West Hills Village Senior Residence

Based on observation and record review conducted during a site visit on 01/27/25, the facility's failure to have sufficient staff to meet the scheduled and unscheduled needs of the residents was substantiated for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:A review Resident 3's service plan dated 10/10/24 and ABST last updated 12/10/24 indicated Resident 3 required two-person transfers. At 11:27 am Resident 3 was observed to be transferred by one staff member from his/her bed to wheelchair.A review of the facility's posted staffing plan indicated the following:· Day Shift: 2.5 Med-techs and 3.5 Caregivers;· Swing Shift: 2 Med-techs and 3 Caregivers; and· Overnight Shift: 1 Med-techs and 2 Caregivers.A review of the facility ABST indicated the facility required seven staff on day shift.A review of the facility staffing from 01/20/25 - 01/27/25 indicated the facility was not consistently staffed to the ABST required staffing. Four of seven day shifts were staffed under the posted staffing plan and seven of seven day shifts were staffed under the ABST required staffing.The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents.The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 01/27/25.Facility Verbal Plan of Correction:Staff 1 was to hold an all-staff in-service meeting on 01/31/25 to review resident service plans and Staff 1 would be reviewing the ABST weekly to ensure staffing appropriately. The facility used the RCC and staffing coordinator to assist on the floor when necessary.

Based on observation, interview and record review, conducted during a site visit on 01/27/25, the facility's failure to adopt an acuity-based staffing tool to determine appropriate staffing levels was substantiated for 1 of 2 sampled residents (# 3). Findings include, but are not limited to:A review Resident 3's service plan dated 10/10/24 and ABST last updated 12/10/24 indicated Resident 3 required two-person transfers. At 11:27 am Resident 3 was observed to be transferred by one staff member from his/her bed to wheelchair.An unsampled residents ABST was last updated on 10/05/24.In an interview on 01/27/25, Staff 1 (Administrator) stated the unsampled residents service plan was last updated on 10/05/24.A review of the facility's posted staffing plan indicated the following:· Day Shift: 2.5 Med-techs and 3.5 Caregivers;· Swing Shift: 2 Med-techs and 3 Caregivers; and· Overnight Shift: 1 Med-techs and 2 Caregivers.A review of the facility ABST indicated the facility required seven staff on day shift.A review of the facility staffing from 01/20/25 - 01/27/25 indicated the facility was not consistently staffed to the ABST required staffing.The facility failed to adopt an acuity-based staffing tool to determine appropriate staffing levels.The findings were reviewed with and acknowledged by Staff 1 on 01/27/25.

Based on interview and record review, it was determined the facility failed to consistently determine and document what action or intervention was needed for a resident and ensure the documentation of staff instructions was made part of the resident record in response to a short-term change of condition, for 1 of 3 sampled residents (#4) who had injury and non-injury falls. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 10/2023 with diagnoses including Type 2 diabetes and end-stage renal disease.

During the survey, Resident 4's current service plan, temporary service plans, and progress notes from 10/19/24 through 01/13/25 were reviewed.

The resident experienced the following changes of condition:

* A progress note dated 01/07/25 indicated that the resident had a non-injury fall while trying to get out of bed when their legs felt weak, and s/he fell over and landed on their bottom.

There was no documented evidence actions or interventions were determined and documented for staff and made part of the resident’s record.

* A progress note dated 01/08/25 stated the resident was on "Alert Charting" for a fall with injury and had sustained a skin tear on their left arm. It was noted the resident had pain all over their body and was sent to the emergency room.

There was no documented evidence actions or interventions were determined and documented for staff and made part of the resident record.

The need to ensure the facility documented what action or intervention was needed for a resident following a short-term change of condition was discussed with Staff 1 (Executive Director) on 01/17/25 and Staff 2 (Director of Nursing) on 01/16/25. They both 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 interview and record review the facility failed to update and review the acuity-based staffing tool (ABST) evaluation for each resident quarterly at the same time the resident’s service plan was updated as required by OAR 411-054-0034, and failed to develop and maintain a posted staffing plan that used the results of the ABST. Findings include, but are not limited to:

On 01/14/25 the facility’s proprietary ABST data and posted staffing plan were requested and reviewed. The following was identified:

a. On 01/15/25 at 2:36 pm, Staff 4 (Quality Coordinator) stated resident’s individual ABST times were not reviewed or updated unless there was a change to the resident’s service plan.

b. The proprietary ABST data determined a total of 108 hours of direct-care staff was needed per day. The facilities posted staffing plan indicated a total of 105 hours were scheduled per day.

