Fox Hollow Residential Care Community

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 1 of 4 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 moved into the facility in 03/2024 with diagnoses including dementia and stroke with left-sided hemiplegia.

Review of Resident 1's 01/01/25 through 01/27/25 MAR and physician orders identified the following:

a. The following PRN medications for pain lacked resident-specific parameters, including sequential order of use:

* Acetaminophen oral tablet 1000 mg (for pain);
* Acetaminophen Suppository 650 mg (for pain or fever); and
* Morphine Sulfate oral solution 100 mg/ml 500mg (for moderate-severe pain or dyspnea).

The resident was administered morphine sulfate on 01/20/25 and 01/22/25, with documented pain levels of 10 and 5, respectively. The resident was administered oral acetaminophen on 01/25/25, with a documented pain level of 7.

b. The following PRN medications for constipation lacked resident-specific parameters, including sequential order of use:

* Bisacodyl rectal suppository; and
* Polyethylene Glycol 3350 powder.

The need to ensure MARs were accurate, including providing resident-specific parameters and instructions for PRN medications, was reviewed with Staff 1 (ED) and Staff 2 (Health Services Director/RN) on 01/29/25. They 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 observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 3 and 4) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

Review of Residents 1, 3 and 4’s ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/RN) on 01/28/25 and 01/29/25. The staff acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING
(b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average.
(c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents.
(d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1).
(e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule.
(f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.
(g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure ABST data was updated at least quarterly and with significant changes in condition. Findings include, but are not limited to:

Review of the facilities ABST entries, staff schedule, calculated staffing hours and posted staffing plan were completed and showed the following:

* Updates to the ABST were not made at least quarterly or with significant changes of condition for 24 of the residents currently residing in the facility.

The need to ensure all residents ABST evaluations were updated at least quarterly and with changes in condition was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/RN) on 01/28/25 and 01/29/25. The staff acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 11, 12, and 13) demonstrated competency in their job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 01/28/25 with Staff 1 (ED).

1. Staff 11 (MT/CG), Staff 12 (CG), and Staff 13 (MT/CG), hired 12/10/24, 11/29/24, and 11/13/24, respectively, had no documented evidence of completion of First Aid and Abdominal Thrust training within 30 days of hire.

2. Staff 11 and Staff 13 had no documented evidence of demonstrated satisfactory performance in all duties they were assigned, including the observation and evaluation of the ability to perform safe medication and treatment administration unsupervised.

Documentation was provided by Staff 1 on 01/28/25 that no MT would be allowed to perform medication administration duties until evidence of competency was obtained.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 and Staff 2 (Health Services Director/RN) on 01/29/25. 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 2 of 3 sampled long-term direct care staff (#s 7 and 9) completed a minimum of 12 hours of annual in-service training, including at least six hours of dementia care. Findings include, but are not limited to:

Staff training records were reviewed on 01/28/25 with Staff 1 (ED).

There was no documented evidence Staff 7 (MT/CG), hired 10/18/21, and Staff 9 (MT/CG), hired 11/24/21, completed at least 12 hours of annual training based on their anniversary date of hire, related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics.

The need to ensure that long-term direct care staff completed the required number of hours of annual in-service training based on their anniversary date of hire was discussed with Staff 1 on 01/28/25. She acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff

(6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF.

(a) Annual infectious disease training requires the following:
(A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.
(B) Annual in-service training must be documented in the employee record.

(b) Biennial LGBTQIA2S+ training requires the following:
(A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff.
(i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite.
(ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility.

(B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either:
(i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or
(ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility.

(C) ORS 441.116 requires all LGBTQIA2S+ trainings address:
(i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus.
(ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status.
(iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status.
(iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns.
(v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination.
(vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training.
(vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state.

(D) The proposal for training submitted by a facility, entity, or individual shall include:
(i) The regulatory criteria described in paragraph (C) of this section as part of the proposal.
(ii) The following elements must be included in the proposal:
(I) A statement of the qualifications and training experience of the facility, individual or entity providing the training;
(II) The proposed methodology for providing the training either online or in person.
(III) An outline of the training.
(IV) Copies of the materials to be used in the training.
(iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision.

