Countryside Living of Redmond

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown origin were promptly investigated to rule out abuse and neglect, and failed to report incidents of abuse for 2 of 2 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2016 with diagnoses including a traumatic brain injury and dementia. Review of the resident's progress notes and incident investigations from 08/01/23 through 11/13/23 identified: * 11/05/23 Progress note - "Resident being placed on alert for a res to res altercation. This resident had been sitting in the living room, watching football, when another resident disrupted [him/her] somehow. [S/he] grabbed [his/her] forearm and caused redness and bruising." * 11/05/23 Resident to Resident Incident Report - "Carestaff [name] stated that [Resident 1] had [resident initials] by the wrist/forearm and twisted it, causing redness and bruising." There was no evidence the incident was immediately reported to the local SPD office. The need to immediately report any incident of abuse and neglect to the local SPD office as required was discussed with Staff 1 (Administrator) and Staff 2 (RCC). They acknowledged the findings and reported the incidents to the local SPD. Confirmation of the reporting was received. 2. Resident 2 was admitted to the facility in 08/2020 with diagnoses including dementia. Review of the resident's progress notes and incident investigations from 08/01/23 through 11/13/23 identified: * 08/22/23 Progress Note - "Resident is being placed on alert for a small bump/abrasion on forehead. Resident observed with a small bump on her forehead...small abrasion with slight swelling also observed." There was no evidence the injury of unknown origin was investigated to rule out possible abuse or neglect, nor evidence the injury was immediately reported to the local SPD. The need to report injuries of unknown cause 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 was not the result of abuse, was discussed with Staff 1 (Administrator) and Staff 2 (RCC). They acknowledged the findings and reported the incident to the local SPD. Confirmation of the reporting was received.

Self Reporting Abuse and Neglect to APS: 1.   Corrected Immediately, RCC/RCC Assistant/All Staff have been made aware and given the APS reporting tool as a guide for what needs to be reported, either by calling the Abuse Hotline or faxing. 2.  The noted violations in the SOD were corrected at the time of the Survey, incidents for Residents 1 and 2 reported.  Injuries of unknown origin or Resident to Resident Incidents etc. (as outlined in the Abuse Reporting Tool will be adhered too immediately if abuse and neglect cannot be ruled out) Staff understand to report within the alloted hours as outlined even if investigation is ongoing. Staff understand if they have questions regarding a situation to follow protocol and either fax to APS or call the Abuse Hotline to make a report.   3.  Evaluated: This will be competed on a daily basis and ongoing. 4.  Responsible Party:  RCC/RCC Assistant and Administrator will follow up and follow through with the process and guiding the staff continuously on self reporting processes.

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations and ensure evaluations were reflective of the residents' current condition for 2 of 3 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2020 with diagnosis of dementia. Resident 2's current evaluation, dated 04/19/23, was not reflective of his/her current care needs related to intrusive behaviors putting the resident at risk for altercations. During the survey Resident 2 was observed to wander throughout the facility, into other residents rooms and personal space. Facility records indicated Resident 2 had been in several altercations with other residents while wandering. The incidents were reported to the local unit. Resident 2's quarterly evaluations, due in 07/2023 and 10/2023, were not done. The need to ensure the quarterly evaluation was completed timely and was reflective was discussed with Staff 1 (ED) and Staff 2 (RCC) on 11/15/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 03/2022 with diagnosis of dementia. Resident 3's current evaluation, dated 04/12/23, was not reflective of his/her current care needs related to: * Weight loss; and * Assistance with eating, aspiration risk, thickened liquids, and meal texture; and * The use of a fall mat. During the survey Resident 3 was observed to be provided thickened liquids and a minced moist texture meal. Staff assisted Resident 3 with eating all meals. A fall mat was observed either under or folded at the foot of Resident 3's bed. Resident 3's quarterly evaluations, due in 07/2023 and 10/2023, were not done. The need to ensure the quarterly evaluation was completed timely and reflective was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 11/15/23. They acknowledged the findings.