On 01/16/25 at 2:00 pm, Staff 1 (Executive Director) reviewed the posted staffing plan and ABST data and recognized the facility did not have a system in place that documented the last individual ABST review date. Additionally, Staff 1 acknowledged the discrepancy of three hours between the posted staffing plan and ABST hours.

The need to ensure each resident’s ABST was reviewed no less than quarterly and that a posted staffing plan was routinely updated using the results of the ABST, was reviewed with Staff 1 on 01/17/25 at 11:13 am. She 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 1 of 3 newly hired direct care staff (#11) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:

Review of the facility’s training records on 01/14/25 revealed the following:

There was no documented evidence Staff 11 (Med Tech/MT) hired 10/16/24, demonstrated competency in all required areas within 30 days of hire including:

* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Identification, documentation and reporting changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.

In an interview with Staff 1 (Executive Director) on 01/14/25 at 4:40 pm, she stated Staff 11 did not demonstrate all required competencies because MTs only receive MT competency training.

The need to ensure newly hired direct care staff demonstrated satisfactory performance in all assigned job duties within 30 days of hire was reviewed with Staff 1 on 01/17/24 at 11:50 am. She 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 conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to:

Fire and life safety records dated 07/2024 through 12/2024 were reviewed and revealed the following:

a. Fire drill records lacked documentation of one or more of the following required areas:

* Escape route used;
* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time period needed;
* Number of occupants evacuated; and
* Evidence alternate routes were used during fire drills.

b. Fire and life safety instruction was not consistently provided to staff on alternate months from fire drills:

In an interview with Staff 1 (Executive Director) on 01/14/25 at 2:50 pm, she stated there was no fire and life instruction provided to staff in 07/2024 or 11/2024.

The need to ensure fire drill records included documentation of all required areas and staff received fire and life safety instruction on alternate months from fire drills was reviewed with Staff 1 on 01/14/24 at 6:10 pm. She 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 covers, grates, or screens of heaters did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

During a tour of the facility on 01/14/25 at 1:45 pm a portable heater was observed between two fabric chairs in room 233.

The heater was on, and the surface temperature was recorded by the surveyor. The unit's surface temperature measured 160 degrees Fahrenheit.

The need to ensure wall heater covers did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (Executive Director) and Staff 6 (Maintenance Director) at 2:00 pm on 1/14/25.

They stated portable heaters had been provided to the residents in rooms 6, 129, 203, 209, 210, 212, 223, and 233. They stated the heaters were of the same model and would all be removed by the end of the day.

On 1/15/25 observations confirmed the heaters had been removed. The requirement for the surface of heaters to not exceed 120 was reviewed with Staff 1 and Staff 6, and they acknowledged the findings.

OAR 411-054-0200 (8) Heating and Ventilation

(8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction.
(a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit.
(A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours.
(B) During times of extreme summer heat, fans must be made available when air conditioning is not provided.
(b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside.
(c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit.
(d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 03/20/24, 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 re-visit to the kitchen inspection of 03/20/24, conducted 05/20/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen practices and protocols were in accordance with the Food Sanitization Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/20/24 at 11:00 am, the following areas were observed: * Five boxes of food were stored on the floor under the shelves in the walk in freezer;* Containers of food (strawberries, fruit, cottage cheese) were stored on ice on the counter without being covered between portioning contents for the lunch service in the dining room, the area was a high traffic area for staff in and out of the kitchen, creating potential cross contamination;* Ceiling light covers and a vent above the food service line had an accumulation of dust;* Improper glove use, failure to change gloves between tasks and wash hands properly between glove changes; and * Lack of hair/beard restraints. The findings were discussed with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 03/20/24. The findings were acknowledged.