(c) Annual Home and Community-Based Services (HCBS) training requires the following:
(A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations.
(B) Annual in-service training must be documented in the employee record.
(C) These annual trainings will be required as of April 1, 2025.

(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.
(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire.
(b) Requirements for annual in-service dementia training:
(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.
(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.
(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.
(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.
(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:
(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).
(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.
(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency.

(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

This Rule is not met as evidenced by:

Based on observation, and interview, it was determined the facility failed to maintain the kitchen 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 facility kitchen areas were reviewed on 01/07/25 from 10:15 am through 1:00 pm and found the following:

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:

* Interior of microwave;
* Underneath, between and behind large equipment;
* Caulking around the perimeter of dish machine dirty side;
* Floors, walls behind, underneath dish machine;
* Counter top mixer, food processor, blender;
* Drains;
* Walls throughout kitchen areas with splatter;
* Door thresholds entering and exiting kitchen;
* Open stainless steel shelving above baking area;
* Utility carts;
* Flooring and shelving in dry storage;
* Wall in dining room where busing station cart sits;

b. The following areas were in need of repair:

* Pipe under the dishwasher was leaking causing damage to flooring, large mineral scale build up on dish machine and flooring under dish machine
* Dish machine rinse temperature gauge not functioning properly (not registering correct rinse temperature).
* Vegetable prep sink not operational;
* Convection oven door not closing properly;
* Flooring in Walk in cooler with paint peeling large sections and rusted metal exposed.
* Some wood shelves in dry storage peeling, cracked or chipped making areas uncleanable
Surfaces.
* Caulking by handwashing sink cracked/missing and needing replaced/repaired.

c. Tabletop mixer was stored uncovered not protected from potential contamination.

d. Multiple plastic trays were found in poor repair being heavily scored, stained and/or with chunks missing or cracks. Utility cart found heavily scored on the top yielding unsmooth surface for effective sanitation.

e. Dish machine temperature gauge for rinse cycle not registering correct temperature to ensure 180 degrees Fahrenheit was reached. Facility did not have a system in place to validate dishes were being effectively sanitized when rinse temperature could not be observed or was not registering the required 180 degrees. Surveyor tested the dish machine with color changing temperature strips and validated dishes were being sanitized at the time of survey. Staff 1 (Executive Director) and Staff 2 (Dietary Manager) and each verified facility did not currently have a system for validating effective sanitation when temperature gauge was malfunctioning.

Staff 2 (Dietary Manager) toured kitchen areas with surveyors and acknowledged the areas of concern. At approximately 1:00 pm, surveyor reviewed above areas with staff 1 (Executive Director) who acknowledged the identified areas.

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:

The findings of the kitchen inspection, conducted 8/21/23, 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 08/16/23, conducted 10/27/23 through 10/30/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen 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: Observations of the facility kitchen areas were reviewed on 8/21/23 from 10:10 am through 1:00 pm and the following was noted: 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: * Walk in cooler floors;* Fans blades and cages in cooler;* Ceiling in walk in cooler;* Metal racks in cooler;* Ceiling vents;* Interior of microwave;* Industrial can opener and housing;* Underneath, between and behind equipment;* Caulking around the perimeter of dish machine dirty side;* Floors, walls behind, underneath dish machine;* Counter top mixer;* Fan cages and blades; and* Edges under juice machine nozzles. b. The following areas were in need of repair: * Food processor plastic cover cracked with pieces missing;* Pipe under the dishwasher was leaking;* Wood door by dish machine to dining room with damage around edges with pieces missing and crack;* Multiple areas of flooring with staining, rust, rips, tears, cracks making floor a non cleanable surface;* Multiple wood shelves in dry storage peeling, cracked or chipped making areas uncleanable surfaces;* Dish machine booster heater making loud unusual sounds and temperature readings irregular and sporadic. After several attempts the dishwasher met the required final rinse temperature of 180; and* Dish machine had large mineral accumulation around external pipes.c. Industrial and tabletop mixer were stored uncovered not protected from potential contamination. Industrial mixer with metal/paint peeling/scraped off exposing rusted metal. d. Multiple plastic spatulas were found in poor repair being heavily scored, stained with chunks missing. e. Multiple food items found uncovered in walk in. Salad dressings and other condiments without use by date on bottle when removed from original package. f. Two heavily dented/damaged cans found in storage area. g. Facility did not have a 3 compartment sink or similar system to effectively sanitize dishes/utensils if ware washing machine was unusable. h. Facility did not have correct strips to check and validate sanitizer solution for surfaces. i. Facility was observed with preset silverware with food contact surfaces which were not protected from possible contamination as required. Staff 2 (Dietary Manager) toured kitchen areas with surveyors and acknowledged the areas of concern. At approximately 12:45 pm, surveyors reviewed above areas with Staff 1 (Executive Director) who acknowledged the identified areas.