Service Planning/Updates: 1.  Transitioning from current system to new system, Service Plan have TSP's in place, and transcribed on to the fluid working plan, dated, what new service is provided, and who made the change. Scheduled Service Plan updates are in place currently to manage keeping on schedule; barring COC's. Resident 2 and 3 evaluations updated. 2.  This has been corrected by utilizing the update schedule and the TSP (Temporary Service Plan) that indicates a change in service, whether temporary, or permanent (which will be added to the fluid plan in red ink, dated, and initialed).  Until new Plan is typed 3.  Evaluated bi-monthly with the Team by the Administrator. By meeting and reviewing each resident plan (chart notes, incidents etc) 4.  Reponsible Party:  Overall it is the Admins responsibility to assure this is completed timely,  RCC/RN/Family/POA's/Caseworker also to be apart of the service planning proccess.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: The most recent service plans for Residents 1, 2, and 3 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team. On 011/15/13, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator) and Staff 2 (RCC). They acknowledged the findings.

Service Plannin Team: 1.  Effective Immediately it will be indicated who was involved in the Service Planning meeting.  this will be documented on the Service Plan itself. 2.  As above 3.  Evaluated each service plan meeting 4.  Admin/RCC will be responsible to notify all parties on the team for service plan updates and meetings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs and service planned interventions for 3 of 3 sampled residents (#s 1, 2, and 3) reviewed for falls.  Findings include but are not limited to: 1. Resident 1 was admitted to the facility in 01/2016 with diagnoses of dementia and was evaluated to be at risk for falls. Resident 1 was observed during the survey to utilize a wheelchair for mobility. Resident 1's current service plan indicated the resident was a fall risk and provided interventions to reduce falls. Resident 1's clinical record revealed the resident was noted to have fallen on 09/14/23 and injured his/her wrist. There was no documented evidence Resident 1's fall interventions were evaluated and monitored for effectiveness. 2. Resident 2 was admitted to the facility in 08/2022 with diagnoses of dementia and was evaluated to be at risk for falls. Resident 2 was observed during the survey to ambulate independently throughout the facility. Resident 2's current service plan indicated the resident was a fall risk and provided interventions to reduce falls. Resident 2's clinical record revealed the resident was noted to have fallen on 10/02/23 and injured his/her head. There was no documented evidence Resident 2's fall interventions were evaluated and monitored for effectiveness. 3. Resident 3 was admitted to the facility in 03/2022 with diagnoses of dementia and was evaluated to be at risk for falls. Resident 3 was observed during the survey to ambulate independently throughout the facility. Resident 3's current service plan indicated the resident was a fall risk and provided interventions to reduce falls. Resident 3's clinical record revealed the resident was noted to have fallen twice on 08/11/23, once on 09/11/23, and once on 09/13/23. There was no documented evidence Resident 3's fall interventions were evaluated with each instance and monitored for effectiveness. The need to monitor interventions related to the falls experienced by Residents 1, 2, and 3 was reviewed with Staff 1 (Administrator) and Staff 2 (RCC) on 11/15/23. They acknowledged the findings.

Change of Condition: 1.  During the investigations for COC person(s) completing the investigation will also review/note if the interventions to minimize risk of injury are effective, if not then a new plan for interventions will be implemented.  This will be documented in the Chartnotes. 2.  Will adhere to the above and/or on a quarterly basis. 3.  Evaluated:  Will be evaluated as a team, on incident or COC or quarterly for effectiveness of plan to minimize risk of injury. 4.  Responsible Party:  RCC/RN and Administrator will follow through and involve team members who are providing day to day services and adhere to their recommendations and update Plan of interventions.

