Tabor Crest Ii Memory Care

Based on observation and interview, it was determined the facility failed to ensure the kitchen was in good repair, clean and appropriate storage was maintained in accordance with the Food Sanitation Rules 333-150-0000. Findings include, but are not limited to:

On 03/28/25 at 10:5 am, the facility kitchen was observed to need repair, cleaning and appropriate storage in the following areas:

* Multiple open bags of sugar in the dry storage area;

* A large bag of cornmeal not stored in a manner to prevent rodents or pest infestation in dry storage area;

* Potatoes stored in cardboard boxes in dry storage area;

*The ice machine had a scoop in the bin and debris build up inside;

* Rolling cart with built up food debris on handle and trays;

* Shelving inside multiple cupboards with uncleanable surfaces;

* Utensil drawer broken with uncleanable edge;

* Drawer containing cloth covers with broken edge that was also an uncleanable surface.

The areas above were observed and discussed with Staff 1 (Executive Director) on 03/28/25. She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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 C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status and needs, and provided clear direction to staff, and were implemented for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 06/2020 with diagnoses including Alzheimer’s disease and had a recent history of falls.

Observations of the resident, review of the most recent service plan dated 12/27/24 and incident reports with a review of fall incidents were reviewed.

The service plan did not reflect the resident's needs as identified in the evaluation and provide clear direction to staff in the following areas:

*One to one feeding assistance, aspiration precautions, and swallow strategies; and
*Fall risk and fall prevention interventions.

The need to ensure service plans were reflective of resident’s needs, as identified in the evaluation, and included clear direction to staff was discussed with Staff 1 (ED), and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

2. Resident 3 moved into the facility in 11/2016 with diagnoses including Alzheimer’s disease.

Observations of the resident, and the most recent service plan dated 12/26/24 were reviewed.

The service plan did not reflect the resident’s needs as identified in the evaluation and provide clear direction to staff in the following area:

*One to one feeding assist.

The need to ensure service plans were reflective of resident’s needs, as identified in the evaluation, and included clear direction to staff was discussed with Staff 1 (ED), and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short term changes of condition, communicated actions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 12/2024 with diagnoses including vascular dementia.

The current service plan dated 01/27/25, temporary care plans, and progress notes dated 12/10/24 through 02/03/25 were reviewed. Observations and interviews with staff were completed between 02/03/25 and 02/04/25.

The facility failed to determine what action or intervention was needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:

* 12/10/24 – New move in;
* 12/27/24 - New behaviors;
* 12/31/24 – Hospital visit for behaviors;
* 01/04/25 – New medication;
* 01/08/25 – Hospital visit for unresponsive event;
* 01/14/25 – Medication change; and
* 01/27/25 – New medication.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Operations Director) at 1:00 pm on 02/06/25. They acknowledged the findings.


2. Resident 2 moved into the facility in 06/2020 with diagnoses including Alzheimer’s disease.

The resident's current service plan dated 12/27/24, progress notes dated 01/11/25 through 02/03/25, interim service plans (ISPs), and incident reports with a review of fall incidents were reviewed.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

*Incident reports indicated Resident 2 experienced a fall on 01/10/25 resulting in facial bruising, a fall on 01/23/25 resulting in redness to left knee and a fall on 01/30/25 resulting in a skin tear on right elbow.

The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.


3. Resident 3 moved into the facility in 11/2016 with diagnoses including Alzheimer’s disease.

The resident's current service plan dated 12/26/24, progress notes dated 01/17/25 through 01/20/25, and an incident report were reviewed.

The following short-term change of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

*A progress noted dated 01/17/25 indicated Resident 3 experienced an abrasion on her/his right arm.

The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They 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 and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:

a. On 02/03/25 at 11:40 am, Staff 3 (Lead MT) was observed to sneeze into their hand, touch their nose, cough into their hand and then applied a blood pressure cuff to a resident with no hand hygiene observed.

b. Lunch service was observed on 02/03/25 and 02/04/25.

Staff were observed serving meals and beverages, touching residents, removing dirty dishes and opening the kitchen door without changing their gloves or performing hand washing.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 7 and 9) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Review of training records showed Staff 7 (Care Partner, Med Tech), hired on 10/21/24, and Staff 9 (Care Partner), hired on 9/9/24, did not have documented evidence first aid and abdominal thrust training had been completed within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff

(5) 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.

(10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule.
(a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Review of fire and life safety records from 08/01/24 through 02/03/25 revealed fire and life safety training for staff was not consistently being provided on alternating months.

Between 08/01/24 and 02/03/25 only one documented life safety training was provided for staff (12/02/24).

On 02/04/25, the need to ensure the facility staff received required fire and life safety training on alternate months from fire drills was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the proper processing of soiled linens. Findings include, but are not limited to:

Inspection of the interior environment of the building on 02/03/25 showed laundry rooms on both the north and south side of the building.

Both laundry rooms were used for resident clothing and for clothing and linens soiled with bodily fluids.

Observations of both laundry rooms and interviews with Staff 6 (Care Partner), Staff 1 (ED), and Staff 5 (Maintenance Director) were conducted on 02/03/25 at 1:00 pm and identified:

* There were no separate areas with closed containers to ensure the separate storage and handling of linens soiled with bodily fluids from resident clean laundry;

* At 1:00 pm in the south laundry room, wet laundry was observed directly on a counter top;

* Soiled linens and soiled clothing were stored in a wire cart next to and above clean resident clothing; and

* Washing machines reached only 120 degrees F, and no laundry disinfectant was used for soiled linens.