The findings of the re-licensure survey, conducted 8/23/21 to 8/25/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.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 08/25/21, conducted on 12/13/21 through 12/14/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 08/25/21, conducted on 01/25/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 third re-visit to the re-licensure survey of 08/25/21, conducted 03/08/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure all incidents and injuries of unknown cause were investigated to rule out abuse and reported to the local SPD when abuse was not reasonably ruled out for 1 of 2 sampled residents (#3) whose facility records were reviewed for incidents and injuries of unknown cause. Findings include, but are not limited to: Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia. During an interview with Resident 3 on 8/24/21 at 10:05 am, an approximately 2 inch by 1 inch yellow/green bruise was observed at the base of his/her right thumb. Resident 3 reported s/he was unaware of how s/he sustained the bruise. Review of Resident 3's facility record revealed no documented evidence related to the bruise. Staff 2 (RN) reported during an interview on 8/25/21 at 12:45 pm that she was unaware the resident had a bruise and that it had not been investigated. Survey instructed the facility to report the injury of unknown cause to the local SPD. Fax confirmation of the report was provided prior to exit. The need to investigate injuries of unknown cause to rule out abuse and to report to the local SPD when unable to reasonably rule out abuse was discussed with Staff 1 (ED) and Staff 2 on 8/25/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in August 2018 with diagnoses including dementia and osteoarthritis.The resident's service plan, dated 8/10/21, was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:* Scoop plate;* Meal assist;* Ability to communicate; and* Preference to sleep in and not eat breakfast. The need to ensure resident service plans were reflective of current care needs and provided clear directions to staff was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.
3. Resident 3 was admitted to the facility in July 2020.Resident 3's 6/3/21 service plans and subsequent temporary service plans were not reflective of the resident's current status and care needs, did not provide clear direction to staff and was not followed in the following areas: * Grooming;* Bed mobility;* Use of blankets and pillows for positioning in the recliner;* Elevation of feet;* Discontinued use of electric scooter; * Signs and symptoms of depression;* Resistance to bathing;* Legs elevated when in chair;* Weakness related to radial nerve palsy;* Meal assist;* Assist with remote control;* Cup with handle and lid at chairside;* Wrist brace; and* Bed cane. The need to ensure service plans were reflective of the resident's current care needs, provided clear direction to staff and were followed was discussed with Staff 1(ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status, provided clear direction to staff regarding the delivery of services and were followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in April 2021 with diagnoses including chronic heart failure, chronic respiratory failure and morbid obesity.Resident 2's current service plan, dated 8/10/21, lacked clear instructions to staff in the following areas:* Side rails; and* CPAP or Bi-PAP machine.Interviews with Resident 2, Staff 7 (CG/MT) and Staff 2 (RN) on 8/24/21 indicated there was confusion about whether the resident used a CPAP or a bi-PAP machine.On 8/25/21 the need to ensure service plans were reflective of residents' current needs and status and provided clear direction to staff regarding the delivery of services was discussed 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 service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee and at least one other staff person who was familiar with or provided services, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2 and 3's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/24/21 and 8/25/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in August 2018 with diagnoses including dementia. Resident 1 was identified during the acuity interview on 8/23/21 with a history of falls.A review of progress notes, facility incident reports and service plans from 5/25/21 through 8/23/21 identified Resident 1 had the following short-term changes of condition related to non-injury falls: * 6/4/21 Resident 1 was found on the floor with his/her head on the floor between the bed and dresser. The interim service plan provided instructions to decrease clutter in the room. * 7/5/21 The resident had an unwitnessed fall and was found next to the bed. The interim service plan provided instructions to assist with