Based on interview and record review, it was determined the facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST tool.  Findings include, but are not limited to: The facility's ABST tool calculations, resident ABST data entries and the facility's staffing plan were reviewed on 11/15/23 and 11/16/23. Review of resident ABST entries showed multiple ADL areas which reflected excessive minutes for care. Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (Administrator). Staff 1 acknowledged the staffing plan was not accurate. The facility had a census of 35 residents at the time of the survey. Review of the staffing plan generated by the ABST indicated a need for over 30 staff at times. The need to ensure ABST resident entries were accurate and staffing calculations were used to develop and implement a staffing plan to meet resident needs was discussed with Staff 1 on 11/15/23.

ABST TooL 1.  This was completed, however, inputted time incorrectly.  Met with Katie via zoom and re-educated on ABST tool. 2.  Correct as of this date 3.  Will be evaluated as services change for residents and updated within 24 hours to reflect current needs for residents.  minimally quarterly. 4.  Responsible Party:  Administrator

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff (#s 11 and 12) completed the required annual infectious disease prevention training. Findings include, but are not limited to: Training records were reviewed on 11/15/23. Staff 11 (CG), hired 11/14/21, and Staff 12 (CG), hired 11/02/15, lacked documented evidence of completing the required annual infectious disease prevention training. The need for all employees to complete annual training on infectious outbreaks and infection control was reviewed with Staff 1 (Administrator) and Staff 4 (Human Resources Manager) on 11/15/23. They acknowledged the findings.

Training: 1.  Action:  Annual Infection Control (2-hour) annual training and upon hire (Orientation). 2.  Corrected as of 12-15-2023 All staff that are currently employed have completed the two hour training and are in compliance. 3.  Orientation internal tool has been updated to include the 2-hour infection control, facility walk through, etc.  All trainings will have Dementia indicated for all in-service or Relias trainings. 4.  Human Resources is responsible, Administrator to follow up with routine audits for compliance.

Based on record review and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: Review of records for Residents 1, 2, and 3 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 11/15/23. They acknowledged the findings.

Individual Door Locks Key Access 1.  Although doors are unlocked, each resident who resides currently and future residents will be provided with one key to their respective unit. 2.  As above 3.  This will be evaluated during the move in process to assure each resident is provided a room key.  this will be documented on the Service Plan as well. 4.  Office Manager/RCC and Admin will be responsible for this process.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 361, and C 374.

Self Reporting Abuse and Neglect to APS: 1.   Corrected Immediately, RCC/RCC Assistant/All Staff have been made aware and given the APS reporting tool as a guide for what needs to be reported, either by calling the Abuse Hotline or faxing. 2.  The noted violations in the SOD were corrected at the time of the Survey.   Injuries of unknown origin or Resident to Resident Incidents etc. (as outlined in the Abuse Reporting Tool will be adhered too immediately if abuse and neglect cannot be ruled out) Staff understand to report within the alloted hours as outlined even if investigation is ongoing. Staff understand if they have questions regarding a situation to follow protocol and either fax to APS or call the Abuse Hotline to make a report.   3.  Evaluated: This will be competed on a daily basis and ongoing. 4.  Responsible Party:  RCC/RCC Assistant and Administrator will follow up and follow through with the process and guiding the staff continuously on self reporting processes. ABST TooL 1.  This was completed, however, inputted time incorrectly.  Met with Katie via zoom and re-educated on ABST tool. 2.  Correct as of this date 3.  Will be evaluated as services change for residents and updated within 24 hours to reflect current needs for residents.  minimally quarterly. 4.  Responsible Party:  Administrator Training: 1.  Action:  Annual Infection Control (2-hour) annual training and upon hire (Orientation). 2.  Corrected as of 12-15-2023 All staff that are currently employed have completed the two hour training and are in compliance. 3.  Orientation internal tool has been updated to include the 2-hour infection control, facility walk through, etc.  All trainings will have Dementia indicated for all in-service or Relias trainings. 4.  Human Resources is responsible, Administrator to follow up with routine audits for compliance.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 7, 8, 9 and 10) completed the pre-service Infectious Disease Prevention training. Findings include, but are not limited to: Training records for Staff 7 (CG), hired 3/24/23, Staff 8 (CG), hired 07/19/23, Staff 9 (CG), hired 07/24/23, and Staff 10 (CG), hired 10/06/23, were reviewed with Staff 4 (Human Resources Manager) on 11/15/23. There was no documented evidence Staff 7, 8, 9, and 10 had completed  the required pre-service Infectious Disease Prevention training. The need to ensure staff completed all required pre-service training was discussed with Staff 1 (Administrator) on 11/15/23. She acknowledged the findings.