Interview with Staff 1 and Staff 5 on 02/02/25 at 1:00 pm confirmed the washing machines did not reach the minimum rinse temperature of 140 degrees Fahrenheit, and a chemical laundry disinfectant was not used with the soiled linens.

The above deficiencies increased the risk that communicable diseases could be spread to residents and staff.

The need to ensure the facility developed and implemented proper soiled linen handling procedures was reviewed with Staff 1 and Staff 5 on 02/03/25. They acknowledged the findings.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry

(b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.

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 C 295, C 372, C 420 and C 530.

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 1 of 3 newly hired staff (#7) completed all required pre-service orientation, 2 of 3 new staff (#s 7 and 9) completed the required pre-service training, and 2 of 3 long term staff (#s 3 and 10) completed the required 16 hours of annual training. Findings include, but are not limited to:

Review of staff training records on 02/04/25 revealed the following:

a. Staff 7 (Care Partner/Med Tech) was hired 10/21/24. There was no documented evidence they had completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of community-based care;
* Abuse reporting requirements;
* Fire safety and emergency procedures;
* Written and signed job description;
* Infectious disease prevention 7/1/22 requirement; and
* Approved HCBS course.

b. There was no documented evidence Staff 7 (Hired on 10/21/24), and Staff 9 (Care Partner), (Hired on 09/09/24), had completed training as required in the following areas:

* Dementia disease process;
* Techniques for understanding and communicating;
* Social needs and activities in dementia,
* Dementia care and safety;
* Environmental factors important to wellbeing;
* Family support and the role family may have in the care of the resident; and
* Recognizing behaviors that indicate a change in condition.

c. There was no documented evidence Staff 10 (Activities) and Staff 3 (Med Tech), completed the required 10 hours of annual training related to provision of care in community-based care or the required six hours related to dementia care.

The facility's failure to ensure staff completed all required training in a timely manner and that training was documented was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. 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 C 260 and C 270.

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

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

This Rule is not met as evidenced by:

Based on observations and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service plan for 2 of 3 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to:

Resident's 2 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

This Rule is not met as evidenced by:

