The Village at Keizer Ridge Memory Care

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition, had resident-specific instructions or interventions developed and reviewed for effectiveness and weekly progress documented until resolution for 2 of 4 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s.

The resident's 09/14/24 service plan, 07/10/24 through 09/24/24 progress notes, Interim Service Plans and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Skin tears;
* Medication changes;
* Loose stools/stomach upset;
* Urinary tract infection; and
* Multiple falls.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (MC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia.

The resident's 08/29/24 service plan, 06/24/24 through 09/24/24 progress notes, Interim Service Plans and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Edema/swelling both lower legs;
* Scratches and bruising to the legs/shin area;
* Scabbed areas to the upper arm, shoulder and coccyx;
* Medication changes; and
* Falls.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (MC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (#1) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s.

Observations of the resident, interviews with staff, review of the service plan dated 09/14/24, 07/10/24 through 09/24/24 progress notes, Interim Service Plans and physician communications were reviewed.

The resident required full assistance from staff for ADL care. The resident was sometimes able to eat on his/her own with cues from staff. The resident required full feeding assistance from staff on other occasions. The resident was frequently anxious and distressed when out in the common areas. The resident could be distracted during mealtimes which required staff intervention to redirect back to his/her meal.

Multiple observations of the resident between 09/23/24 and 09/25/24 showed the resident asleep in a recliner in the common area, asleep in his/her bed or up in a wheelchair at one of the dining room tables. The resident meal observations showed s/he missed breakfast on all three days but did have some intake for lunch and dinner. Staff were observed to fully assist the resident with meals, snacks, and drinks. The resident did not initiate any food or fluids but accepted the items staff offered. The resident was provided a health shake on two occasions during snack/hydration pass. The resident did not interact with other residents but would respond intermittently to staff interactions.

Weight records for 07/2024 through 09/2024 showed the following:

* An 8-pound weight loss between 07/09/24 and 08/05/24, which constituted a significant weight loss of 6.08% in one month.
* A 5.8-pound weight gain between 08/05/24 and 09/12/24, which constituted a 4.7% weight gain in one month, this was not significant for the resident.

The resident’s most recent weight on 09/21/24 showed an additional 3.6-pound loss since 09/12/24, this was not a significant loss for the resident.

The resident was not interviewed due to his/her current cognitive impairment and anxiety.

In interviews between 09/23//24 and 09/25/24, Staff 14, Staff 15, and Staff 19 (CGs) indicated the resident required full assistance with ADL care. The resident required assistance with meals from cues to full meal assistance. The resident often slept through breakfast, especially when s/he was up all night. The resident was offered snacks as well as any replacement meals when s/he was awake. The staff indicated the resident’s intake varied, but generally did not eat a lot for any of the meals. The resident had been sleeping a lot more lately.

In interview on 08/30/24, Staff 1 (MCC ED/LPN) indicated she was unable to locate any significant change assessment completed related to the weight loss. The resident was having an overall decline and increased anxiety over the last few months and was admitted to hospice on 09/17/24.

There was no additional documentation located to show any interventions that were initiated related to the resident’s weight loss.

The facility failed to ensure an RN assessment was completed for the weight loss and gain which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 3 sampled residents (#s 2 and 4) who were administered as-needed controlled medications. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease and anxiety.

The resident had a physician order for lorazepam 0.5 mg by mouth every two hours as needed for anxiety or agitation.

Resident 4's 09/01/24 through 09/23/24 Controlled Substance Disposition Logs and MARs were reviewed and revealed the following:

*Between 09/01/24 and 09/23/2024, there were five occasions when staff signed the medication out in the disposition log; however, the MAR lacked documentation the resident received the PRN medication.

Comparison of the medication bottle to the disposition log, showed the amount of medication left was reflected accurately on the log.

Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (MCC ED/LPN), and Witness 1 (Consultant Operations Specialist) on 09/25/24. No additional information was provided.

