Clackamas Heights Senior Living

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 02/20/25 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas:

* Ceiling vent and ceiling area around vent – accumulation of dust;

* Bottom shelves in refrigerator and freezer – food debris/spill;

* Exterior doors and vents below doors of refrigerator and freezer – spills/drips/smears/dust;

* Wall behind stove – grease drips;

* Walls below exhaust hood control panel, under single sink, behind and below dishwasher and above dishwashing sink – brown drips;

* Oven doors and sides of oven – drips/spills;

* Cabinet doors and door handles throughout the kitchen – drips/spills/splatters;

* Window blinds above prep counter – accumulation of dust;

* Flooring throughout the kitchen under equipment – accumulation of black/brown matter;

* Drain under single sink – accumulation of black matter; and

* Ice machine tray – standing mucky water.

Other concern:

Colored cutting boards heavily scored and finish worn off (potentially uncleanable).

The areas of concern were observed and discussed with Staff 1 (Kitchen Manager) and discussed with Staff 2 (Administrator) and Staff 3 (Owner) on 02/20/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 caregiving staff (#s 10 and 11), demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 02/12/25 and revealed the following:

There was no documented evidence Staff 10 (Universal Caregiver), hired 12/14/24, demonstrated competency within 30 days of hire in the following areas:

*Role of service plans in providing individualized care;
*Providing assistance with ADLs;
*Changes associated with normal aging;
*Identification, documentation and reporting of changes in condition;
*Conditions that require assessment, treatment, observation and reporting; and
*First Aid/Abdominal Thrust.

There was no documented evidence Staff 11 (Universal Caregiver), hired 01/06/25, demonstrated competency within 30 days of hire in the following areas:

*Changes associated with normal aging; and
*First Aid/Abdominal Thrust.

The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was reviewed with Staff 1 (ED), Staff 3 (Owner), Staff 4 (Owner/Maintenance) and Staff 15 (Nurse) on 02/12/25 at 2:52 pm. They acknowledged these 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 1 of 2 long-term, direct care Staff (#7) and 1 of 1 long-term non-direct care Staff (#14) completed required annual in-service training. Findings include, but are not limited to:

Training records were reviewed on 02/12/25 and revealed the following:

There was no documented evidence Staff 7 (Universal Worker/MT), hired 05/01/23, completed the required HCBS training.

There was no documented evidence Staff 14 (Cook), hired 07/06/23, completed the required Infectious Disease training.

The need to ensure long-term direct care and non-direct care staff completed required annual training was reviewed with Staff 1 (ED), Staff 3 (Owner), Staff 4 (Owner/Maintenance) and Staff 15 (Nurse) on 02/12/25 at 2:52 pm. They acknowledged these 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 interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Fire and life safety records, dated between 08/2024 and 01/2025, were reviewed and revealed the following:

a. Fire drill records lacked documentation of the following components:

*The escape route used; and
*Number of occupants evacuated.

b. The facility failed to provide fire and life safety instruction to staff on alternate months.

In an interview on 02/11/25 at 9:10 am, Staff 1 (ED) and Staff 3 (Owner) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months and fire drill records lacked required components.

The need to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months was reviewed with Staff 1, Staff 3, Staff 4 (Owner/Maintenance) and Staff 15 (Nurse) on 02/12/25 at 2:52 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents at least annually, 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. Findings include, but are not limited to:

There was no documented evidence the facility had a process for instructing residents in fire and life safety procedures upon admission and annually. Staff 1 (ED) and Staff 3 (Owner), verified the findings.

The need to instruct residents upon move-in and at least annually in general fire safety procedures was discussed with Staff 1, Staff 3, Staff 4 (Owner/Maintenance) and Staff 15 (Nurse) on 02/12/25 at 2:52 pm. They acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

(5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, 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. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to have the capacity for locked storage of chemicals and equipment in on-site laundry facilities used by staff for facility and resident laundry. Findings include, but are not limited to:

The facility laundry rooms were observed on 02/10/25, 02/11/25 and 02/12/25 and chemicals were found accessible in each laundry room, each day. One of three laundry rooms had the ability to lock the cabinet under the sink but observation over the period of the survey found the cabinet unlocked. The other two laundry rooms did not have a lockable cabinet under the sink or in the room.

Interview with Staff 3 (Owner) on 02/10/25, verified the access to chemicals concern and Staff 3 stated they would remove the chemicals.

The need to ensure capacity for locked storage was reviewed with Staff 1 (ED), Staff 3, Staff 4 (Owner/Maintenance) and Staff 15 (Nurse) on 02/12/25 at 2:52 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and community bathrooms were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

From 02/10/25 through 02/12/25, the surveyor measured water temperatures in two resident rooms and two community bathrooms. Water temperatures were found as low as 106.2 and as high as 144.7 degrees Fahrenheit.

