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 and OARs 411 Division 004 Home and Community Based Services Regulations.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 re-visit to the relicensure survey of 07/20/21, conducted 03/28/22 through 03/29/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 07/29/21, conducted on 06/01/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home, and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to provide a safe and homelike environment for 1 of 1 sampled resident (#2) who lived with cats. Findings include, but are not limited to:Resident 2's service plan identified the resident was independent of taking care of his/her two cats. Observations of Resident 2's apartment revealed the following: * Three cats were living inside; * Excessive stains, cat hair, and litter debris throughout the bedroom carpet;* Buildup of cat waste in the litter box; * Flies swarming around the garbage and cat food; and* A malodorous odor throughout the apartment. In an interview on 7/27/21, Staff 3 (LPN) stated Resident 2 often refused housekeeping services and staff's assistance with caring for the cats.On 7/28/21, the survey team requested the facility develop a plan to address Resident 2's unsafe home environment. The facility submitted a plan the same day which included:* Resident 2 agreed with allowing housekeeping and carpet cleaning in his/her apartment; * Staff would assist with maintaining the litter box and garbage, the specific instructions would be added to the resident's service plan; and* The Executive Director would monitor the resident's room. On 7/28/21, housekeeping was observed entering Resident 2's apartment with cleaning supplies and a vacuum. On 7/29/21, Staff 1 (ED) informed the survey team they had used the facility's carpet cleaner but was unable to remove the stains and odors and scheduled a professional carpet cleaner to come in later that day. The need to provide a safe and homelike environment was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 7/29/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The kitchen was toured on 7/27/21 at 9:40 am. The following areas were in need of cleaning or repair:* Plastic mesh shelf liner was discolored and deteriorating on shelves under the steam table, the prep table with the small sink, and the warewashing counter;* There was grease build-up on the lower shelf of the steam table;* There was dried debris on the underside of the motor housing of the Kitchen-Aid stand mixer;* There was a dried white substance on the inside of the ice scoop holder;* There was dark, dried debris in the corners of the interior of the microwave oven;* There was dust build-up on the grate of a large floor fan;* There were areas of black mold along the wall above the warewashing counter;* There was dark debris collecting around multiple recessed round, metal plates in the kitchen floor; and* Several shelves in wall cabinets had chipped/broken laminate, exposing uncleanable bare wood.The kitchen was toured on 7/28/21 with Staff 1 (ED), Staff 5 (Dining Coordinator) and Staff 6 (Maintenance). Areas needing cleaning or repair were identified. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean, in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:On 03/28/22 at 10:30 am, the facility kitchen was toured with Staff 18 (Dietary Manager). The following areas were in need of cleaning:Black matter, debris, grease, food matter and dirt buildup were observed on or underneath the following:* Walls, pipes and floor under the dish machine;* Caulking in dish machine area;* Shelves, floor and floor-drain underneath the beverage area;* Plastic mesh liners on numerous shelves was discolored and had an accumulation of dried food matter;* Shelves, floor and floor-drain underneath the serving area;* Shelf that housed flour and sugar;* Microwave interior;* The shelf underneath the grill;* Floor underneath the ovens;* Stand mixer;* Lower shelf under the food prep island;* Shelving to left of the stove;* Plate warmer;* The blades and cage of a standing floor fan;* Spice shelves;* Hand wash sink; * Floor drain underneath the two-compartment sink; and * Several walls and ceiling had an accumulation of lint and dirt.The areas that required cleaning were observed and discussed with Staff 1 (Executive Director) and Staff 18 on 03/28/22 at 11:15 am. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4), and failed to ensure quarterly evaluations addressed components that were relevant to the needs and current condition of the resident for 1 of 3 sampled residents (# 2) whose records were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 6/2021. A review of the resident's initial move-in evaluation failed to address and provide accurate information for the following required elements: * Customary routines;* Spiritual, cultural preferences;* Physical health status including list of medications and PRN use, visits to health practitioner, ER, hospital or NF in the past year;* Cognition, including decision making abilities;* Communication and sensory including ability to understand and be understood;* Activities of daily living including toileting, bowel and bladder management, mobility - ambulation, transfer and eating status;* Independent activities of daily living including housework and laundry and transportation;* Pain with non-pharmaceutical interventions;* Nutrition habits;* List of treatments;* Indicators of nursing needs, including potential for delegated nursing tasks; and* Emergency evacuation ability.Additionally, there was no documentation an evaluation had been completed which included changes as appropriate within the first 30 days.The need to ensure all required elements were accurately addressed and changes were evaluated and included within the first 30 days was discussed with Staff 1 (ED) and Staff 2 (RN) on 7/28/21 and 7/29/21. The staff acknowledged the findings.2. Resident 2's 7/27/21 quarterly evaluation failed to be reflective of the resident's condition in the following areas:* Ability to perform ADLs; * Status of cats including the ability to take care of them;* Behaviors related to resisting care;* Recent loss;* Mental status including hallucinations; and* Skin status.The need to ensure evaluations were accurate and reflective of the resident's condition was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) during the survey. The staff acknowledged the findings.