The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 and Witness 1 on 09/25/24. The findings were acknowledged.

2. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia.

Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 08/30/24 included the following orders:

* Lorazepam 0.5mg tablet, give one tablet every two hours PRN for agitation or anxiety; and
* Morphine 20 mg/ml, give .25 ml every hour PRN for pain or shortness of breath.

The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/24 through 09/24/24 showed the following:

* On 09/18/24, the PRN Morphine was recorded on the MAR but was not signed out on the disposition log; and
* On 09/23/24, the PRN Lorazepam was signed out on the disposition log but not recorded on the MAR.

Comparison of the medication bottles to the disposition logs, showed the amount of medication left was reflected accurately on the log.

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances

(e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the accuracy of MARs which included resident specific parameters and instructions for PRN medications, including instructions for when or how often to administer the prn medications for 3 of 4 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2018 with diagnoses including dementia.

The resident's 09/01/24 through 09/23/24 MARs were reviewed, and the following inaccuracies were identified:

a. Multiple medications lacked direction on how often the PRN medications could be administered as follows:

* Haloperidol as needed for agitation or nausea;
* Nitroglycerin as needed for chest pain; and
* Loperamide as needed for diarrhea.

b. Multiple PRN pain medications lacked resident specific parameters as to order of administration as follows:

* Acetaminophen 1000 mg every four hours as needed for pain or elevated temperature;
* Acetaminophen 650 mg suppository every six hours as needed for pain or elevated temperature; and
* Morphine Sulphate .25 ml as needed for pain or shortness of breath.

The need to ensure residents' MARs had clear resident specific parameters and instruction to staff for administration of PRN medications was discussed with Staff 1 (MCC ED/LPN), and Witness 1 (Consultant Operations Specialist) on 09/25/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 07/2024 with diagnoses including anxiety and Alzheimer’s disease.

Observation of the resident between 09/23/24 and 09/25/24 showed the resident was unable to answer detailed questions. The resident required simple questions without multiple choices or answer options. When questioned by staff the resident would become very anxious.

Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following:

* PRN Tylenol and PRN Oxycodone were both prescribed for pain.

The parameters indicated Tylenol PRN for pain rating of 0-4 and Oxycodone PRN for pain rating 5-10. Both medications were administered with documented pain ratings that did not meet the directed parameter. There were no other resident specific directions for staff on when to use the Tylenol vs. the Oxycodone if/when a pain scale rating could not be obtained from the resident or other times the parameters should be disregarded.

* PRN Bisacodyl Suppository ordered for constipation.

There were no resident specific directions for staff on when to start use.

The need to ensure medication administration records were complete and resident specific parameters were reflected was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

3. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia.

Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following:

* PRN Morphine and PRN Tylenol were both prescribed for pain.

There were no parameters in place to direct staff which medication to treat with first.

* PRN Bisacodyl Suppository ordered for constipation.

There were no resident specific directions for staff on when to start use.

The need to ensure medication administration records were complete and resident specific parameters were reflected was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 4 sampled resident (#s 1, 2 and 3) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2024 with diagnose including anxiety and Alzheimer’s disease.

Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following:

* Lorazepam 0.5 mg tablet, give one tablet every two hours PRN for anxiety or agitation; and
* Haloperidol 2 mg/ml, administer 0.50 ml every two hours PRN for agitation, anxiety, nausea, or vomiting.

The Haloperidol started on 09/20/24 had no direction for staff when to use the Haloperidol vs. the Lorazepam. There was no indication how long after Lorazepam administration the Haloperidol should be given.

The Lorazepam PRN dose was administered thirteen times, and the Haloperidol was administered six times between 09/18/24 and 09/24/24. The doses of Lorazepam and Haloperidol were administered between thirty-seven minutes and two hours apart depending on the specific administration date and time.

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, distress or agitation.

The need to ensure resident-specific information on how the resident expressed anxiety/agitation and when to administer consecutive doses was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia.

Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following:

* Lorazepam 0.5 mg tablet, give one tablet every two hours PRN for anxiety or agitation; and
* Haloperidol 2 mg/ml, administer 0.25 ml every two hours PRN for agitation, anxiety, nausea, or vomiting.

The Lorazepam was administered six times and the Haloperidol two times between 09/01/24 and 09/24/24. There was no resident specific direction for staff to indicate which medication should be given first or second and when.

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, distress, or agitation.

The need to ensure resident-specific information on how the resident expressed anxiety/agitation and when to give specific medications das discussed with Staff 1 (MC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 03/2018 with diagnoses including dementia, depression, and anxiety.

The resident's 09/01/24 through 09/23/24 MAR and prescriber orders were reviewed.

Resident 3 had the following physician orders for PRN psychotropic medications on the MAR:

* Lorazepam, 0.5 mg tab every two hours as needed for anxiety; and
* Haloperidol 1mg tab as needed for agitation.

The MAR indicated the resident received the PRN lorazepam on 09/02/24. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication.

During an interview, Staff 11 (MT) verified there was no documented evidence non-pharmacological interventions were listed on the MAR or had been attempted and documented as ineffective prior to administering the PRN lorazepam.

The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed on 09/25/24 with Staff 1 (MC ED/LPN) and Witness 1 (Consultant Operations Specialist). The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 12, 13 and 18) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 09/24/24 with Staff 20 (Business Office Manager).

Staff 12 (CG), hired 05/09/24, Staff 13 (CG), hired on 06/11/24, and Staff 18 (MA), hired 08/07/24, lacked documented evidence they had completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure staff completed the required training within 30 days of hire was reviewed with Staff 1 (MCC ED/LPN) and Witness 1 (Consultant Operations Specialist) on 09/25/24. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

"Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (6) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:(A) The role of service plans in providing individualized resident care.(B) Providing assistance with the activities of daily living.(C) Changes associated with normal aging.(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.(E) Conditions that require assessment, treatment, observation and reporting.(F) General food safety, serving and sanitation.(G) If the direct care staff person ' s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.(9) ADDITIONAL REQUIREMENTS. Staff:(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed."

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit. Findings include, but are not limited to:

During an interview on 09/25/24 with Staff 1 (MCC ED/LPN) and Witness 1 (Consultant Operations Specialist) it was reported that all shared resident bathroom doors were not lockable for resident privacy.

The need to ensure residents' rights of privacy in his or her own unit was discussed with Staff 1 and Staff 2 on 09/25/24. They acknowledged the findings.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(d) Each individual has privacy in his or her own unit.

This Rule is not met as evidenced by:

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

Refer to C372.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly-hired staff (#s 12, 13, and 18) completed all required pre-service orientation and dementia training topics; 4 of 4 staff (#s 8, 12, 13 and 18) demonstrated competency in all assigned job duties within 30 days of hire; a system to ensure long term staff completed the required number of annual in-service training hours, including the annual infectious disease training, and at least six hours of training on dementia care; and 2 of 2 long term non-care staff (#s 6 and 10) completed annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 20 (Business Office Manager) on 09/24/24. The following was identified:

1. There was no documented evidence Staff 12 (CG), hired 05/09/24, Staff 13 (CG), hired 06/11/24, and Staff 18 (MT), hired 08/07/24, completed one or more of the following pre-service orientation and dementia training topics:

* Infectious Disease Prevention;
* Approved Home and Community Based Care course;
* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to distressful behavioral symptoms;
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;
* How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require ongoing assessment; and
* Use of supportive devices with restraining qualities in memory care communities.

2. There was no documented evidence Staff 8 (MT), hired 07/20/24, Staff 12 (CG), hired 05/09/24, Staff 13 (CG), hired 06/11/24, and Staff 18 (MT), hired 08/07/24 demonstrated competency in one or more of the following areas within 30 days of hire:

* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* Medication and treatment administration training for Staff 8 and 18.