In an interview with Staff 4 (Owner/Maintenance) on 02/10/25, he stated he would adjust the water heaters.

Additional temperatures were noted at 109 and 127 degrees Fahrenheit on 02/11/25.

In an interview on 02/11/25 at approximately 9:55 am with Staff 2 (RCC/Maintenance), he stated Staff 4 (Owner/Maintenance) would adjust the water heaters.

In an interview with Staff 4 (Owner/Maintenance) on 02/12/25, he stated he had adjusted the water temperatures. The temperature range was noted to be between 115.9 and 119.8 degrees Fahrenheit.

The need to ensure water temperatures were monitored and maintained within a range of 110 - 120 degrees Fahrenheit was discussed with Staff 1 (ED, Staff 3 (Owner), Staff 4 (Owner/Maintenance) and Staff 15 (Nurse) on 02/12/25 at 2:52 pm. They acknowledged these findings.

OAR 411-054-0200 (9) Plumbing Systems

(9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exited the building. Findings include, but are not limited to:

During a tour of the facility on 02/10/25, three exit doors to outside deck areas did not have an exit door alarm or other acceptable system provided for security purposes and to alert staff when residents exited the building.

An interview with Staff 5 (Universal Worker/MT), on 02/10/25 at 11:58 am, revealed that staff were not alerted when a resident exited to the deck area.

An interview on 02/10/25 at 2:20 pm with Staff 1 (ED), Staff 3 (Owner), Staff 4 (Owner/Maintenance) and Staff 2 (RCC/Maintenance), verified no exit door alarm on the three doors to the deck.

The need to ensure an exit door alarm or other acceptable system for security purposes alerted staff when residents exited the building was discussed with Staff 1 (ED), Staff 3 (Owner), Staff 4 (Owner/Maintenance) and Staff 15 (Nurse) on 02/12/25 at 2:52 pm. They acknowledged these findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

(11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 12/01/23, 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 12/01/23, conducted 02/22/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and dining room service area were conducted on 12/01/23 from 10:35 am through 2:06 pm. The following was observed: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: * Dining room: interior cabinets and drawers of the juice counter;* Main kitchen: coffee counter interior and exterior surfaces;* Interior and exterior of all gray colored cabinets and drawers throughout the kitchen;* Standing water in the ice machine tray;* Mineral build up on the ice machine; * Interior and exterior of oven;* Exterior of stove;* Grease buildup on stove/oven hood vent;* Floor drain under the prep sink (left of the stove);* Flooring near the hot water heater and underneath the three compartment sink;* Reach-in freezer shelves and exterior door and door handles;* Reach-in refrigerator exterior door and door handles;* Interior and exterior of toaster;* Utility/server carts; and* Interior and exterior of microwave.b. The following areas were in need of repair: * Dining room: juice counter cabinet had gouges in the wood, door hinge was loose and missing drawer knob;* Main kitchen: cabinet wall underneath eyewash sink had exposed wood and was not easily cleanable;* Main kitchen: center island cabinet door hinge broken;* Main kitchen: floor near entrance was cracked;* Dry storage area: shelf in the back right corner was broken with exposed wood; and* Janitor closet: scrapes, gauges and approximately a four by six inch cut hole in the wall near the floor.c. Food Storage:* Multiple uncovered, unlabeled and undated food items in the reach-in refrigerator and freezer, including three types of meat protein and protein rich dressings;* Open food items in the dry storage area;* Perishable food items were stored on the floor (box of potatoes and crate of apples); and* Expired perishable food items in the dry storage area and stored on the counter top in the main kitchen area.d. Infection control: * The thermometer was not disinfected properly between use (alcohol wipes);* The facility lacked a small diameter probe to ensure accurate temperature of thin liquids;* Eggs were unpasteurized; * Trash cans lacked lids;* Quaternary sanitizer bucket was not at proper concentration for surface sanitation;* Dish sponges were not of commercial grade and had a buildup of food product and/or were damaged; * Food was not covered and protected from contamination when transported to resident apartments; and* The facility lacked a written sick leave policy. At approximately 12:45 pm on 12/01/23, the kitchen was toured and the above areas of concern were discussed with Staff 1 (Executive Director), Staff 2 (Administrator/Owner) and Staff 3 (Lead Cook). They acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 03/24/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on observation, interview, and record review, it was confirmed that the failed to exercise reasonable precautions against any condition that may threaten the health, safety, and welfare of the residents. Findings include but not limited to:During an unannounced site visit on 3/24/2023, Compliance Specialist (CS)observed the following rooms and bedrooms which were not clean:Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.Room 15 had bowel movement stains in the toilet.Room 16 had a large ball of hair on top of the shower drain.Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.Room 11 had dirty ring in the toilet, shower and debris all over the carpet.Room 6 had a dirty ring in the toilet and sink and debris all over carpet.Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.During separate interview, Staff #1 - Staff #2 (S1-S2) stated:*They don't refill hand sanitizer because they don't have any. *They clean rooms on resident shower days.*They do not have any housekeeping staff.*They do not clean the toilets because they don't have toilet brushes.A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023.These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.Plan of Correction: Facility to deep clean 2-3 resident rooms per day beginning 3/25/2023. Facility to add cleaning room to ADL task list.