ADLs as needed, continue frequent checks and encourage a family member to acquire a hospital bed;* 7/23/21 The resident was found on the bedroom floor. There were no new fall interventions implemented nor were previous interventions reviewed to determine if they were in place; and* 8/8/21 The resident was found on the bedroom floor. Interim service plan instructed staff to place a rolled up blanket under the sheet along the edge of the bed. There was no documented evidence the facility investigated the falls to include identifying causal factors, the service-planned interventions were not reviewed to determine if in place and whether they continued to be effective to help minimize the reoccurrence of falls.Observations and interviews with staff on 8/23/21 and 8/24/21 confirmed Resident 1 needed full assist for all ADL cares. The Resident was observed to ambulate with one person assist using a walker. The resident was primarily non-verbal, unable to effectively communicate his/her needs. The need to ensure the facility had a system in place to investigate and evaluate fall incidents, patterns of falls, determine actions or interventions needed for short-term changes of condition and review the interventions for effectiveness was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/24/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to evaluate residents who experienced significant changes of condition, document findings, update the service plan and refer to the nurse for 1 of 2 sampled residents (#3) who experienced significant changes of condition. The facility failed to determine what actions or interventions were needed, communicate information to staff on all shifts, monitor effectiveness of interventions and document weekly through resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced short-term changes of condition. Resident 3 had repeated falls with injury. Findings include but are not limited to:1. Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia and monoplegia of left arm (paralysis). A. Resident 3's current service plan dated 6/3/21 noted the resident had a history of falls, was at risk for falls and required assistance with ADLs and mobility. Fall prevention interventions included:* Check routinely and during safety rounds;* Put electric scooter where s/he cannot trip over it;* Added 7/9/21: "Ensure resident wears non-slip footwear at all times"; and * Transfer to his/her strong side.Progress notes dated 5/23/21 through 8/20/21 revealed the following falls: * 5/30/21: Resident found uninjured on the floor next to his/her table. * 7/9/21: Resident found uninjured on floor in apartment stating s/he tripped over his/her socks. * 7/24/21: Resident fell backwards and hit his/her head on walker. * On 8/9/21, Resident 3 was heard yelling in his/her room and was found on the floor reporting that s/he had hit his/her head. The resident was transported to the ED by ambulance and returned the same day with diagnoses including right-sided radial nerve palsy, a neurological injury which impacted the resident's strength and functional use of his/her right arm for ADLs and mobility with a walker. * 8/17/21: Resident 3 experienced a witnessed fall from toilet, hit his/her head and sustained a laceration to his/her forehead. The resident was transported to the emergency department where s/he received sutures to his/her forehead and was diagnosed with a small brain bleed. * 8/20/21: Resident experienced a non-injury fall in his/her room where s/he was found on the floor. During the survey, on 8/24/21, Resident 3 was observed being transported in the hallway in a wheelchair by a caregiver. There was no documented evidence the facility had monitored the circumstances of each fall, evaluated if there was a pattern to the falls, if previously identified fall prevention interventions were in place at the time of the falls, whether the interventions were effective and did not consistently identify new fall prevention interventions. The resident continued to fall and sustained injuries. B. On 8/9/21, Resident 3 fell and was diagnosed with right-sided radial nerve palsy, a neurological injury which impacted the resident's strength and functional use of his/her right arm for ADL and mobility. During interviews with Staff 4 (RCC) and Staff 6 (CG), they stated the resident experienced a major decline in the ability to feed him/herself, toilet, groom, hold the walker and manipulate the television remote control after the injury. This constituted a significant change of condition. There was no documented evidence the facility evaluated the resident, documented the findings, determined what actions an interventions were needed for the resident, communicated the actions and interventions to staff on all shifts and updated the service plan to include all pertinent information