Training: 1.  Action:  Annual Infection Control (2-hour) annual training and upon hire (Orientation). 2.  Corrected as of 12-15-2023 All staff that are currently employed have completed the two hour training and are in compliance. 3.  Orientation internal tool has been updated to include the 2-hour infection control, facility walk through, etc.  All trainings will have Dementia indicated for all in-service or Relias trainings. 4.  Human Resources is responsible, Administrator to follow up with routine audits for compliance.

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 C 252, C 262, and C 270.

Service Planning/Updates: 1.  Transitioning from current system to new system, Service Plan have TSP's in place, and transcribed on to the fluid working plan, dated, what new service is provided, and who made the change. Scheduled Service Plan updates are in place currently to manage keeping on schedule; barring COC's. 2.  This has been corrected by utilizing the update schedule and the TSP (Temporary Service Plan) that indicates a change in service, whether temporary, or permanent (which will be added to the fluid plan in red ink, dated, and initialed).  Until new Plan is typed 3.  Evaluated bi-monthly with the Team by the Administrator. By meeting and reviewing each resident plan (chart notes, incidents etc) 4.  Reponsible Party:  Overall it is the Admins responsibility to assure this is completed timely,  RCC/RN/Family/POA's/Caseworker also to be apart of the service planning proccess.. Service Plannin Team: 1.  Effective Immediately it will be indicated who was involved in the Service Planning meeting.  this will be documented on the Service Plan itself 2.  As above 3.  Evaluated each service plan meeting 4.  Admin/RCC will be responsible to notify all parties on the team for service plan updates and meetings. Change of Condition: 1.  During the investigations for COC person(s) completing the investigation will also review/note if the interventions to minimize risk of injury are effective, if not then a new plan for interventions will be implemented.  This will be documented in the Chartnotes. 2.  Will adhere to the above and/or on a quarterly basis. 3.  Evaluated:  Will be evaluated as a team, on incident or COC or quarterly fdor effectiveness of plan to minimize risk of injury. 4.  Responsible Party:  RCC/RN and Administrator will follow through and involve team members who are providing day to day services and adhere to their recommendations and update Plan of interventions.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to: Observations during the survey between 11/14/23 and 11/16/23 showed the doors to the exterior courtyard were locked at times and did not allow residents to exit and return. The courtyard doors were locked on 11/14/23. In an interview on 11/14/23, with Staff 2 (RCC), he explained the doors were on a schedule to be automatically locked and unlocked, and the computer required a reset. The courtyard doors were unlocked on 11/15/23. The doors were locked on 11/16/23. The need to ensure residents had access to the secured outdoor space without staff assistance was reviewed with Staff 1 and Staff 2. They acknowledged the findings.

Outside Area: 1. Action corrected immediately barring severe inclement weather 2.  Doors will be open during waking hours to allow access to outdoor courtyard barring severe inclement weather; 3.  This will be evaluated daily as weather changes. 4.  Responsible Party:  Activities team and RCC, RCC Assistant to assure outdoor access is available

The findings of the re-licensure survey, conducted 11/14/23 through 11/16/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the re-visit to the re-licensure survey of 11/16/23, conducted 02/07/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. Upon entering the facility on 09/14/22, two facility kitchen staff were observed not wearing face masks. The need to ensure staff fully and consistently complied with masking requirements was discussed with Staff 1 (Resident Care Coordinator) and Staff 2 (Human Resources). They acknowledged the findings.