Based on observation, interview, and record review, it was confirmed that the facility failed to provide household services essential for the health and comfort of the resident that are based upon the resident's needs and preferences (e.g., floor cleaning, dusting, bed making, etc.) Findings include but not limited to:During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed the following rooms and bedrooms which were not clean:Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.Room 15 had bowel movement stains in the toilet.Room 16 had a large ball of hair on top of the shower drain.Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.Room 11 had dirty ring in the toilet, shower and debris all over the carpet.Room 6 had a dirty ring in the toilet and sink and debris all over carpet.Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.During separate interview, Staff #1 - Staff #2 (S1-S2) stated:*They don't refill hand sanitizer because they don't have any. *They clean rooms on resident shower days.*They do not have any housekeeping staff.*They do not clean the toilets because they don't have toilet brushes.A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023.These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.Plan of Correction: Facility to deep clean of 2-3 resident rooms per day beginning 3/25/23. Facility to add cleaning room to ADL task list.

Based on interview and record review, it was confirmed that the facility failed to contact the emergency contact. Findings include but not limited to:During a phone interview on 3/24/2023, Witness #1 (W1) stated that the facility called their partner, an employee of the facility to notify of Resident #2 (R2)'s passing. W1 never received a call from the facility to notify of R2's passing and stated that the partner was not to be contacted.A review of R2's facesheet and progress notes for November 2022 revealed W1 is the Power of Attorney and there is no documentation about anyone being notified of R2's passing.These findings were reviewed Staff #3 on 3/24/2023 who was in agreement.Plan of Correction: Facility to in-service staff on notification and documentation practices within 24 hours.

Based on observation and interview, it was confirmed that the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. Findings include but not limited to:During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed Staff #2 and Staff #4 in the kitchen and not wearing masks. Staff #1 (S1) was wearing an ill-fitted mask that was below the nose and mouth was exposed. CS heard S1 coughing and overheard S1 tell a resident that they were starting to feel better but still had a cough. Room 12 did not have hand sanitizer.During interview, S1 stated that they don't refill hand sanitizer because they don't have any.These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.Plan of Correction: Facility to in-service staff on infection control policies and masking beginning 3/24/2023. Mask usage audit to begin immediately. LPN will discuss further with Administrator.

Based on observation, interview, and record review, it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed the following rooms which were not clean:Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.Room 15 had bowel movement stains in the toilet.Room 16 had a large ball of hair on top of the shower drain.Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.Room 11 had dirty ring in the toilet, shower and debris all over the carpet.Room 6 had a dirty ring in the toilet and sink and debris all over carpet.Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.During separate interview, Staff #1 - Staff #2 (S1-S2) stated:*They don't refill hand sanitizer because they don't have any. *They clean rooms on resident shower days.*They do not have any housekeeping staff.*They do not clean the toilets because they don't have toilet brushes.*They do not have enough staff to keep up with housekeeping.*Room 2 has to be mopped three times a day because the resident urinates everywhere.A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023. The facility's posted staffing plan indicated that Medication Technicians and caregivers are universal workers.These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.Plan of Correction: Deep clean of 2-3 resident rooms per day beginning 3/25/23. Facility to add cleaning room to ADL task list. Facility to have all resident data entered into Acuity-Based Staffing Tool (ABST) by end of day 3/27/2023 and will use data to generate a staffing plan.

Based on interview and record review, it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:During an unannounced site visit on 3/24/2023, Staff #3 (S3) stated that they did not know how the staffing plan was determined and were not aware of the facility using an ABST. S3 stated the facility census was 12 residents. Compliance Specialist (CS) interviewed Staff #5 (S5) by phone on 3/27/2023 who stated that the facility was not using an ABST but is entering the required data immediately into the Oregon Department of Human Services (ODHS) tool and will have all information entered by the end of day on 3/27/2023.A review of the ODHS ABST tool on 3/20/2023 revealed that the facility had 14 resident names in the system. Only four residents had any data entered, and only three of those were complete. 10 of 14 had not been edited since their creation on 8/11/2022.These findings were reviewed with S5 by phone on 3/27/2023.Plan of Correction: Facility to enter data by end of day 3/27/2023.