The findings of the re-licensure survey conducted 9/28/21 through 9/30/21 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.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 re-visit to the re-licensure survey of 09/30/21, conducted 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 second revisit to the re-licensure survey of 9/30/21, conducted on 3/22/22, 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 Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 4 was admitted to the facility in 11/2018. Resident 4's quarterly evaluation was not reflective in the following areas:* Vision (Resident was legally blind);* Hearing (Resident was hard of hearing); * Weight loss (Resident had weight loss); and* Resident self-administering vitamins/supplements.The failure to ensure all areas in the quarterly evaluation were accurate was shared with Staff 2 (Director of Nursing/RN) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and quarterly evaluations were reflective of care for 1 of 4 sampled residents (#4) whose evaluations were reviewed. Findings include, but are not limited to:1. Resident 3's move-in evaluation, dated 5/19/21, lacked information regarding the following required elements:* Spiritual/Cultural preferences; and* Unsuccessful prior placements.The move-in evaluation was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Nursing /RN) and Staff 3 (Regional RN) on 9/29/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 7 and 10) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 10's move-in evaluation, dated 12/19/21, lacked information regarding the following required elements:* History of mental health treatments; * Cognition - memory, confusion, decision making abilities;* Personality;* Housekeeping;* Indicators of nursing needs;* Complex medication regimen;* History of dehydration or weight loss/gain; * Unsuccessful prior placements;* Elopement risk or history; and* Environmental factors.The move-in evaluation was reviewed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/25/22. They acknowledged the findings.
2. Resident 7's move-in evaluation, dated 12/24/21, lacked information regarding the following required elements:* Visits to health practitioner, ER, hospital, nursing facility in the past year;* Vital signs if indicated by diagnosis, health problems, or medications;* History of mental health treatments; * Personality, including how a person copes with change or challenging situations;* Non-pharmaceutical interventions for pain;* Nutrition habits, fluid preferences;* Indicators of nursing needs;* Environmental factors that impact behaviors;* Complex medication regimen;* History of dehydration or weight loss/gain; * Recent losses; and* Unsuccessful prior placements.The move-in evaluation was reviewed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/25/22. 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' needs and provided clear instructions for staff for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2018 with diagnoses including diabetes. During the acuity interview on 9/28/21 the resident was identified to have a personal caregiver and to have a recent weight loss. The service plan dated 7/22/21 was not reflective in the following areas:* Weight loss and current interventions;* Resident self-administering vitamins and supplements; * Personal caregiver administering some medications as physician ordered; and* Fall mats used when the Resident was in bed.The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 2 (Director of Nursing/RN) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.
4. Resident 6's 9/3/21 service plan was reviewed, was not reflective and did not provide clear direction to staff in the following areas:During observations and interviews with caregivers and Resident 6 on 9/29/21, it was reported s/he received all meals in the apartment, needed the help of one person for transfers and incontinence care daily. Resident 6 was able to respond to conversation but communication was inconsistent as there were times when s/he would not respond and appeared confused and unable to communicate needs.* Dining preferences, receiving meals in apartment;* Communication ability and needs;* Mobility and need for assistance with transfers;* Evacuation assistance needed; and* Toileting ability and need for assistance.The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (Executive Director) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.
2. Resident 3's service plan was reviewed. The service plan, dated 7/2/21, was not reflective of the resident's status and lacked clear instructions to staff in the following areas:* Home health PT;* Wheelchair use as a mobility device; and* Mood disorder and interventions.The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Nursing/RN) on 9/29/21. They acknowledged the findings.