Staff are required to wear masks while working in a setting other than an office (with door closed):  Staff will wear a facial mask at all times while working. 1.  Upon entering CSL, masks are availabe after COVID screening is completed. staff will garner a facial mask that is provided and as needed throughout their working shift. 2.  Staff will be monitored throughout the working shift, for compliance:  by in person impromptu visits from a Manager, by camera view, and by peer monitoring. Managers consist of:  Admin, RCC, HR, OM.  Camera view access by HR and Admin.  Correction will be made at the time for compliance. 3.  Failure to comply will result in disciplinary action up to and including termination of employment.

Based on observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facilities kitchen, food storage areas, food preparation and food service on 09/13/22 revealed: * Frozen chicken was observed left in a sink basin at 8:00 am. At 8:15 it was noted to be in standing water. Staff were directed to thaw the chicken under cold running water; * No documented evidence the wiping cloth sanitizer bucket was monitored to ensure the sanitizer was dispensing at the correct parts per million; * Staff were observed to not change gloves between tasks or sanitize hands upon entering the kitchen; and   * Staff in the kitchen did not have hair fully restrained. The food handling, hand hygiene process, and hair restraint requirements were reviewed with Staff 1 (Resident Care Coordinator) and Staff 2 (Human Resources). They acknowledged the findings.

Defrosting frozen items:  1.  Staff will pull frozen product and place in the refridgerated area for defrosting at least 2-days prior to cooking.  2. Sanitation bucket (red bucket).  Santizing strips purchased for use to ensure correct parts per million.  this will be completed each time the bucket is refilled. 3.  Changing of gloves in between tasks:  Hand sanitizer has been purchased and place at each site for the Cook and Dining Service Aide to use in between serving plates at meals time;  DSA will deliver food plates to residents, return to kitchen sanitize hands before delivering additional plates.  Cooks will utilize gloves, if utensils are a not available, changing in between tasks: Cooks will use serving utensils while dishing food onto plates at meal time.  4.  All cooks are required to have their hair pulled back away from their face, (in a bun) or restrained by a cap or hair-net. Staff will be monitored throughout the working shift, for compliance:  by in person impromptu visits from a Manager, by camera view, and by peer monitoring. Managers consist of:  Admin, RCC, HR, OM.  Camera view access by HR and Admin.  Correction will be made at the time for compliance. 3.  Failure to comply will result in disciplinary action up to and including termination of employment.

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 160 and C 240.

Staff are required to wear masks while working in a setting other than an office (with door closed):  Staff will wear a facial mask at all times while working. 1.  Upon entering CSL, masks are availabe after COVID screening is completed. staff will garner a facial mask that is provided and as needed throughout their working shift. 2.  Staff will be monitored throughout the working shift, for compliance:  by in person impromptu visits from a Manager, by camera view, and by peer monitoring. Managers consist of:  Admin, RCC, HR, OM.  Camera view access by HR and Admin.  Correction will be made at the time for compliance. 3.  Failure to comply will result in disciplinary action up to and including termination of employment. Defrosting frozen items:  1.  Staff will pull frozen product and place in the refridgerated area for defrosting at least 2-days prior to cooking.  2. Sanitation bucket (red bucket).  Santizing strips purchased for use to ensure correct parts per million.  this will be completed each time the bucket is refilled. 3.  Changing of gloves in between tasks:  Hand sanitizer has been purchased and place at each site for the Cook and Dining Service Aide to use in between serving plates at meals time;  DSA will deliver food plates to residents, return to kitchen sanitize hands before delivering additional plates.  Cooks will utilize gloves, if utensils are a not available, changing in between tasks: Cooks will use serving utensils while dishing food onto plates at meal time.  4.  All cooks are required to have their hair pulled back away from their face, (in a bun) or restrained by a cap or hair-net.   Staff will be monitored throughout the working shift, for compliance:  by in person impromptu visits from a Manager, by camera view, and by peer monitoring. Managers consist of:  Admin, RCC, HR, OM.  Camera view access by HR and Admin.  Correction will be made at the time for compliance. 3.  Failure to comply will result in disciplinary action up to and including termination of employment.