Based on observation, interview, and record review, it was confirmed that the facility failed to keep all interior materials and surfaces clean. Findings include but not limited to:During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed the following rooms and bedrooms which were not clean:Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.Room 15 had bowel movement stains in the toilet.Room 16 had a large ball of hair on top of the shower drain.Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.Room 11 had dirty ring in the toilet, shower and debris all over the carpet.Room 6 had a dirty ring in the toilet and sink and debris all over carpet.Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.During separate interview, Staff #1 - Staff #2 (S1-S2) stated:*They don't refill hand sanitizer because they don't have any. *They clean rooms on resident shower days.*They do not have any housekeeping staff.*They do not clean the toilets because they don't have toilet brushes.A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023.These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.Plan of Correction: Deep clean of 2-3 resident rooms per day beginning 3/25/23. Facility to add cleaning room to ADL task list.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 08/31/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interviews and record review it has been confirmed the facility failed to submit a background check to the department for a criminal fitness determination. Findings include, but not limited to:In interviews on 08/31/2022, Staff #1(S1) and Staff #2 (S2) confirmed that Staff #4 (S4) worked without a cleared background check from 05/02/2022 to 05/31/2022.A record review on 08/31/2022 verified an incomplete background check on file. Background documentation for S4 dated 08/05/2022 stated the following: "Action needed --notify the subject individual that fingerprints are required for this background check."A review of timecards dated 05/01/2022 to 05/31/2022, verified S4 worked a total of 141.02 hours.On 08/31/2022, these findings were reviewed with and acknowledged by S2.Facility Plan of Correction: The facility will add "Complete Background Check" to the new employee caregiver training checklist. Facility will ensure that no staff are working without a completed and cleared background check.

The findings of the re-licensure survey conducted 9/21/21 through 9/23/21 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 first re-visit to the re-licensure survey of 09/23/21, conducted 01/27/22, 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 re-visit to the re-licensure survey of 09/23/21, conducted 04/07/22, 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 09/23/21, conducted 05/18/22, 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 5 was admitted to the facility in November 2017.The 06/30/21 evaluation indicated the resident had a diagnosis of dementia and required staff assistance in bathing, dressing, transfers and locomotion with a wheelchair. The 07/02/21 service plan indicated the resident was incontinent of both bowel and bladder, was a 2-person assist with a Hoyer lift and full assistance for bathing, dressing and ambulation with wheelchair.On 08/09/21, staff documented the resident's "[Right] big toe [had a] 0.5 cm opening...and...bruise noted..."On 09/23/21, an incident report was requested. On 09/23/21 at 11:45 am, Staff 1 (ED) stated there was no incident report and confirmed there was no documented evidence the facility conducted an immediate investigation to reasonably conclude the injury noted on 08/09/21, was not the result of abuse or neglect of care.The need to ensure resident incidents including physical injury were promptly investigated to rule out abuse and neglect was discussed with Staff 1 and Staff 2 (Regional Director of Operations) during the survey. The staff acknowledged the findings. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 09/23/21 prior to survey exit.
Based on interview and record review, it was determined the facility failed to investigate injuries of unknown cause in order to rule out suspected abuse or neglect for 2 of 2 sampled residents (#s 1 and 5), who were identified with injuries of unknown cause. Findings include but are not limited to: Resident 1 was admitted to the facility in July 2019 with diagnoses including dementia and was identified during the acuity interview as having experienced an injury of unknown cause.Facility staff observed bruising to the residents back on 09/06/21. A "Fall Investigation Report," dated 09/07/21, noted the following:* "[Resident] doesn't remember ...";* "[s/he] has been isolated in room ...";* "Resident was confused ..."; and* "Resident probably wandering around room and lost [his/her] balance." On 09/23/21, Staff 1 (ED) stated the resident did not remember how the bruising occurred and since s/he was isolated in the room, there must have been a fall. There was no documented evidence of how abuse and neglect had been ruled out regarding the injury Resident 1 sustained.The need to investigate injuries of unknown cause in order to rule out suspected abuse or neglect was discussed with Staff 1, Staff 2 (Regional Director of Operations) and Staff 3 (LPN) on 09/23/21. They acknowledged the findings.Staff 1 was asked to report the incident to the local SPD office and provided confirmation of the reports prior to survey exit.