The findings of the re-licensure survey, conducted 8/30/2021 through 9/1/2021, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 survey to the relicensure survey of 09/01/21, conducted 12/20/21 through 12/21/21, 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 57 for Memory Care Communities.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second revisit to the re-licensure survey of 09/01/21, conducted 02/16/22, are documented in this report. It was determined the facility was in substantial 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 for Home and Community Based Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure allegations of suspected abuse involving a resident-to-resident altercation and repeated incidents of being found on the floor were promptly investigated to rule out abuse/neglect and were reported to the local SPD office if abuse and/or neglect could not be reasonably ruled out for 2 of 2 sampled residents (#s 1 and 3). Findings include but are not limited to: 1. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia. Observations of Resident 1 from 8/30/21 to 9/1/21 revealed the resident was mostly non-verbal and required staff assistance for all ADL care, including 2-person transfer and incontinent care.a. On 5/4/21 staff documented the resident "attached [sic] another resident from the back by pulling from the back of [his/her] sweatshirt, not only scarring [sic] [him/her] but almost chocking [sic] [him/her]." There was no evidence the facility conducted an immediate investigation to rule out abuse or potential abuse nor was the incident reported to the local SPD office. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 8/31/21 prior to survey exit. The need to ensure allegations of suspected abuse involving a resident-to-resident altercation were immediately investigated and reported if necessary was discussed with Staff 1 (ED) and Staff 2 (RN). No further information was provided. b. A review of the resident's clinical records, 3/6/21 through 8/30/21, showed the resident had unwitnessed falls on 7/3/21, 7/10/21, 7/15/21 and 7/18/21 and indicated the following: * On 7/3/21 staff documented on a facility Incident Report Investigation that "resident was found on the floor lying on [his/her] right side, complaining of neck pain and right arm pain ... staff called 911 ..." Staff failed to document response of staff at the time of the event, follow-up action or administrator review. The incident was not reported to SPD.* On 7/10/21 staff documented "Resident was found on the ground. Resident reported no pain or discomfort. Resident was able to stand with staff assist." Staff failed to document individuals present, a complete description of the event and indicated abuse had been ruled out without documentation of a thorough investigation.* On 7/15/21 staff noted "Resident was hear [sic] falling, found on the ground, reported hitting [his/her] head ...." The resident was sent to the hospital. Staff failed to document the time and individuals present, a complete description of the event, or staff response at the time of the incident.* On 7/18/21 staff noted "Resident had an unwitnessed fall, found on the ground ..." Staff failed to document individuals present, a complete description of the event, or staff response at the time of the incident. Resident 1 experienced four unwitnessed falls from 3/6/21 through 8/30/21, and on the 7/3/21 and 7/15/21 falls the resident was sent to the emergency room related to complaints of pain or signs/symptoms of injuries. There was no evidence the facility conducted an immediate investigation to reasonably conclude that the above incidents were not the result of abuse or neglect nor were the incidents reported to the local SPD. The need to investigate incidents of suspected abuse and neglect and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21.Staff 1 confirmed she had not reported the above incidents to the local unit, at which time the surveyor requested Staff 1 to immediately report the incidents. Confirmation that the incidents were reported was received on 9/1/21 prior to the survey team exiting the facility.
2. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia and his/her 8/11/21 service plan indicated he/she was dependent on staff for all ADLs.A review of the resident's clinical record revealed he/she fell on 6/24/21. Staff completed an electronic incident report form and wrote a progress note that resident was on alert for an unwitnessed fall.There was no documented evidence the facility conducted an immediate investigation to rule out abuse or potential abuse or reported the incident to the local SPD office. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 9/1/21 prior to survey exit. On 9/1/21 the need to investigate incidents to determine if there was abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be reasonably ruled out, was discussed with Staff 1 (ED). She 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:On 8/30/21 at 10:50 am the kitchen was observed to need cleaning and/or repair in the following areas:* Door and walls had food splatters and spills, black marks and chips and gouges in the paint;* Cabinet doors, drawer fronts and all around the kitchen island had food splatters, spills and drips;* Cabinets shelves had food particles;* Windows above sink had a build-up of gray matter;* Microwave had food particles, splatters and drips inside;* Toaster had a build-up of brown matter on the top and sides;* Stove top had food particles, splatters and drips;* Oven had dried black/brown matter on the bottom and glass door;* Freezer had food particles on bottom shelf;* Refrigerator had opened containers that were not dated, some of which had sticky food splatters on the outside;* Refrigerator had rusted shelves and food particles, splatters and sticky brown matter on bottom shelf;* Bottom of upper cabinet doors to the right of the sink was coming unglued;* Water heater tray had build-up of gray matter and splatters; and* Food debris, splatters and drips on the floor.Observations on 8/30/21 revealed the Food Sanitation Rules were not being followed in the following areas:* There was an uncovered cup of berries in the refrigerator;* A baking tray was stored between water pipes in the dry storage area next to the water heater;* There were stacks of boxes containing food piled in front of the shelving in the dry storage area;* The garbage can did not have a cover;* There was no bleach solution or test strips available; and* The dishwasher wash cycle was observed to reach 130 degrees F, not the manufacturer's recommended 150 degrees F. The dishwasher rinse cycle was observed to reach 170 degree F temperature recommended by the manufacturer and chemicals were being used with the washing cycle. Staff 5 stated someone would be called to fix the dishwasher immediately.In addition, there was a package of meat in a pitcher in the sink with cold water running over it. Staff 5 (Cook) stated he was thawing the meat for lunch. The water temperature was 67 degrees F, as taken by surveyor. Staff 5 opened the package of meat and it was observed to be mostly frozen.The areas needing cleaning and/or repair and food safety were discussed with Staff 1 (ED) and Staff 5 on 8/30/21. The need to comply with the Food Sanitation Rules and keep the kitchen clean and in good repair was discussed with Staff 1 and Staff 2 (ED) on 8/31/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests and opportunities for active participation in the community at large. Findings include, but are not limited to:The following observations were made on 8/30/21 through 9/1/21: * There were no scheduled activities after 3:00 pm. * Coffee Chat, scheduled for 8/30/21 at 10:00 am and Hand Massages, scheduled for 8/30/21 at 11:00 am, did not take place.* On 8/30/21 at 11:30 am, observed "Bingo" activity in dining room, which was scheduled for 8/30/21 at 3:00 pm. No other activity was observed.* Staff did not provide any individualized activities to residents. During the survey, there was a lack of unscheduled and scheduled activities that occurred for residents who were unable to self-initiate activities or the community at large. The primary activity observed included residents sitting out in the common area for long periods of time watching movies or other TV shows, wandering the halls, or remaining in their rooms. On 9/1/21 at 2:55 pm Staff 1 (ED) stated the activity staff was out of sick and he had returned to work that day. The failure to provide an activity program based on individual and group needs was reviewed with Staff 1 during the survey. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to:During the re-visit survey conducted 12/20/21 through 12/21/21, there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community.a. The December 2021 activity calendar provided during the entrance conference indicated the following activities would occur on 12/20/21:* 10:00 am Coffee Chat;* 11:00 am Exercise;* 3:00 pm Read aloud; and* 6:00 pm Movie and snack.On 12/20/21 the only activities observed between 9:00 am and 4:00 pm were coffee and snacks at 10:45 am and bingo at 3:30 pm. b. On 12/21/21 the activity calendar indicated the following activities would occur:* 10:00 am Coffee Chat;* 11:00 am Bowling;* 2:00 pm Paint Nails; and* 6:00 pm Movie and Snack.On 12/20/21 the only activities observed between 8:00 am and 4:00 pm were a Christmas movie shown in the common living room at 11:05 am, another movie was shown in the living room at 1:25 pm, and a staff member engaged a few residents in a card game in the dining area at 3:05 pm.Multiple observations of the memory care unit on day shift and swing shift between 12/20/21 and 12/21/21 showed a lack of group or individualized activities provided for the residents. Multiple residents were observed sitting in the common areas alone, watching TV, wandering the halls and sitting in their rooms.During an interview with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21, Staff 1 stated the facility had been without a person to direct activities. Care staff, who were assigned to provide ADL care, cleaning, laundry, serving meals and medication administration "helped out" and provided activities to the residents when they were able.The lack of an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large was discussed with Staff 1 and Staff 2 on 12/21/21. They acknowledged the findings.

3. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia. The resident's 6/6/21 quarterly evaluation and 7/29/21 change of condition evaluation were not reflective of Resident 1's status or care needs in the following areas:* Transfer status;* Vision status;* Bathing assistance needs:* Fall interventions including use of floor mattress; and* Fall risks.The need to ensure evaluations were accurate and reflective of the resident's condition and care needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. The staff 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 newly admitted resident (#2) and failed to complete quarterly evaluations for 2 of 2 sampled residents (#s 1 and 3), whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in August 2021 with diagnoses including dementia.The move-in evaluation, dated 8/12/21, was reviewed and revealed the following elements were missing:* Personality including how the person copes with change or challenging situations;* How a person expresses pain or discomfort; and* Environmental factors which impact the resident's behavior (e.g., noise, lighting, room temperature).The need to address all required elements in the move-in evaluation was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21. They acknowledged the findings.2. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.A review of the resident's 7/15/21 quarterly evaluation revealed it was not reflective of his/her current status or care needs in the following areas:* Skin breakdown risks and interventions;* Weight changes;* Sleep aids;* Dietary needs;* Meal assistance needed;* Bathing assistance needed;* Use of fall mat;* Assistive and/or supportive devices used; and* Life enrichment activities.The need for quarterly evaluations to accurately reflect the current status and needs of the resident was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