3. Resident 3's service plan, dated 6/4/21, and subsequent temporary service plans were reviewed during the survey and lacked specific instruction to staff in the following areas: * Showering, dressing/undressing and toileting status related to receiving wound vac machine:* Mobility and use of assisted device; and* Current skin status.4. Resident 4's service plan, dated 7/19/21, and subsequent temporary service plans were reviewed during the survey and lacked specific instruction to staff in the following areas: * Use of Coumadin including what to monitor and who to report if any; and* Ability to use of call light.The need to ensure resident service plans were reflective of resident needs and provided instructions for staff as to what, when, how and how often services would be provided was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 7/28/21 and 7/29/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided instructions for staff as to what, when, how and how often services would be provided, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3 and 4's service plans were reviewed during the survey. The following deficiencies were identified:1. Resident 1's current service plan, dated 5/14/21, lacked information about the resident's status and care needs or lacked instructions for staff as to the services to be provided in the following areas:* The service plan did not indicate the resident used adaptive silverware due to his/her physical conditions;* The service plan stated both that the resident was continent and incontinent; interviews with staff indicated the resident was incontinent;* The service plan lacked specific instructions for staff as to how to transfer and assist the resident with toileting, given the resident's physical conditions;* The service plan did not indicate the resident used a transfer pole and there were no instructions for staff as to how to monitor that the transfer pole continued to be safely installed;* The service plan did not indicate the resident used a fall mat and lacked instructions for staff as to its use;* The service plan did not indicate the resident used a pillow to help with positioning in his/her wheelchair and lacked instructions for staff for its proper use; and* The service plan did not indicate the resident was experiencing increased confusion and delusions.
2. Resident 2's service plan dated 4/23/21 was not reflective of the resident's current status and care needs and lacked clear direction to staff in the following areas:* Dressing, grooming, and personal hygiene status; * Bathroom assistance;* Meal assistance;* Hospice shower schedule;* Hallucinations;* How many pets were living in the apartment; and* The resident's ability to care for her/his cats.