Based on observation and interview, it was determined the facility failed to prepare and serve food in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: Kitchen observations on 09/21/21 at 10:35 am and 09/23/21 at 9:50 am revealed the following:In the dining room area: * The cabinet had brown matter, sticky matter buildup, was sticky to the touch on the surface and was frayed at the edge, exposing wood;* The juice machine's front and a side surface had food matter and was sticky to the touch;* Cabinet door hinges were detached, and were not able to securely open or close;* The cabinet door handles/knobs were sticky to the touch; and* A free-standing water dispenser had gray matter on the front and sides.In the kitchen area:* The area around the handwashing sink had food matter on the backsplash;* The pipe under the handwashing sink had black and brown matter present;* Walls throughout the kitchen had multiple spills, smears, splatters or black streaks;* Inside the coffee serving cabinet drawers had built-up brown matter;* Cabinet door hinges were detached, and weren't able to securely open or close;* The cabinet drawer knobs had built-up grease and were sticky to the touch;* Inside a cabinet drawer had brown/black matter; * Exteriors and front of the oven had grease buildup;* An accumulation of dust was observed on the commercial hood above the stove;* Interior and exterior of the microwave had dried food matter and buildup food matter at the edges;* Racks for clean dishes were stored on the floor by the dishwashing machine;* A broom, a dust pan and a mop were stored between the gas stove and the coffee servicing area;* Butter was stored on the countertop, at room temperature;* A hot water faucet handle, located on the three compartment sink, was loose and not functional to turn the water on and off;* The ceiling vent and the area surrounding it which was located near the dry storage area, was covered with gray/black matter;* The dish machine, gas oven control panel box, walls, floor and pipes under the dish machine and sink area had an accumulation of black matter, debris and food matter;* The reach-in refrigerator had sticky door handles, food debris on shelves and the shelving vinyl was chipped with rust developing;* The refrigerator had food matter and evidence of spillage inside of it; * Two packages of raw meat stored on the bottom shelf- not inside a container per Food Sanitation Rules; * Wooden blind located above the three compartment sink window was detached; and* Wooden knife block had brown/black matter and was sticky to the touch.Dry food storage area:* A doorframe had chipped-off paint, exposing metal underneath;* The wall was missing a part of the baseboard;* Onions were stored on the floor;* Multiple shelves had chipped-off paint, exposing wood underneath and was splintered;* A significantly dented can was observed; and* A pack of marshmallows was opened which had attracted insect and ants.Additionally, the dishwasher did not reach the hot water temperature at the manufacturer's recommendation level and a sanitation solution test strip did not change in color which indicated the solution was not at the required sanitizing level.The facility was using disposable dishware during the survey process.The areas that required cleaning and repair were observed and discussed with Staff 1 (ED) and Staff 4 (Dietary Manager) on 09/21/21 and 09/23/21. They acknowledged the area needed cleaning and repair.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:The kitchen was toured on 01/27/22 at 10:00 am, 1:30 pm and 2:45 pm. Observations included the following:In the kitchen area:* The area below the pipe of the handwashing sink had a build-up of black and brown matter;* The floor drain located below the sink located next to the stove had a build-up of food particles and brown matter;* There was an accumulation of grease and dust on the commercial hood above the stove;* The stove grills and the flat surface below had a build-up of dry food particles and grease;* A large cube of butter was stored on a plate next to a sink, uncovered and at room temperature; and* At 2:45 pm, leftover chicken from lunch was observed left out on the counter in a bowl and was uncovered.In the dry food storage area:* Three brooms, a dustpan and a dust mop, all with accumulated dust, were stored in the dry food storage area;* A box and bag of potatoes were stored on the floor beneath the shelving;* Sweet potatoes stored in a crate on a shelf were spoiled. Liquid matter from the spoiled perishables had leaked on to the shelves; and* Shelves had a build-up of dust. The brooms, dust mop and the spoiled perishables were removed from the dry food storage area by a staff member upon the surveyor request. The need to ensure the kitchen was clean and maintained in accordance with Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) on 01/27/22. She acknowledged the findings.
The facility will comply with all food and sanitation rules. Food will be prepared and served in accordance Ther area that was noted to have black matter has since been cleaned. Commercial hood cleaning has been scheduled. Food supply will be checked weekly and bad produce will be disposed off. A daily cleaning log and a weekly deep cleaning log will be in place to maintain the cleanliness of the kitchen.The hood cleaning will be scheduled on a routine basis. A daily check of log will be used to ensure all open food is labeled and dated and all expired or poor quaility food will be discarded. A weekly kitchen audit will be conducted by a management staff member from another departement to ensure complinance. The Dietary Manager, Maintenace Director and Executive Director will be responsible.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective, were used as the foundation of the service plan and were updated timely for 1 of 4 sampled residents (# 2) whose quarterly evaluations were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in March 2018. The resident's most recent quarterly evaluation and service plan were requested. The quarterly evaluation, dated 06/09/21, and the service plan, dated 06/10/21, noted the following inconsistencies: * Meal assistance; * Transfers; * Mood interventions; and * Skin monitoring relating to the administration of a blood thinner.In addition, the evaluation was not updated quarterly.The need to ensure quarterly evaluations were reflective and used as the foundation of residents' service plans and were updated timely was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (LPN). 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, provided clear direction to staff regarding the delivery of services and were updated quarterly for 3 of 4 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in November 2017.Resident 5's service plan, updated 07/02/21, and subsequent temporary service plans were reviewed during the survey and were not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas: * Use of an air mattress while in bed; and* Use of a side rail while in bed.The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 09/23/21. They acknowledged the findings.
3. Resident 2 was admitted to the facility in March 2018.The resident's service plan, dated 6/10/21, and subsequent "Change in Service Plan" documents were reviewed during the survey. The following were either not reflective or lacked clear caregiver instruction:* Frequency of oral care; * Which side of the resident's body to start dressing first; * Transfer assistance; * Outside provider information including how often they come to the facility, what services they provide for the resident and contact information; * Resident preferences relating to male caregivers; * Ability to communicate needs and wants; * Scoop mattress; * Wedge cushion; and * Emergency evacuation needs.In addition, the service plan had not been updated quarterly. The need to ensure service plans were reflective of residents' needs and preferences, provided clear direction to staff regarding the delivery of services and were updated quarterly was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (LPN) on 9/23/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility in September 2019 with diagnoses including traumatic brain injury and dementia. Resident 3's 6/10/21 service plan was reviewed and was not reflective of the resident's evaluated needs or was lacking clear direction for staff in the following areas:* Smoking (Smoking relating to the resident's smoking schedule and evaluated need to be supervised by staff; and *Behaviors (including displays of agitation and aggression.)The need to ensure service plans were reflective of the resident's needs and gave clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (LPN) on 9/23/21. 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' needs and provided clear direction to staff regarding the delivery of services for 1 of 3 sampled residents (#9) whose service plan was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 9 was admitted to the facility in March 2020. Resident 9's service plan, updated 01/19/22, and subsequent temporary service plans were reviewed during the survey and were not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas: * Use of a wheelchair; and* Self administration of daily eye drops was not accurate information.The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/27/22. They acknowledged the findings.