2. Resident 1's service plan, updated 8/11/21, and subsequent temporary service plans were reviewed during the survey and were not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas: * Bathing status;* Transfer status:* Toileting status;* Eating status;* Risk of fall and fall interventions;* Use of floor mattress; and* Signs and symptoms of aggressive behaviors and interventions.The need to ensure resident service plans were reflective of the resident's current status and provided specific instruction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. The staff 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 status and needs and provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.Resident 3's current service plan, updated with handwritten notes on 8/11/21, was not reflective of his/her current status and needs and did not provide clear direction in the following areas:* Risk for skin breakdown and interventions;* Use of a fall mat;* Use of a geri-chair;* Use of an air scoop mattress;* Swallowing precautions; and* Activities.The need for service plans to accurately reflect residents' current status and needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure short-term changes were evaluated; specific resident interventions determined and documented and the condition monitored with weekly progress noted until resolved for 1 of 2 sampled residents (#1) who experienced short-term changes in the area of skin and medication. The facility failed to evaluate and monitor service-planned interventions for 2 of 2 sampled residents (#s 1 and 3) who had repeated falls. Resident 1 continued to have falls with injury. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia.Observations of the resident from 8/30/21 to 9/1/21 noted the resident used a floor mat next to the bed, required staff assistance with transfers and bladder and bowel management. a. The resident's clinical records dated 3/6/21 through 8/30/21 indicated the following:* 4/12/21 staff documented on a facility progress note that the resident was on alert for a fall on 4/12/21. " ...resident fell face first on carpet causing a rug burn of [his/her] left side of nose and cheekbone ..."The resident had experienced a fall, was evaluated to be at risk for falls and the service plan failed to be reflective of the fall risk and there were no identified interventions to minimize falls.b. Reviewing the resident's progress notes and incident reports noted the following: * On 6/24/21 staff documented on a facility incident report "Resident fell while staff present. Resident reported pain in [his/her] left leg ..."* On 7/1/21 "Resident fell backward from standing and hit the back of [his/her] head on a dining room chair ..." The resident was sent to the hospital.* On 7/3/21 staff documented on a facility Incident Report Investigation that "resident was found on the floor lying on [his/her] right side, complaining of neck pain and right arm pain ... staff called 911 ..." * On 7/15/21 staff noted "Resident was hear [sic] falling, found on the ground, reported hitting [his/her] head ...." The resident was sent to the hospital. Hospital reported to have stables on [his/her] head from a previous head laceration.* On 7/18/21 staff noted "Resident had an unwitnessed fall, found on the ground ..." * On 7/23/21 staff noted they saw the resident "stand up from recliner and take a couple steps, [he/she] lost balance and nose dived into a cornered wall ...notice a big ball on right side of forehead." The resident was sent to emergency department and received a new diagnosis of a fractured nose. * On 8/4/21 staff noted that the resident fell backwards hitting the back of [his/her] head on closet doors.There was no documented evidence the facility developed actions or interventions to address the resident's falls noted between 6/24 and 8/4/21. c. On 7/10/21 staff documented "Resident was found on the ground. Resident reported no pain or discomfort. Resident was able to stand with staff assist." The incident report directed staff to make sure the resident was always wearing shoes, but the intervention was not documented on the temporary service plan for all staff to review, and there was no documented evidence the intervention was monitored for effectiveness.The resident experienced 9 falls between 3/6/21 and 8/30/21, had multiple emergency department visits due to the falls and some resulted in physical injuries including a head laceration with staples and a fractured nose. The facility failed to thoroughly review each incident in order to determine if the resident's specific actions or interventions were developed, documented, provided clear direction to staff, were communicated to all staff and were monitored for effectiveness. This placed Resident 1 at further risk of repeated serious injury. d. Resident 1's clinical records dated 3/6/21 through 8/30/21 were reviewed during the survey and revealed the following:* 4/4/21 - Resident-to-resident altercation;* 4/12/21, 6/24/21, 7/3/21, 7/18/21 and 8/4/21 - Falls;* 7/23/21 - Bruise on forehead, fall with ER visit and a new diagnosis of nose fracture;* 7/30/21 - Discontinue on Melatonin; and * 8/4/21 - Three new medications to treat dementia, mental health disorder and dry eyes.There was no documented evidence the resident's short-term changes of condition were consistently monitored and progress documented weekly to resolution.The need to ensure resident-specific actions or interventions were developed, communicated to all staff and monitored for effectiveness when Resident 1 experienced short-term changes of condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.A review of the resident's clinical record revealed the following:a. Resident 3 experienced a fall on 6/24/21. A progress note dated 6/24/21 stated staff should "continue to monitor for any changes in pain, mobility." There was no documented evidence the resident was monitored after the fall.b. A physician order dated 5/26/21 provided direction to staff for changing the dressing on a wound on Resident 3's left buttock. There was no documented evidence the wound was monitored through resolution.In interviews on 8/31/21 and 9/1/21 the need to monitor short-term changes of condition and document progress at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (RN), They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, or updated the service plan for 1 of 1 sampled resident (# 1) who experienced a significant change of condition and 7 of 17 residents (#s 1, 3, 4 , 5, 6, 7 and 8) reviewed for weight changes. Residents 1, 3, 5, 6 and 7 experienced significant weight changes. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia.Observations of the resident from 8/30/21 to 9/1/21 showed the resident required staff assistance with transfers and meal intake.Clinical records dated 3/6/21 through 8/30/21 including progress notes, alert charting, health assessments/evaluations, service plans, after visit summaries, physician faxes and incident reports were reviewed during the survey and revealed the following:* The resident experienced 9 falls between 3/6/21 and 8/30/21;* Had multiple emergency department visits due to the falls including 7/1/21, 7/15/21 and 7/23/21; * Physical injuries identified including a head laceration with staples on and a fractured nose on 7/23/21;* No longer ambulating, staying bed;* No longer transfer independently, needing 2-person assistance with transfer; and* RN assessment for the changes of condition completed on 7/29/21 did not address findings, resident status, and interventions made as a result of the assessment.The lack of an RN assessment regarding Resident 1's significant change in condition was reviewed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.2. A review of Resident 1, 3, 4, 5, 6, 7 and 8's weight records revealed each resident had a significant to severe amount of weight change. a. Resident 1's weight record revealed the following:* 3/2021 (Admission) - 121 pounds;* 5/2021 - 110.6 pounds;* 7/2021 - 106 pounds; and* 8/2021 - 100.8 pounds.From 3/2021 to 5/2021, Resident 1 lost 10.4 pounds or 8.59% of his/her body weight in 2 months, which represented a significant change of condition.From 5/2021 to 6/2021, additionally, the resident lost 4.0 pounds or 3.22% of his/her body weight in a month.From 6/2021 to 8/2021, Resident 1 again lost 5.8 pounds or 4.82% of his/her body weight in 2 months, which represented a severe weight loss.Resident 1 continued experiencing a significant weight loss. b. Resident 3's weight record revealed the following:* 3/2021 - 133.4 pounds; and* 6/2021 - 144.6 pounds.From 3/2021 to 6/2021, Resident 3 gained 11.2 pounds or 8.39% of his/her body weight in three months. This represented a significant change of condition.On 8/31/21 the resident weighed 149.8 pounds, revealing an ongoing weight gain.c. Resident 4's weight record revealed the following:* 5/2021 - 181.4 pounds;* 7/2021 - 172 pounds; and * 8/2021 - 