The findings of the kitchen inspection, conducted 09/14/22, 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 revisit to the kitchen inspection of 09/14/22, conducted 11/30/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, it was determined the facility failed to ensure direct care staff were aware of resident specific reasons for the use of psychotropic medications and documented non-pharmacological interventions had been attempted prior to administering PRN psychotropic medications for 2 of 2 sampled resident (#s 1 and 4) who were prescribed PRN medications to treat behaviors. Findings include, but are not limited to: 1. Resident 1's 7/1/21 through 8/4/21 MAR was reviewed and indicated the resident was prescribed Lorazepam 0.5mg tablet sublingually (under the tongue) as needed for anxiety. The facility failed to inform staff of the resident specific reasons for use of the psychotropic medications. There was no documented evidence non-pharmacological interventions had been attempted prior to administering the psychotropic medication. 2. Resident 4's 7/15/21 through 8/4/21 MAR was reviewed and indicated the resident was prescribed Lorazepam 0.5 mg tablet every 8 hours as needed for anxiety. The facility failed to inform staff of the resident specific reasons for use of the psychotropic medications. There was no documented evidence non-pharmacological interventions had been attempted prior to administering the psychotropic medication. The need to ensure staff were informed of resident specific reasons for use of psychotropic medications and non-pharmacological interventions were attempted and ineffective prior to the administration of psychotropic medications to treat behaviors, was discussed with Staff 1 (Administrator). She acknowledged the findings.

Action Taken:  RN to review all PRN medications and provide guidance to all Staff dispensing medications:  Interventions, Signs/Symptoms that would require intervention prior to medications being dispensed. Med Techs have received training. System Correction:  RN, RCC, Assistant, Med Tech, and Admin will be monitoring daily new medications that have been ordered, flag them for immediate review and complete the above action in the QMAR as well as a TSP in place for Staff, following updated Service Plan. How Often Evaluated:  This will be audited at least three times per week. Responsibilty:  Team Effort, RCC, RN, Assistant and Admin will be responsible for this task.

Based on interview and record review, it was determined the facility failed to ensure fire drill documentation included all required components in accordance with Oregon Fire Code, 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 8/4/21 for January 2021 through July 2021 lacked documentation of the following: * Fire and life safety instruction to staff on alternate months; * 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. The need to ensure 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 (Administrator). She acknowledged the findings.

Fire and Life Safety:  Action taken:  Fire Drill form has been revised to meet the criteria per State Guidelines, reviewed by Surveyor at the time.  Also, developed Fire and Life Safety Calendar to meet the training requirements every other month. Correction:  Updated Fire Drill Format, Calendar of scheduled Fire and Life Safety training every other month Evaluated:  Monthly Responsibility:  Maintenance, Human Resources and Administrator will be responsible to assure this is completed by rule.

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 C420.

See C 420

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 C330.

See C 330

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to: During the survey, observations of resident rooms revealed they were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open all residents' rooms. In an interview with caregiving staff on 8/4/21, she explained resident room doors were all routinely locked. The need to ensure residents were not locked outside their rooms was discussed with with Staff 1 (Administrator). She acknowledged the findings.

Action Taken:  Immediately unlocked apartments for those residents not service planned for locking units:  Educating employees and Temp Agency employees, provided visual cues at doors to remind them not to lock the apartments. Correction:  As Above, and RCC, Assistant, will make morning rounds to check apartment doors to make sure they are unlocked.  Continue to educate staff. Evaluated:  Weekly for issues, monitored daily. Responsible:  RCC, Assistant, Med Tech, Administrator will monitor daily, and address any concerns with staff immediately.  Visual tools have been provided for all Team Members.

The findings of the re- licensure survey, conducted 8/4/21 through 8/5/21, 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, and Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.  Tag numbers beginning with C refer to the Residential Care Facilities rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 8/5/21, conducted 10/13/21, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.