Service plan for resident 9 has been updated. We are reviewing all service plans to ensure reflective of all resident needs or preferences for care and safety.We are updating out tools for service planning to allow for more specific instructions and a clear identification of residents needs.Service plans will be audited and review quaterly to ensure all residents need are identified.Executive Director and Resident Service Coordinator are responsible.

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 4 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 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), Staff 2 (Regional Director of Operations) and Staff 3 (LPN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure short-term changes were evaluated; specific resident interventions determined and documented and the conditions were monitored with weekly progress noted until resolved for 4 of 4 sampled residents (#s 1, 2, 3 and 5) who experienced short-term changes of condition. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in November 2017 with diagnoses including a urinary tract infection.The resident's clinical records dated 6/1/21 through 8/20/21 indicated the following:* 4/12/21 staff documented on a facility progress note the resident was on alert for receiving two different antibiotics to treat urinary tract infection and pneumonia.There was no documented evidence the resident's short-term change of condition was consistently monitored and progress documented weekly through resolution.The need to ensure the facility monitored the resident's changes of condition weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 9/23/21. They acknowledged the findings.
2. Resident 2 was admitted to the facility in March 2018 and was identified as experiencing weight loss. Progress notes dated 7/1/21 through 9/21/21 indicated the following:* 7/1/21 - staff documented the resident wasn't eating at meals, was refusing the nutritional supplement at times and they had notified an outside agency;* 7/7/21 - "ate 3 to 4 bites of [cantaloupe] and drank one container of Boost;"* 7/29/21 - "refusing meals, [had] very minimal intake [of food] and of fluids" and "declines Boost at times;" and* 9/2/21 - the facility contacted an outside agency relating to a "six pound weight loss, resident eats few bites minimal at meals or none, will drink most of the time." "Change in Service Plan" documentation was reviewed. The change made on 7/2/21 instructed staff to record the resident's meal intake in the progress notes. The change made on 9/3/21 instructed staff to offer the nutritional supplement and not "just leave it on the table," to assist with "feeding and encourage" the resident to eat. Night shift staff to "offer Boost at least once during the night." The facility added meal monitoring to Resident 2's MAR on 7/7/21. The resident's September 1 through 21, 2021 MAR had documentation of meal monitoring. The numbers staff documented on the MAR were 0, 2, 3, 4, 5, 10 and 15. In an interview on 09/23/21 at 10:53 am, Staff 3 (LPN) attempted to explain how staff were documenting the "percentage of food intake for weight loss." Staff 3 reported she instructed staff to document the percentages of meal intake, but the numbers 2, 3 and 4 indicated documentation of how many bites the resident took. The numbers 0, 5, 10 and 15 were percentages. When asked how Staff 3 knew the difference, she was unable to explain how staff documented the resident's meal intake. There was no documented evidence the interventions were being monitored for effectiveness.Resident 2 weighed 126 pounds in July 2021. The resident's MAR reflected his/her weight was 118 pounds on 09/6/21. On 9/12/21, the facility RN completed a "Resident Evaluation/Assessment" for "weight loss." There were no additional interventions provided. An interview with Staff 3 on 9/23/21 at 10:48 am revealed there was no weight taken in August 2021. Resident 2's weight was taken on 9/23/21 at 11:19 am and was reported as 121 pounds. The need to ensure the facility monitored the resident's changes of condition weekly through resolution and for the implemented interventions to be monitored for effectiveness was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 on 9/23/21. They acknowledged the findings.