165.6 pounds.From 5/2021 to 7/2021, Resident 4 lost 10 pounds or 5.5% of his/her body weight in 2 months.From 7/2021 to 8/2021, additionally, the resident lost 6.4 pounds or 3.52% of his/her body weight in a month which represented a significant weight loss.From 5/2021 to 8/2021, Resident 4 lost a total of 16.4 pounds or 9.1% of his/her body weight in 3 months which represented a significant change of condition.d. Resident 5's weight record revealed the following:* 1/2021 - 144.8 pounds;* 3/2021 - 152 pounds;* 5/2021 - 160 pounds; and * 8/2021 - 163.3 pounds.From 1/2021 to 3/2021, Resident 5 gained 7.2 pounds or 4.97% of his/her body weight in 2 months.From 3/2021 to 5/2021, additionally, the resident gained 8.0 pounds or 5.52% of his/her body weight in 2 months which represented a significant change of condition. From 5/2021 to 8/2021, Resident 5 gained 3.3 pounds or 2.27% of his/her body weight in 3 months which represented a severe weight change.Residents 5 continued experiencing a significant weight gain.e. Resident 6's weight record revealed the following:* 1/2021 - 91.6 pounds;* 2/2021 - 97.0 pounds;* 3/2021 - 103 pounds;* 6/2021 - 136.4 pounds; and * 8/2021 - 127.8 pounds.From 1/2021 to 2/2021, Resident 6 gained 5.4 pounds or 5.89% of his/her body weight in a month which represented a significant change of condition.From 2/2021 to 3/2021, additionally, the resident gained 6.0 pounds or 6.55% of his/her body weight in a month.From 3/2021 to 6/2021, Resident 6 gained 33.4 pounds or 36.4% of his/her body weight in 3 months which represented a severe weight change.Residents 6 experienced a severe weight gain.f. Resident 7's weight record revealed the following:* 3/2021 - 109 pounds;* 6/2021 - 131.2 pounds;* 7/2021 - 135.2 pounds; and * 8/2021 - 138.8 pounds.From 3/2021 to 6/2021, Resident 7 gained 22.2 pounds or 20.36% of his/her body weight in 3 months which represented a significant change of condition.From 6/2021 to 7/2021, additionally, the resident gained 4.0 pounds or 3.66% of his/her body weight in a month.From 7/2021 to 8/2021, Resident 7 gained 3.6 pounds or 3.30% of his/her body weight in a month which represented a severe weight change.Residents 7 continued to experience severe weight gain.g. Resident 8's weight record revealed the following:* 1/2021 - 151.8 pounds;* 3/2021 - 145.7 pounds; and* 6/2021 - 137.6 pounds.From 1/2021 to 3/2021, Resident 7 lost 6.1 pounds or 4.01% of his/her body weight in 2 months.From 3/2021 to 6/2021, additionally, the resident lost 8.1 pounds or 5.55% of his/her body weight in 3 months which represented a significant change of condition.There was no documented evidence the RN had assessed any of the residents for weight changes. On 9/1/21, Staff 2 (RN) stated she was not aware of the weight changes and confirmed that she had not assessed residents' weight changes.The facility's failure to implement an effective system for monitoring residents' weights led to multiple residents experiencing significant weight changes. The lack of an RN assessment regarding multiple residents identified with weight loss or weight gain, was reviewed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers for 1 of 2 sampled residents (# 1) who received outside services. Findings include, but are not limited to: Resident 1 was admitted to hospice in March 2021 with diagnoses including dementia.Clinical records indicated Resident 1 was receiving palliative care from an outside provider. The facility failed to ensure the following recommendations, made by the outside provider, were initiated and/or communicated to staff:* 6/29/21: clean wound, (R) knee instruction;* 7/06/21: push fluid; * 7/19/21 and 8/5/21: fall follow-up;* 7/23/21: Hospital discharge summary including a fractured nose home care instructions;* 8/02/21: bowel suppository instructions; and* 8/04/21: monitoring and reporting guidelines for head injury.The need to ensure the outside provider recommendations were implemented and communicated to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. They 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 1 of 1 sampled resident (# 1) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in March 2021. Resident 1 had signed physician orders for scheduled and as need morphine for pain and as needed Lorazepam for agitation.Resident 1's Controlled Substance Disposition logs and MARS were reviewed from 8/1/21 - 8/30/21. The following deficiencies were identified:* An 8/5/21 dose of PRN morphine was documented as being removed from storage on the disposition log at 10:00 am, but it was documented as being administered on the MAR at 2:50 pm, 5 hours 50 minutes later.* An 8/20/21 dose of PRN morphine was documented as being removed from storage on the disposition log at 2:20 pm, but it was documented as being administered on the MAR at 12:47 am, 10 hours 27 minutes later. * On three occasions, 8/11/21, 8/17,21 and 8/20/21, staff documented scheduled morphine was administered on the MAR at 8:00 pm. There was no documented evidence on the Controlled Substance Disposition log the medication was dispensed on those days.* On four occasions, 8/18/21, 8/19/21, 8/26/21 and 8/27/21, dose of PRN morphine was documented as being removed from storage on the disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 1 on those days. * On six occasions, 8/21/21, 8/26/21, 8/27/21 x 2, 8/28/21 and 8/29/21, PRN Lorazepam was documented as being removed from storage on the disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 1 on those days.On 8/31/21 and 9/1/21, inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 8/31/21 and 9/1/21 with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1's current physician orders and 8/1/21 - 8/30/21 MARs were reviewed and indicated the following medication or treatment orders were not carried out as prescribed:a. An order for Celexa (an anti-depression medication) was discontinued by the physician on 7/27/27, after 5 days of use. The MAR indicated staff continued to administer the medication to Resident 1 in 8/2021 MAR.b. An order for Memantine (a medication to treat dementia) was discontinued by the physician on 7/27/21. The MAR indicated staff continued to administer the medication to Resident 1 in 8/2021 MAR.c. An order for Rivastigmine (a medication to treat dementia) was discontinued on the 8/2021 MAR, but there was no physician order to discontinue the medication.d. An order for Senna (a medication to help bowel movement) 8.6 mg twice daily as needed but carried out on the MAR as one time daily, not two times daily as prescribed.e. An order for Perphenazine (an anti-psychotic medication) 2 mg two times daily was prescribed on 7/27/21, but was there was no indication the order was transcribed to the MAR.f. A 7/2/21 order for instructions when the resident was wandering the facility and instruction for blood glucose monitoring and reporting monthly were not transcribed to the MAR.g. An order for PRN Lorazepam 1mg for "seizure" and 0.5 mg for "anxiety/agitation/restlessness".Resident 1's 3/6/21 through 8/30/21 progress note and Controlled Substance Disposition logs from 8/1/21 - 8/30/21 revealed the resident was administered 1.0 mg of Lorazepam for agitation on 8/21/21, not 0.5 mg as prescribed.The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 4 sampled residents (#s 6 and 11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 11 moved into the facility in 2016 with diagnoses which included hypertension, gout and chronic pain. Physician orders and MARs for Resident 11, reviewed from 12/01/21 - 12/20/21, revealed the following orders were not followed:* Tylenol 500 mg 1 tablet four times a day: the 12:00 pm dose was not administered on 12/07/21 and 12/10/21; and * Allopurinol (given for gout) 100 mg 1 tablet once a day: was not administered on 12/07/21. On 12/21/21 at 12:45 pm, the surveyor and Staff 3 (RCC) observed/checked the MARs and medication supply. The Allopurinol tablet for 12/07/21 was still in the card. Staff 3 was unable to verify if the Tylenol had been given.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21 at 3:30 pm. They acknowledged the findings. No further information was provided.2. Resident 6 was admitted 01/2021 with diagnoses which included hypertension.S/he had an order for Metoprolol (antihypertensive) 25 mg 1 tablet twice a day. Staff were instructed to hold the medication if the systolic blood pressure (upper number) was less than 100 or pulse was less than 50. Review of the clinical record and MARs, from 11/01/21 - 12/20/21, indicated no blood pressure or pulse had been taken prior to giving the medication. In an interview on 12/21/21 at 10:10 am, Staff 3 (RCC) reviewed the resident's record and was unable to find documentation that the blood pressure and pulse were measured before the medication was given. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21 at 3:30 pm. They acknowledged the findings. No further information was provided.