related to the resident's injury and decline in function. C. On 8/17/21, Resident 3 fell from the toilet, hit his/her head and sustained a laceration to the forehead. The resident was transported to the emergency department where s/he received sutures to the forehead and was diagnosed with a small brain bleed. Staff 4 and Staff 6 reported the resident was not able to walk after the injury. There was no documented evidence the facility evaluated the resident, documented the findings or updated the service plan in all pertinent areas. D. On 7/16/21, Resident 3 was sent to the emergency department of the local hospital for urinary retention. S/he returned the same day with a prescription for Flomax to be administered for 10 days. There was no documented evidence the facility monitored the resident for adverse reactions to the medications or whether it was effective. Resident 3's significant changes of condition and on going falls including referring to the RN, determining what actions or interventions were needed, communicating information to staff on all shifts, monitoring effectiveness of interventions and documenting weekly progress through resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. Staff acknowledged the findings.
3. Resident 2 was admitted to the facility in April 2021 with diagnoses including chronic heart failure, chronic respiratory failure and morbid obesity.Review of progress notes dated 5/23/21 through 8/23/21 revealed staff identified a "very dark red and peeling" area on the back of Resident 2's right leg on 7/31/21. There was no documented evidence this skin condition was monitored, with at least weekly documentation of progress, through resolution.The need to monitor changes of condition and document progress at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the RN completed a timely assessment when 1 of 2 sampled residents (#3) experienced significant changes of condition. Resident 3 experienced falls with a laceration to forehead, a brain bleed and right radial nerve palsy. Findings include, but are not limited to: Resident 3 was admitted to the facility with vascular dementia and monoplegia of the left arm (paralysis). Review of Resident 3's facility record revealed the following: 1. On 8/9/21, Resident 3 was found on the floor and reported s/he hit his/her head. The resident was transported to the hospital and returned that day with a diagnoses of right radial nerve palsy, a nerve injury that impacted the resident's strength and functional use of his/her right arm. During interviews with Staff 4 (RCC) and Staff 6 (CG) they reported that, prior to the fall, the resident was able to feed themselves, change the television channel with the remote control, manage clothing and toilet hygiene unassisted and manipulate grooming tools when desired. After the fall, they reported the resident required assistance with all of the above-mentioned tasks. This constituted a significant change of condition for which there was no documented evidence an RN assessment had been completed. 2. On 8/17/24, Resident 3 fell off the toilet and sustained a laceration to his/her forehead. S/he was transported the the emergency department by ambulance and returned the same day with sutures to the forehead laceration and a diagnosis of a small brain bleed. Staff 4 reported in an interview that Resident 3 walked with a walker with supervision prior to the injury, but had not walked since. This constituted a significant change for which there was no documented evidence an RN assessment had been completed. On 8/24/21, the resident was observed to be transported in a wheelchair by facility staff. 3. Review of Resident 3's facility record revealed the following medication changes: * 6/22/21 Resident 3 had an increase to her dosage of Prozac: * 6/30/21 Resident 3's Buprenorphine HCL - Naloxone HCL for pain was changed to administration via patches on her skin vs orally.* 7/8/21 Resident's Buprenorphine HCL - Naloxone HCL was increased from one to two patches. * 7/22/21 Resident's Buprenorphine HCL - Naloxone HCL was decreased from two to one patch.Resident 3 experienced an unwitnessed non-injury fall on 7/9/21. The medication technician who completed the form checked a box which indicated medication changes may have been a predisposing factor. Resident 3 experienced an unwitnessed non-injury fall on 7/24/21. In a progress note written 8/4/21, Staff 2 (RN) indicated Resident 3 had changes to the above medications with a subsequent increase in agitation and falls. The 8/24/21 RN progress note was written 26 days and 11 days respectively after the 7/9/21 and 7/24/21 falls. The RN indicated in the 8/4/21 note that she had contacted the doctor and the resident would be seen the following day for an evaluation. Resident 3 experienced significant changes of condition