3. Resident 1 was admitted to the facility in July 2019 with diagnoses including dementia.The resident's clinical records, dated 6/4/21 through 9/21/21, were reviewed and noted the resident experienced unwitnessed falls on 8/10/21 and 9/6/21. There was no documented evidence the resident's falls were evaluated, interventions were determined, monitored for effectiveness and communicated with staff, or the resident was monitored weekly through resolution.In an 9/22/21 interview with Staff 3 (LPN) she confirmed the lack of evaluation and monitoring for Resident 2's falls. The need to ensure short term changes of condition were evaluated, interventions determined and communicated with all staff, and monitored weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 on 9/23/21. They acknowledged the findings. 4. Resident 3 was admitted to the facility in September 2019 with diagnoses including dementia. Clinical records 6/14/21 through 9/21/21 were reviewed and revealed the following medication changes:* 8/13/21 - new orders were received for Nicoderm (nicotine patch) and Ciprofloxacin (antibiotic), dosage changes for Tamsulosin (for urinary retention) and discontinuation orders for Furosemide (diuretic) and Lactulose (ammonia reducer);* 8/26/21- an order was received to increase the resident's PRN Haloperidol (for agitation and aggression); and* 8/30/21 - the facility received a discontinuation order for Nicoderm.Resident 3 experienced changes of condition related to medications and there was no documented evidence the resident was being monitored through resolution. During an interview on 9/22/21, Staff 3 confirmed the lack of monitoring for Resident 3's short term changes in condition. The need to ensure short term changes of condition were monitored weekly through resolution was discussed with Staff 1, Staff 2 and Staff 3 on 9/23/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in March 2018. The resident had a physician's order for PRN Morphine, to be administered for dyspnea or shortness of breath. The resident also had an order for a PRN acetaminophen suppository for fever or pain. Staff administered the PRN Morphine on 9/3/21 and 9/9/21 for pain. The PRN acetaminophen suppository (ordered for pain) had not been administered during these dates. Resident 2 had an order for dovalproex (for seizures) three times daily with instruction to administer "as close to eight hours as possible." The MAR had the order transcribed for the medication to be administered at 8:00 am, 12:00 pm and 8:00 pm. The need to ensure orders were carried out as prescribed by the physician was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (LPN) on 9/23/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 5) whose orders were reviewed. Findings include, but are not limited to:1. Resident 5 moved into the facility in 2017 with diagnoses including hypothyroidism.Resident 5 had a physician's order, dated 7/26/21, to administer Levothyroxine (a medication to treat underactive thyroid gland) 50 mcg daily, before breakfast and all other medications.Resident 5's 9/1/21 through 9/21/21 MAR revealed the resident received the medication at 8:00 am in the morning with all other morning medications including Aspirin, Bupropion for improving mood, Celexa for depression and Vitamins.On 9/23/21, the physician orders and current MARs were reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 3 of 4 sampled residents (#s 2, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in November 2017 with diagnoses including Type II diabetes.Resident 5 had a physician order for Toujeo Max (an insulin to treat diabetes) 150 units, administer injection once daily.Resident 5's 09/01/21 through 09/21/21 MAR revealed the following: a. 09/13/21 - Staff 7 (MA) singed on the MAR that she administered Toujeo Max insulin when Staff 3 (LPN) administered the insulin injection.b. Two scheduled ointments (Sodium Fl and Diclofenac gel) had no reason for use.On 9/23/21, the need to ensure accurate documentation of the MAR was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.
2. Resident 3 was admitted to the facility in September 2019.The resident's 09/01/21 - 09/23/21 MAR was reviewed and showed the resident was prescribed the following PRN medications:* Senna (constipation) 8.6 mg tabs one to two tabs by mouth and;* Benzontate (cough) 100 mg one to two capsules by mouth. The facility lacked documented evidence of resident specific parameters and staff instructions for the medication. The need to ensure resident specific parameters and staff instructions were included for PRN medications was discussed with Staff 1 (ED), Staff 2 (Regional Directors of Operations) and Staff 3 (LPN) on 9/22/21. They acknowledged the findings. Surveyor: Pipkin, Julian3. Resident 2 was admitted to the facility in March 2018. Resident 5's 09/01/21 through 09/21/21 MAR revealed the following:a. The medications levetiracetam and chlorhexidine gluconate were missing reasons for use. b. Per interview with Staff 3 (LPN) on 9/23/21 at 10:48 am, she entered the weight she took on 9/2/21 on the MAR for 9/6/21 as "that was when the weight was supposed to be documented." The need to ensure reasons for use were included on the resident's MAR and that the documentation was accurate was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 on 9/23/21. They acknowledged the findings.