2. Resident 3 was admitted to the facility in 8/2016 with diagnoses including, Type II Diabetes.Resident 3's clinical records were reviewed during the survey and revealed the following:* 5/20/21 MAR directed staff to administer Hydroxyzine 25 mg three times daily;* The medication was not administered to the resident due to the medication was unavailable or the resident was sleeping; and* 6/8/21 -Primary care provider prescribed Hydroxyzine to 50 mg three times daily due to continued itching. The dose was increased from 25 mg to 50 mg.There was no documented evidence of evaluation for the new dose of the medication and monitoring the effectiveness of the medication including least weekly progress notes until resolution.On 7/28/21 and 7/29/21, the failure to evaluate the for the new dose of the medication and monitoring the effectiveness of the medication was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN). They acknowledged the findings.3. Resident 4 was admitted to the facility in 6/2021 with diagnoses including stroke.Resident 4's clinical records were reviewed during the survey. There was no documented evidence the facility evaluated the resident status with a new environment, relocation from independent living to assisted living setting and monitored the resident condition including adjustment to the new living setting condition until resolved.On 7/29/21, the failure to monitor Resident 4's change of condition was reviewed with Staff 1 (ED) and Staff 3 (LPN). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure actions or interventions were determined, documented and communicated to staff, determined actions were resident-specific and the resident was monitored consistent with his/her evaluated needs and service plan, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who had changes of condition or who required monitoring. Findings include, but are not limited to:Resident 1, 2, 3 and 4's records were reviewed during the survey. The following deficiencies were identified:1. Between 4/27/21 and 7/26/21, the record indicated Resident 1 had 10 documented incidents where staff found the resident on the floor or the resident reported s/he had fallen. Two of the ten falls resulted in minor injuries.a. * There were no actions/interventions documented and communicated to staff for a fall on 5/21/21.* Actions/interventions noted on the Temporary Service Plans (TSPs) were not resident-specific for falls on 5/15/21, 6/23/21, and two falls on 7/9/21 and 7/12/21.* There was no documented monitoring of the resident's status following falls on 5/21/21, 6/11/21, two falls on 7/9/21 and 7/12/21.* The facility did not document on the status of a laceration to the forehead sustained 5/5/21 and three abrasions around the left eye sustained 6/11/21 at least weekly until resolved.b. Following each of the ten falls, the facility failed to monitor service-planned fall interventions to determine and document if the service plan was being followed and the interventions were effective or whether additional interventions needed to be developed to try to minimize further falls.The need to ensure the facility had a process for informing staff what actions were needed following Resident 1's falls and for monitoring whether the actions were being implemented and were effective, was reviewed with Staff 1 (ED) and Staff 3 (LPN) on 7/28/21 and 7/29/21. They acknowledged the findings.
4. On 7/26/21, Resident 2 was identified as a fall risk during the entrance conference. Resident 2's current service plan had universal/generic fall precautions. Review of the resident's temporary service plans (TSPs) identified the resident experienced a fall on 4/12/21.The TSP and subsequent documentation lacked documented evidence the facility determined what actions or resident-specific fall interventions were needed for the resident or monitored and documented on the resident's status until it was resolved. The need to ensure the fall interventions were resident-specific and reviewed to determine if they were effective and appropriate was shared with Staff 1 (ED) on 7/29/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 2 of 3 sampled residents (#s 2 and 3) whose MARs and Controlled Substance Drug Disposition logs were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2020 with diagnoses including chronic pain and major depressive disorder. Resident 2's physician orders directed staff to administer Lorazepam, Oxycodone and Pregabalin for pain and anxiety. Resident 2's 7/1/21 - 7/26/21 MARs and the Controlled Substance Disposition Log were reviewed and revealed the following: * On 7/6/21, staff documented Lorazepam was dispensed on the Controlled Substance Disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 2.* On five occasions, 7/8/21, 7/10/21, 7/18/21, 7/22/21 and 7/24/21, Staff documented the Pregabalin was administered on the MAR at 2:00 pm. There was no documented evidence on the Controlled Substance Disposition log the medication was dispensed on those days. * On 7/23/21, staff documented Pregabalin was dispensed on the Controlled Substance Disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 2.* On 7/5/21, staff documented the Oxycodone was dispensed on the Controlled Substance Disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 2.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 7/29/21 with Staff 1 (ED).2. Resident 3 was admitted to the facility in 2016 with diagnoses including chronic pain.Resident 3's physician order dated 5/25/21 directed staff to administer PRN Hydrocodone-Acetaminophen 10-325 mg every six hours for pain. Resident 3's 5/1/21 - 7/26/21 MAR and the Controlled Substance Disposition Log were reviewed and revealed the following: * On 13 occasions, 5/19/21, 5/20/21, 5/24/21, 6/7/21, 6/13/21, 6/14/21, 6/21/21, 7/1/21, 7/7/21, 7/12/21, 7/16/21, 7/21/21, and 7/24/21, staff documented Hydrocodone-Acetaminophen 10-325 mg were dispensed on the Controlled Substance Disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 3 on those days;* On 5/22/21, staff documented Hydrocodone-Acetaminophen 10-325 mg was dispensed on the Controlled Substance Disposition log at 3:49 am. However, Staff documented on the MAR, they administered the Hydrocodone-Acetaminophen 10-325 mg medications at 3:47 pm, approximately 12 hours later.* On 5/28/21, staff documented Hydrocodone-Acetaminophen 10-325 mg was dispensed on the Controlled Substance Disposition log at 3:00 pm. However, Staff documented on the MAR, they administered the Hydrocodone-Acetaminophen 10-325 mg medications at 12:20 am, approximately 15 hours before the medication was dispensed.* On 6/2/21, staff documented Hydrocodone-Acetaminophen 10-325 mg was dispensed on the Controlled Substance Disposition log two times. However, Staff documented on the MAR, they administered the Hydrocodone-Acetaminophen 10-325 mg medication three times on 6/2/21.* On 7/17/21, staff documented Hydrocodone-Acetaminophen 10-325 mg was dispensed on the Controlled Substance Disposition log one time to Resident 3. However, Staff documented on the MAR, they administered the Hydrocodone-Acetaminophen 10-325 mg medication two times on 7/17/21.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (RN) on 7/28/21 and 7/29/21. They reviewed the documentation and acknowledged the discrepancies.