without documented evidence an RN assessment was completed to include findings, resident status, and interventions made as a result. Resident 3 experienced changes to medication which potentially contributed to increased falls without a timely RN assessment to document on the resident condition. Resident 3's changes of condition were discussed with Staff 1 (ED) and Staff 2 on 8/25/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in August 2018 with diagnoses including dementia.Current physician orders and Resident 1's August 1-23, 2021 MAR were reviewed. There was no documented evidence physician orders were carried out as prescribed for the following:* COVID-19 monitoring daily lacked documentation on seven occasions; and* Levothyroxine ordered daily for hypothyroidism was not documented as administered as ordered on 8/11/21.The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/24/21. They acknowledged the findings.
3. Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia. Physician orders dated 8/9/21 and Resident 3's August 1-23, 2021 MAR were reviewed. There was no documented evidence physician orders were carried out as prescribed for the following:* COVID-19 monitoring daily lacked documentation on five occasions; * Temazepam ordered daily at 9:00 pm for insomnia was not documented as administered as ordered on 8/2/2.* Hand therapy "carrot" for contractures in left hand was not documented as applied six times;* Compression stockings for edema ordered to be donned in the AM and removed in the PM were not documented as applied six times; and* Diclofenac Sodium for pain was not documented as administered on 8/2/21. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as written for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in April 2021 with diagnoses including chronic heart failure, chronic respiratory failure and morbid obesity.Current physician orders and Resident 2's August 1-23, 2021 MAR were reviewed. There was no documented evidence physician orders were carried out as prescribed on 18 occasions for the following treatments:* COVID-19 monitoring:* Bi-PAP;* Oxygen; and* Nebulizer.The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 9 was admitted to the facility in 09/2021 with diagnoses including major depression. Resident 9 had an ordered, dated 10/12/21 to receive fluoxetine (for depression) daily.Review of the Resident's 11/15/21 through 11/30/21 MAR revealed the medication had not been administered as ordered. During an interview on 12/14/21, Staff 12 (RN Consultant) stated, there was no documented evidence of a physician's order to hold the medication. She indicated the previous RN may have placed the order on hold when the facility was out of the medication. On 12/7/21, a signed physician summary instructed the facility to hold fluoxetine. Review of Resident 9's 12/01/21 through 12/12/21 MAR revealed the medication had been administered daily, not held as ordered.The need to ensure written, signed physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 12 (RN Consultant) and Staff 13 (RN). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician's orders were followed for 1 of 2 sampled residents (#12) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 12 was admitted to the facility in 2019 with diagnoses including diabetes.a. Resident 12 had physician orders, dated 12/30/21, to administer Polytrim drops (an eye drop to treat bacterial infection of the eye) every four hours while awake for seven days.Resident 12's 01/01/22 through 01/25/22 MAR revealed the eye drops were not administered until 01/12/22.b. Resident 12 had physician orders, dated 01/10/22, to administer Polytrim drops (an eye drop to treat bacterial infection of the eye) four times a day for seven days.Resident 12's 01/01/22 through 01/25/22 MAR revealed the eye drops were administered for nine days (received five extra doses) without clear documentation of why.On 01/25/22, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 13 (RN/Health Services Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when 1 of 2 sampled residents (# 3) refused to consent to medication and treatment orders. Findings include, but are not limited to: Resident 3's 8/1/21-8/23/21 MAR and 8/3/21 physician orders were reviewed. There was no documented evidence in the resident's facility record the physician was notified when Resident 3 refused to consent to the following medication and treatment orders: * Darifenacin Hydrobromide ER (overactive bladder) on 8/1/21, 8/2/21, 8/3/21;* Buprenorphine HCL-Naloxalone HCL (pain) on 8/19/21; and* Hand therapy "carrot" (contractures left hand) on 8/5/21, 8/6/21, 8/8/21, 8/18/21, 8/22/21. The need to notify the physician when residents refused to consent to medication and treatment orders was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