3. During the staff training review, Staff 20 was unable to explain or show documented evidence the facility had a system in place to ensure the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training related to dementia care was completed.

4. There was no documented evidence Staff 6 (Housekeeper), hired 12/30/23, and Staff 10 (Lifestyle Assistant), hired 12/30/23, completed the required infectious disease training.

The need to ensure the required pre-service and annual training was completed by staff as required, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire, was discussed with Staff 1 (MCC ED/LPN) and Witness 1 (Consultant Operations Specialist) on 09/25/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Refer to C270, C280, C302, C310 and C330.

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

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 11/14/23, 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 revisit to the kitchen inspection of 11/14/23, conducted 02/29/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen and memory care kitchenette in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and memory care kitchenette were conducted on 11/14/23 from 10:10 am through 2:40 pm. The following was identified:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Walls throughout kitchen;* Flooring (near, under, and around large equipment);* Top of ice machine;* Top of juice machine;* Top of refrigerator;* Top of dishware machine;* Walk-in cooler floor;* Standing water in the walk-in cooler;* Walk-in cooling fan and ceiling;* Freezer floor;* Food trap under dishware washer;* Grease bucket;* Ceiling, ceiling vents, light fixtures;* Fire sprinklers;* Walkie Talkies and bases;* Meat slicer;* Wall behind meat slicer;* Industrial can opener;* Industrial mixer;* Wall behind industrial mixer;* Wall behind ware washing area;* Wall behind food prep area;* Walls and wall fixtures;* Food Ninja blender base;* Corners and edges of steam table line;* Corners and edges of deli cooler top;* Steam table hot water holders;* Electrical outlet behind meat slicer with black mold-like substance outlining plate;* Interior of oven;* Exterior of stove;* Interior and exterior of toaster;* Interior and exterior of hot plate holder;* Flat top grill and siding;* Interior of soup warmer;* Utility carts;* Interior and exterior of hot food cart;* Knife holder;* Interior and exterior of microwave;* Metal shelving in walk in cooler;* Interior and exterior of MCC oven; and* Interior of MCC kitchenette drawers and cupboards. b. The following areas were found in need of repair: * Dish machine with heavy mineral build-up in need of descaling;* Handwashing sink (left of juice dispenser) drainage was slow and without paper towels;* Stove knobs and handles cracked;* Several cooking utensils were observed to have integrity concerns (example: parts of utensils melted);* Thermometer on server refrigerator gauging incorrect temperatures. Gauge read 50 degrees F, Digital thermometer and food items read 40 degrees F;* Caulking behind dish pit area with dark mold-like substance;* MCC oven stove top cracked;* Food warming cart with multiple holes/cracks; and* Multiple cutting boards found heavily stained/scored.c. Poor infection control practices observed, but not limited to:* Ice machine had pink and black mold-like residue on inside of machine;* While prepping salads and sandwiches, same cutting board was used for multiple foods (lunch meat, cheese, bread, tomato);* When plating meals, cooks touched ready-to-eat food items with potentially contaminated gloves and did not use tongs for bread products;* On several occasions, thermometer was not disinfected properly between use;* Thawing protein in walk-in fridge with chicken above other proteins;* Sausage and bacon from breakfast service out for over four hours, sausage tempted at 79 degrees F. Staff planned on using for lunch service (e.g., BLTs, etc.);* Poor hand sanitizing practice between food handling;* Poor gloving practice between food handling;* Dry towels stored outside of sanitizer throughout kitchen (appeared to be for sanitizing buckets);* Open and exposed coffee filters;* Unlabeled product in walk-in cooler;* Uncovered product in walk-in cooler;* Uncovered ice cream stored in small freezer;* Unlabeled, undated food product in small freezer;* Facility's eggs were unpasteurized. Staff 2 confirmed facility makes eggs to order each morning including soft/under-cooked versions (over easy, over medium, poached);* Staff had open beverages located throughout kitchen;* Employee jacket on top of dish ware rack;* Cutting board not sanitized between uses;* Multiple kitchen staff preparing food without facial hair restraints;* Sanitizer bucket not at proper concentration for surface sanitation, and staff not changing every two hours as recommended;* Scoop observed to be stored in bulk food/beverage containers;* Small diameter thermometer probe was not observed in MCC kitchenette;* MCC care staff observed providing dietary services without the use of aprons; and* MCC care staff not checking temperatures of reheated food for residents to ensure safety.d. During Person-in-Charge (PIC) interview, Staff 2 (Executive Chef) struggled to verbally demonstrate adequate knowledge in storing of protein products to prevent cross contamination, proper cooling methods, three sink method for sanitization, time frames to change surface sanitizers, and proper reheat food temperature requirements. Staff 2 acknowledged she did not have any additional food service training/education beyond her food handler's card and her experience in other food establishments, including long term care facilities and restaurants.At approximately 2:20 - 2:40 pm, surveyors reviewed above areas with Staff 1 (Executive Director) and Staff 2 (Executive Chef). who acknowledged the identified areas.