Based on interview and record review, it was determined the facility failed to carry out medication or treatment orders as prescribed, for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:Resident 1, 2 and 3's signed physicians orders were reviewed during the survey, along with their MAR and medication administration notes. The following deficiencies were identified:1. Between 6/1/21 and 7/25/21, documentation indicated Resident 1 was not administered the following medications as ordered on multiple occasions because the medication was not available:* Docusate sodium (to treat constipation) to be administered once daily;* Tylenol PM Extra Strength tablet (to treat pain) to be administered at bedtime;* Morphine sulfate extended release tablet (to treat chronic pain) to be administered twice daily; and* Selegiline tablet (to treat symptoms of Parkinson's disease) to be administered twice daily.2. Between 7/1/21 and 7/25/21, the MAR lacked documentation that Resident 2 was administered the following medications on multiple occasions as ordered:* Atorvastatin 80 mg (lowers cholesterol) to be administered once daily;* Wellbutrin 150 mg (for depression) to be administered once daily;* Basaglar (insulin to lower blood sugar level) 50 units to be administered twice daily;* Ferrous sulfate 325 mg (supplement) to be administered twice daily;* Metoprolol 100 mg (lowers high blood pressure) to be administered twice daily;* Hydroxyzine 10 mg (for pain) to be administered three times daily; and* Pregabalin (for pain) to be administered three times daily.3a. Between 7/1/21 and 7/25/21, documentation indicated Resident 3 was not administered the following medications as ordered on multiple occasions because the medications were not available, the resident was asleep or other unspecified reason:* Aspirin (for heart health) to be administered once daily;* Fluticason inhaler (for chronic obstructive pulmonary disease) to be administered once daily;* Methiamazole tablet (for chronic obstructive pulmonary disease) to be administered once daily; * Latanoprost eye drops (for glaucoma) to be administered once daily;* Losartan potassium (for hypertension) to be administered once daily;* Metoprolol succinate (for hypertension) to be administered once daily;* Spironolactone tablet (for hypertension) to be administered once daily;* Lactobacillus (supplement) to be administered twice daily;* Senna - docusate sodium tablet (for constipation) to be administered twice daily;* Cephalexin (antibiotic to treat cellulitis) to be administered three times daily;* Hydroxyzine (for itching) to be administered three times daily; and* Nystatin cream (for yeast rash) to be administered four times daily.b. Resident 3's physician order dated 5/25/21 directed staff to administer PRN Hydrocodone-Acetaminophen 10-325 mg every six hours for pain. Resident 3's 6/1/21 through 7/26/21 MAR revealed one occasion, 6/29/21, the medication was administered in 4 hours 17 minutes between doses, not in 6 hours as ordered. The need to ensure medications were available, were administered as ordered and were documented as administered was reviewed with Staff 1 (ED) and Staff 3 (LPN) on 7/28/21 and 7/29/21. They acknowledged there needed to be better oversight of the medication administration system.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused consent to an order, for 2 of 2 sampled residents (#s 1 and 3) with documented refusals to take medications as ordered. Findings include, but are not limited to:Resident 1 and 3's MARs and administration notes were reviewed between 7/1/21 and 7/26/21.Documentation indicated Residents 1 and 3 refused multiple prescribed medications on multiple days during the time period. There was no documented evidence the residents' physicians/prescribers were notified when the resident refused a medication.In interviews on 7/28/21, Staff 10 (MT) and Staff 3 (LPN) acknowledged the residents' physicians had not been notified of the refusals. Staff 3 acknowledged the facility did not have a policy and procedure by which physicians were notified when a resident refused an ordered medication or treatment.The need to develop and implement a policy and procedure for notifying the physician when a resident refused consent to an order was discussed with Staff 1 (ED) on 7/29/21. She acknowledged the findings.