2. Resident 9 was admitted in 01/2021 with diagnoses including dementia.The residents 11/01/21 through 12/20/21 MARs were reviewed and revealed the following:* Staff failed to initial on the MAR that the following medications were administered:- Senna (for bowel care) was not given on 11/09/21; and - Lamotrigine (for seizures) was not given on 11/09/21.In an interview on 12/21/21 with Staff 3 (RCC), she verified the medications were given, but staff failed to document on the MAR. On 12/21/21 the need to ensure MARs were accurate was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 4 sampled residents (#s 9 and 11). Findings include, but are not limited to:1. Resident 11 was admitted in 2016 with diagnoses which included hypertension, gout and chronic pain. His/her MARs were reviewed from 12/01/21 through 12/20/21 and the following was noted:* Staff failed to initial on the MAR that the following medications were administered:- Levothyroxine (for hypothyroidism) was not given on 12/10/21; and - Allopurinol (for gout) was not given on 12/10/21.On 12/21/21 at 12:45 pm, the surveyor and Staff 3 (RCC) reviewed the MAR and checked the medication cart. She verified the medications had been given, but staff failed to document on the MAR.On 12/21/21 at 3:30 pm, the need to ensure MARs were accurate was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were documented ineffective, for 2 of 2 sampled residents (#s 1 and 3) who had an order for PRN psychoactive medication. Findings include, but are not limited to:Resident 1 and 3 resided in a Memory Care Community with diagnoses including dementia.Resident 1's records indicated s/he had an order for PRN Lorazepam 1.0 mg for seizure and 0.5 mg for "anxiety/agitation/restlessness" and Resident 3 had an order for Lorazepam, 0.25 ml (0.5 mg) orally every 6 hours if needed for agitation. Reviewing Resident 1 and 3's 8/1/21 - 8/30/21 MARs revealed that there was no instruction to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety for which staff could consider administering the medications and no listed non-drug interventions that staff should attempt prior to the administration of the PRN psychoactive medication.Resident 1's 8/1/21 - 8/30/21 MAR and progress notes were reviewed and indicated the resident was administered PRN lorazepam (an anti-anxiety medication) on one occasion for agitation without documented, specific symptoms and without appropriate non-drug interventions being attempted with ineffective results prior to the administration.On 8/31/21 and 9/1/21, the need to ensure staff documented the resident-specific signs and symptoms of behaviors and only after attempting non-drug interventions was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed, including a thorough review by an RN, PT or OT prior to use and that staff were instructed on the correct use of and precautions of the device for 1 of 1 sampled residents (#3) who had a supportive device. Findings include, but are not limited to:Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.Observations during the re-licensure survey on 8/30/21, 8/31/21 and 9/1/21 revealed Resident 3 had an air-filled scoop mattress on his/her hospital bed. In an interview 8/31/21, Staff 13 (CG) stated the scoop mattress was to keep the resident from falling out of bed and that it worked.There were no documented instructions to staff on the use of or precautions for the air-filled scoop mattress.There was no documented evidence the scoop mattress had been evaluated to determine if it was a restrictive device for Resident 3.The need to have an RN, PT or OT assess all devices with potentially restraining qualities, prior to use and quarterly, was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 9 and 15) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 8/31/21 and revealed Staff 9 (MT) and Staff 15 (CG), hired on 7/7/21 and 6/22/21 respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Review of fire and life safety records on 8/31/21, for May 2021 through July 2021, revealed the following:1. Training regarding fire and life safety training for staff was not consistently being provided on alternating months.2. The facility was not consistently relocating or evacuating residents during fire drills.3. Documentation of fire drills was lacking or incomplete regarding: - Escape route used; - Resident evacuation problems encountered; and - Number of occupants evacuated.On 8/31/21, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training on alternate months and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1 (ED) and Staff 4 (Maintenance).They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Review of fire and life safety records on 8/31/21, for May 2021 through July 2021,identified the facility lacked documented evidence of the following: * Alternate exit routes were used during fire drills;* Fire and life safety training for residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and * A written record of fire safety training, including content of the training sessions and the residents attending. On 8/31/21, the need to ensure alternate exit routes were used during fire drills, residents were being relocated during drills and fire and life safety was provided on admission and annually was discussed with Staff 1 (ED) and Staff 4 (Maintenance). They acknowledged the findings.