3. Resident 5 was admitted to the facility in September 2019 with diagnosis of edema. During the acuity interview on 9/28/21 the resident was identified as using PRN psychotropic medications.Observations of resident ADL care on 9/28/21 through 9/30/21, interviews with staff, and review of the resident's current service plan and interim service plans were conducted during the survey. The service plan dated 9/17/21 was not reflective of the resident's status and lacked clear instructions to staff in the following areas:* Use of compression stockings;* Use of psychotropic medications and non pharmacological interventions;* Behaviors related to anxiety; and* Instructions for incontinent care to be completed in bed.The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/30/21. 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 4 sampled residents (#5) whose orders were reviewed. Findings include, but are not limited to:Resident 5 was admitted to the facility in September 2019 with diagnosis including chronic kidney disease.Resident 5 had a signed physician order, dated 7/28/21, to administer polyethylene glycol powder (Miralax) every other day at 8:00 am.The MAR, dated 8/28/21 through 9/27/21, showed Resident 5 was administered the medication daily.The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 3 sampled residents (#7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 7 was admitted to the facility in January 2022 with diagnoses including end stage renal disease, type 2 diabetes and bilateral lower extremity amputation.Resident 7's signed physician orders, dated 01/04/22, and MAR dated 01/01/22 through 01/24/22, were reviewed and showed the following inaccuracies:a. The following prescribed treatments had not been added on the MAR/TAR and were not being administered as prescribed:* Check fistula on left arm every shift; and* Enter weight post dialysis upon return three times per week.b. During an interview and review of the medication blister pack for Sevelamer Carbonate (phosphorus binder), on 1/25/22, with Staff 17 (CG/RA), showed the following routine medication was not administered: * On 01/12/22 at 5:00 PM Sevelamer Carbonate was still in the blister pack and was not administered. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/25/22. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 11/2018 with diagnoses that included diabetes and was legally blind.Resident 4's 9/1/21 through 9/28/21 MARs were reviewed and revealed the following inaccuracies: a. Medications scheduled to be given routinely, but did not identified if staff, private caregiver, or resident was responsible for administering them:* Dorzolamide - Timolol eye drop (for glaucoma); * Latanoprost eye drops (for glaucoma); and* Prednisone eye drops (anti-inflammatory).The need to ensure residents' MARs had correct information as to who was responsible for administration and administration times for medications including insulin was discussed with Staff 2 (Director of Nursing/RN) and Staff 3 (Regional RN) on 9/28/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate for 4 of 4 sampled residents (#3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 6's 9/1/21 through 9/28/21 MAR was reviewed and revealed the following inaccuracies:* A 8/31/21 physician's order for Onadesteron (anti-nausea medication) directed to take 1 tablet by mouth every 6 hours as needed for nausea. The MAR instructed staff to administer 1 tablet by mouth every 8 hours as needed for nausea; and* Lacked clear parameters for staff to follow related to when to administer Polyethylene Glycol OTC powder (bowel care medication) which instructed staff to give the medication every day as needed for bowel care.The need to ensure accuracy of MAR documentation and provide clear parameters to staff was discussed with Staff 1 (Executive Director), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.
2. Resident 3's 9/1/21 through 9/28/21 MAR was reviewed and revealed the following inaccuracies:* An 8/25/21 physician's order was to discontinue a prescription for Estradiol cream. The medication continued to be on the MAR; * Stated a range of times for administration of medications but did not contain documentation of the time medications were given; * Resident 3 was prescribed two PRN bowel care medications - Bisacodyl and Docusate sodium. The MAR lacked clear parameters for staff regarding when to administer each medication;* Resident 3 was prescribed three PRN medications to treat pain - Acetaminophen, Lidocaine patch and Tramadol (a narcotic pain med). The MAR lacked parameters for staff regarding when to administer each medication.The need to ensure accuracy of MAR documentation and provide clear parameters to staff was discussed with Staff 1 (Executive Director), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.
3. Resident 5 was admitted to the facility in September 2019 with diagnoses of chronic kidney disease and frequent urinary tract infection.Review of Resident 5's MAR dated 8/28/21 through 9/27/21 identified the following inaccuracies: * The entry for monthly weight was not documented on 9/4/21; and* Self administering Estradiol cream was not accurate information. On 9/30/21, the need to ensure an accurate MAR was kept for all medications and treatments was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN), and Staff 4 (Quality Coordinator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 2 of 2 sampled residents (#s 1 and 5) who had bilateral half-length side rails on their bed. Findings include, but are not limited to:a. Resident 1 was admitted to the facility in 9/2021 with diagnoses including cerebral infarction and history of falls.Interviews with staff, and review of the resident's current service plan and interim service plans were conducted during the survey. Review of a bed rail evaluation, dated 9/28/21, had been completed by Staff 2 (Director of Nursing/RN). The evaluation lacked the following documentation: * Instruction to caregivers on the correct use and precautions related to the use of the device; and* Documentation of the use of the side rail on the service plan.b. Resident 5 was admitted to the facility in September 2019. During the acuity interview on 9/28/21, Resident 5 was identified as using side rails. Interviews with staff and a review of the current service plan and interim service plans were conducted during the survey. Review of a bed rail evaluation dated 7/8/21, lacked the following documentation: * Less restrictive alternatives evaluated prior to the use of the device; and* Instruction to caregivers on the correct use and precautions related to use of the device.The need to ensure the use of side rails were thoroughly evaluated was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/30/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired caregiving staff (#s 10, 11 and 15) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 9/29 and 9/30/21.There was no documented evidence Staff 10 (CG/Resident Assistant), hired 5/16/21, Staff 11 (CG/Resident Assistant), hired 7/12/21 and Staff 15 (CG/Resident Assistant), hired 8/25/21 had demonstrated competence in the following required areas within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* Staff 10 lacked documented evidence of medication administration competency.The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days was reviewed with Staff 1 (Executive Director) on 9/30/21. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of residents with dementia, was completed for 2 of 3 long-term staff (#s 12 and 16) whose training records were reviewed. Findings include, but are not limited to:The annual in-service training records were reviewed on 9/29 and 9/30/21.Staff 12 (CG/Resident Assistant), hired 8/21/16, and Staff 16 (CG/Resident Assistant), hired 9/26/18, failed to have documented evidence of completing 12 hours of required in-service training. The need to ensure staff completed 12 hours of on-going training, including 6 hours related to dementia, was reviewed with Staff 1 (Executive Director) on 9/30/21. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:On 9/29/21, review of facility fire drill and fire and life safety instruction records, from 4/2021 through 9/2021, and interviews with staff indicated the facility was not documented; * The escape route used;* Number of occupants evacuated; * Problems encountered and comments related to residents who resisted or failed to participate in the drills was not documented; and* There was no documented evidence the facility provided fire and life safety instruction to staff every other month as required. On 9/30/21, the need to ensure fire and life safety instruction was provided to staff on alternate months and residents were relocated during fire drills was discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:Fire drill records, from 4/2021 through 9/2021, were reviewed on 9/29/21 with Staff 1 (Executive Director). * Staff 1 stated the facility was not providing or documenting annual instruction for residents in 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. * The facility was not using alternate routes during fire drills.The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 on 9/29/21. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 252, C 303 and C 613.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:Observations on 9/28/21 revealed multiple drop-offs of 2-4 inches along pathway edges and sitting areas in the patio, garden areas and walkways.Additionally, several walkways were obstructed with branches, over-grown plants and garden hoses that posed a potential tripping hazard. The need to ensure pathways did not have potential safety hazards was discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 9/29/21. They acknowledged the findings and stated a delivery of landscaping material had been ordered and would be installed.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility on 9/28/21 and 9/29/21 showed the following areas in need of cleaning or repair:* Multiple areas of the carpet in the corridors and entry ways throughout the ground floor of the facility had black stains and worn areas; and* Rooms 120 and 226 had multiple dark stains on the carpets.The areas in need of cleaning and repair were discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 9/29/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 01/25/22 showed the following areas in need of cleaning or repair:* Multiple areas of the carpet in the corridors and entry ways throughout the ground floor of the facility had black stains and worn areas; and* Rooms 120 and 226 had multiple dark stains on the carpets.The areas in need of cleaning and repair were discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 01/25/22. They acknowledged the findings. An extension was granted until 03/21/22.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:The building was toured on 9/29/21 with Staff 5 (Maintenance Director). Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building. Some of the exit doors had an alarm installed, however, the audible chime was not sufficient to alert staff when the door was opened.On 9/29/21, the need to ensure exit doors were equipped with an alarming device to alert staff when residents exited the building was discussed with Staff 1 (Executive Director). He acknowledged the findings.