2. Resident 3 was admitted to the facility in August 2016 with chronic pain.Resident 3's 7/1/21 through 7/26/21 MARs were reviewed and lacked resident-specific parameters regarding PRN medications to guide unlicensed staff in the following area:* No indication of location for the administration of topical cream.The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 7/28/21 and 7/29/21. The staff acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications and medication-specific instruction to direct non-licensed staff for 2 of 3 sampled residents (#s 2 and 3) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 2020 with diagnoses including type II diabetes. The resident's 7/1/21 through 7/26/21 MAR and physician orders were reviewed and identified the following:* Multiple blanks were located on the July 2021 MAR for medications including Basaglar and Novolog (insulin's for lowering blood sugar), Senna (constipation), Wellbutrin (depression), ferrous sulfate (supplement) and metoprolol (blood pressure); and* Observations and interview of the resident on 7/27/21 and 7/28/21 revealed the MT's were checking Resident 2's blood sugar. The MAR indicated the resident was checking her/his own blood sugar and communicating those results to staff. The need to ensure MARs were accurate and included clear direction to staff for medication administration was discussed with Staff 1 (ED) on 7/29/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#4) who self-administered medications. Findings include, but are not limited to:On 7/27/19 at 10:45 am, a pill box was observed in Resident 4's room. Resident 4 and his/her partner stated they managed their own medications.Resident 4's 7/1/21 - 7/26/21 MAR indicated the resident self-administered his/her medications.There was no documented evidence the facility evaluated Resident 4's ability to safely self-administer the medications.On 7/27/21, Staff 2 (RN) confirmed there was no evaluation related to self-administration for Resident 4. During an interview on 7/28/21 and 7/29/21, the lack of an evaluation was shared with Staff 1 (ED). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled direct care staff (#15) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (ED) on 7/29/21. Staff 15 (CG) was hired 3/31/20. Annual training records, provided through online training courses and monthly staff meetings, was reviewed between 4/1/2020 and 3/31/2021.The records indicated Staff 15 completed a total of four hours of in-service training on topics related to the provision of care for persons in a community-based care setting. None of the training was related to dementia.The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 on 7/29/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented all required components in accordance with Oregon Fire Code every other month, and Life Safety instruction was provided to staff on alternating months. Findings include, but are not limited to:Review of Fire and Life safety records on 7/27/21 for January 2021 through June 2021 lacked documentation of the following:* Fire and life safety instruction to staff on alternate months;* Fire drills conducted and recorded every other month;* The facility was not consistently relocating or evacuating residents during fire drills; and* Documentation was lacking or incomplete regarding: - Escape route used; - Resident evacuation problems encountered; and - Number of occupants evacuated.On 7/29/21, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drills included required components according to the Oregon Fire Code was reviewed with Staff 1 (ED) and Staff 6 (Maintenance). They acknowledged the findings.

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

Based on observation 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 of the facility on 7/26/21 and 7/27/21 revealed the following:* Multiple chairs and couches throughout the facility had scuffs, scrapes, and worn off finishes, creating an uncleanable surface;* Carpet throughout the common areas had spots, stains and blackened areas in the hallways and in front of multiple resident rooms throughout the building;* Handrails had chip painted exposing wood;* Room 24 had a gouged door and doorframe;* The laundry room floors had black particles and stains; * There was an unpleasant odor in Room 29; and* Washing machines and dryers had thick layers of dust, debris, and black matter on the surfaces.The environment was toured on 7/27/21 with Staff 6 (Maintenance). He acknowledged the above areas needed to be cleaned and repaired.