2. Resident 1 was admitted to the facility in August 2018 with a diagnosis of dementia. Resident 1's August 1 through August 23, 2021 MAR was reviewed and identified the following PRN pain medications ordered: * Acetaminophen oral PRN every six hours for mild to moderate pain "level 1-4 out of 10"; and* Morphine Sulfate oral every two hours as needed for pain or shortness of breath. Staff 4 (RCC) reported on 8/25/21 that Resident 1 was unable to verbalize pain using the pain scale, but the resident would show facial grimacing and/or say "ouch" when in pain.There were no clear instructions for which medication should be used first or in what order the remaining medications should be utilized for the resident's pain. The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included parameters for the administration of PRN medications and had clear instructions to staff for the administration of all medications and treatments the facility was responsible to administer. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia. Review of Resident 3's current physician orders and 8/1/21- 8/23/21 MARs revealed the following: * PRN Trazadone 1 - 2 tablets for sleep lacked clear instructions regarding when the resident should be given one versus two tablets. * Scheduled buprenophrine - naloxolone for pain indicated the facility was to "start with 1/2 tab three times a day, then go to one tablet three times a day if needed." There were no clear instructions on when the resident should be given half tab versus a full tab. * Diclofenac sodium gel for pain lacked instructions where staff should apply the gel. * Milk of Magnesia, glycerin suppository and enema prescribed for constipation, lacked parameters and clear instruction regarding when to administer the medication and in what sequence. *Inaccurate documentation on the MAR of staff who administered diclofenac gel and triamcinalone cream. The need to ensure MARs were accurate, included parameters and clear instructions for the administration of all medications and treatments the facility was responsible to administer and the individual administering the medication initialed the MAR was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed, included a thorough review by an RN, PT or OT prior to use, documented less restrictive alternatives prior to use, and provided instruction to caregivers on the correct use of and precautions for the device for 1 of 2 sampled residents (#1) who had side rails on their bed. Findings include, but are not limited to:Resident 1 was admitted to the facility August 2018.On 8/23/21 the resident's bed was observed to have two quarter length side rails in the up position. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the use of and precautions related to the device.The lack of assessment and instructions provided for use of supportive devices with potentially restraining qualities was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/24/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to meet requirements for Fire and Life Safety drills and instruction, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 8/24/21 identified the following deficiencies:* There was no documented evidence that Fire and Life Safety instruction was provided to staff on alternating months; and* Fire drill records kept by the facility lacked the following components: - evacuation times; - number of residents evacuated; and - staff who participated.On 8/25/21 the need to ensure all requirements were met for Fire and Life Safety drills and instruction according to the OFC was discussed with Staff 1 (ED). She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to meet requirements for Fire and Life Safety instruction and documentation, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 8/24/21 identified the following deficiencies:* There was no documented evidence that residents were instructed on fire safety procedures within 24 hours of admission; and* Records showed no documented evidence that annual training on fire safety was provided to residents.On 8/24/21 the need to meet requirements for Fire and Life Safety instruction and documentation, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings. No further information was provided.

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 Division. Findings include, but are not limited to:Refer to C 303.
Based on interview and record review, it was determined the facility failed to ensure their survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:Refer to C 303.

Based on interview and record review, it was determined the facility failed to maintain a safe outdoor area for resident use. Findings include, but are not limited to:On 8/23/21 at 1:10 pm, the exterior pathways surrounding the building were observed. Along extensive sections of the concrete walkways there were multiple areas with drop-offs approximately one to four inches high, from the concrete surfaces to the bark dust beds. This created a potential tripping hazard for residents using assistive devices.On 8/23/21 the need to maintain a safe outdoor area for resident use was discussed with Staff 1 (ED). She acknowledged the outdoor drop-offs presented a safety hazard for residents.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:During a walk-through of the facility on 8/25/21 at 1:45 pm, multiple exit doors were found to have no alarm or system in place to alert staff when a resident exited the building.On 8/25/21 the need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited was discussed with Staff 1 (ED). She acknowledged the findings.