Based on observation, 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 Z 142, Z 162, Z 164, C 242 and C 303.

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:During a tour of the facility on 8/30/21 and 8/31/21, the following was observed:* Carpet throughout the common areas and hallways had spots, stains, blackened areas and uneven surface; and* Furniture throughout the facility (including chairs, recliners and tables) had stains, exposed wood and frayed edges.The environment was toured on 8/31/21 with Staff 1 (ED). She acknowledged the above areas needed to be cleaned and repaired.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:The licensee is responsible for the operation of the Memory Care Community and the provision of person-directed care that promotes each resident's dignity, independence and comfort. That includes the supervision and overall conduct of the staff.During the re-licensure survey, conducted 8/30/21 through 9/1/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey. Refer to deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C231, C240, C242, C372, C420, C422 and C513.
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 242 and C 455.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 9 and 10) completed all required pre-service orientation, dementia training and 30-day competency demonstration and 2 of 3 long term staff (#s 7 and 11) completed 16 hours of annual training. Findings include, but are not limited to:A review of staff training records revealed the following:1. Staff 10 (CG) was hired 5/19/21. There was no documented evidence they had completed the following elements of the required pre-service orientation prior to performing any job duties: * Resident rights and values of community based care;* Abuse reporting requirements; and* Fire safety and emergency procedures.2. There was no documented evidence that Staff 6 (MA) and Staff 9 (CG), hired 6/16/21 and 7/26/21 respectively, or Staff 10 completed one or both of the following pre-service dementia care training prior to performing care and services independently:* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and* Use of supportive devices with restraining qualities in memory care communities.3. There was no documented evidence that Staff 6, Staff 9 or Staff 10 demonstrated competency in their job duties within 30 days of hire in one or more of the following areas:* The 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;* General food safety, serving and sanitation; and* Other duties as applicable (e.g. medication pass, treatments).The facility was unable to provide documentation that any of the MAs had demonstrated competency in performing a medication pass. The facility was asked to provide a plan for ensuring all MAs were trained and satisfactorily demonstrated competency in their job duties before they were scheduled to work again. The facility provided a plan 8/31/21 at 1:05 pm.4. There was no documented evidence Staff 7 (MA), and Staff 11, hired 7/18/19 and 8/15/19, respectively, completed the required 10 hours of annual training related to provision of care in community-based care or the required 6 hours related to dementia care.The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C252, C260, C270, C280, C290, C302, C303, C330 and C340.
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 303 and C 310.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 1 of 2 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.Observations of lunch on 8/30/21, breakfast on 8/31/21 and lunch on 9/1/21 indicated Resident 3 needed full assistance from staff with eating. Resident 3's 8/11/21 service plan was reviewed. The service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose activity plans were reviewed. Findings include, but are not limited to:During the survey, the primary activities observed in the MCC included residents sitting out in the common area for long periods of time watching movies or other TV shows, wandering the halls or remaining in their rooms. Service plans for Residents 1, 2 and 3 revealed the facility had not fully evaluated the residents':* Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED) on 9/1/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 6, 9, 10 and 11) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Residents 6, 9, 10 and 11's records were reviewed during the survey. Though an activity evaluation was completed for each resident, the evaluations failed to address all of the following components: * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.Although the service plans did include some information regarding activities, there was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:Resident 1 was admitted to the facility in March 2021, with diagnoses including dementia.Resident 1's record documented behaviors including:* Was involved in two physical altercations with other residents between 3/2021 and 8/2021 including slapping a resident and attacking another resident from behind by pulling the back of their sweatshirt and "almost" choking him/her; and* Was administered as needed Lorazepam for being "very agitated."The resident's current service plan did not address these behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of these behaviors. The need to include an individualized behavior plan for residents with behavioral symptoms was discussed with Staff 1 (ED) on 8/31/21 and 9/1/21. She acknowledged the findings.

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 8/30/21 and 8/31/21 indicated the doors to the exterior courtyards were locked and did not allow residents to exit and return without staff assistance.A sign was observed in the dining area with "Patio Door" operation hours listed: * April - October: 5:00 am - 10:00 pm; and* November - March : 7:00 am - 6:00 pmDuring a tour of the building on 8/31/21 with Staff 1 (ED) she acknowledged the courtyard doors were locked.The need to ensure residents had access to secured outdoor spaces without staff assistance was discussed with Staff 1 on 8/31/21. She acknowledged the findings.

Based on interview, observation and record review, it was confirmed the facility failed to ensure reasonable precautions against conditions that may threaten the health and welfare of residents were enforced. Findings include: Compliance Specialist (CS) review of Covid 19 Employee/Non-Employee Screening Tool forms revealed the facility is not consistently screening in staff, essential employees, or outside providers. Review of 24-Hour Nursing Report Forms reveal they are allowing residents to have visitors; Resident #1 had daughter visit on 2/19/2020 and Resident #4 had a visitor on 1/22/21.On 2/2/21 CS observed Staff #1-5, to not be wearing eye protection while onsite and working with residents. CS observed disinfectant (cleaner) in staff area to be labeled and staff observed cleaning throughout the facility. During interview with Staff #1, s/he stated they were not aware eye protection was still a requirement or that visitors were not allowed if the facility was not under an Executive Order. The above findings were discussed with Staff #1, who was in agreement.