Based on observation, record review and interview, 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 C240.

The findings of the relicensure survey conducted 05/01/23 through 05/03/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 05/03/23, conducted 07/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.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 05/03/23, conducted 10/13/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in January of 2023. The following required elements were either incomplete or were not included on the evaluation form:* Mental health issues, including:a) Presence of depression, thought disorders, behavioral or mood problems;b) History of treatment;c) Effective non-drug interventions;* Personality, including how the person copes with change or challenging situations; and* Recent losses.On 05/03/23, the need to ensure the initial move-in evaluation contained all required elements was discussed with Staff 1 (Memory Care Director) and Staff 3 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 1 was admitted to the MCC facility in 07/2023. The following required elements were either incomplete or were not included on the evaluation form:* Cognition, including decision making abilities;* Activities of daily living including dental status;* Fluid preferences; and* History of dehydrationOn 07/27/23, the need to ensure the initial move-in evaluation contained all required elements was discussed with Staff (10) and Staff 3 (LPN). They acknowledged the findings.

Based on interview and record review, the facility failed to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's staffing plan. Findings included, but are not limited to:Record review on 05/02/23 of the posted staffing plan, the facility's ABST, and the staffing schedule for 04/01/23 to 05/03/23 revealed the scheduled staffing plan was not reflective of the ABST. In an interview on 05/02/23 with Staff 1 (Memory Care Director) and Staff 10 (ALF Executive Director) it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST. The need to ensure the facility followed the staffing plan generated by the ABST was discussed with Staff 1 and Staff 10 on 05/03/23. They acknowledged the findings.
Based on interview and record review, the facility failed to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's staffing plan. This is a repeat citation. Findings included, but are not limited to:Record review on 07/27/23 of the posted staffing plan, the facility's ABST, and the staffing schedule for 07/02/23 to 07/27/23 revealed the scheduled staffing plan was not reflective of the ABST. In an interview on 07/27/23 with Staff 10 (ALF Executive Director), it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST. On 07/27/23 the need to ensure the facility followed the staffing plan generated by the ABST was discussed with Staff 2 (Health Services Director/RN), Staff 3 (Medication Licensed Nurse), and Staff 10. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code (OFC), and fire and life safety instruction to staff was provided and documented on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records for 11/01/22 through 05/01/23 identified the following:1. The facility had not documented the following areas related to fire drills conducted:* Escape route used;* Problems encountered; * Comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; * Evidence alternate routes were used; and* Number of occupants evacuated.2. In an interview conducted 05/02/23 at 1:30 pm with Staff 8 (CG) and Staff 9 (CG), they were unable to clearly state where the designated point of safety was located.3. The facility did not consistently conduct and document fire and life safety instruction for staff on alternate months.The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Memory Care Director) on 05/03/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 252, C 361, Z 142, and Z 162.

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: C 361 and C 420.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 361.

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