Based on observation, interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 1 of 3 sampled residents (#9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 9's 01/01/22 through 01/27/22 MARs were reviewed during the survey. The following inaccuracies were identified:Resident 9 was prescribed Latanoprost eye drops (ophthalmic used to treat glaucoma) daily at bedtime. There were 26 days the facility failed to document administration of the eye drops and the treatment lacked reason for use. During an interview and observation of the med cart on 01/27/22, Staff 11 (MA), reported the medications were available and were being administered, however s/he forgot to initial administering the eye drops. The need to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/27/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were documented as ineffective, for 2 of 2 sampled residents (#s 3 and 6) who had an order for PRN psychoactive medication. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in May 2019.Resident 6's records indicated s/he had an order for PRN Seroquel (a medication to treat mental or mood disorder) for agitation.Resident 6's 09/01/21 through 09/21/21 MAR and progress notes were reviewed and indicated the resident was administered PRN Seroquel on three occasions for agitation without documented, specific symptoms and without non-drug interventions being attempted with ineffective results prior to the administration.On 09/23/21, the need to ensure staff documented the resident-specific signs and symptoms of behaviors and only after attempting non-drug interventions was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.
2. Resident 3's 09/01/21 through 09/21/21 MAR was reviewed during the survey. The resident was prescribed Haloperidol 1 ml by mouth as needed for agitation or anxiety. The medication was administered on 9/9/21 and 9/16/21.In each instance, there was no documented evidence the facility attempted non-pharmacological interventions with ineffective results, prior to administering the psychotropic medication.The need to ensure non-pharmacological interventions were attempted and found to be ineffective prior to administering psychotropic medication was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) and Staff 3 (LPN) on 9/23/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 7, 8 and 9) completed all required pre-service orientation topics prior to beginning their job responsibilities. Findings include, but are not limited to:Training records were reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 9/22/21. The following was identified:Staff 7 (MA), Staff 8 (CG) and Staff 9 (CG), hired on 04/15/21, 06/08/21 and 08/30/21 respectively, did not complete pre-service orientation training prior to beginning their job responsibilities. Staff 9 lacked documented evidence of the training for dementia disease process including progression, memory loss, psychiatric and behavioral symptoms. The need to ensure newly-hired direct care staff completed pre-service training prior to working independently was reviewed with Staff 1 and Staff 2 on 9/22/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 8 and 9) had documented demonstration of competency in all required areas, completed all required training and received First Aid training within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 9/21/21 indicated the following:1. Staff 7 (MA), Staff 8 (CG) and Staff 9 (CG), hired on 04/15/21, 06/08/21 and 08/30/21 respectively, did not have documentation of competency demonstrated in the following areas:* Providing assistance with ADL's;* Identification, documentation and reporting of changes of condition;* General food safety, serving and sanitation; * Performing the duties of a medication aide pertaining to Staff 7; and* First Aid training.2. Staff 8 lacked documented evidence of training completed in the areas of: * The role of service plans in providing individualized resident care; and* Changes associated with normal aging.3. Staff 7 lacked documented evidence competency demonstration was completed within the first 30 days of hire in the areas including, but not limited to: * The role of service plans in providing individualized resident care;* Providing assistance with ADL's;* Changes associated with normal aging; * Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* Performing the duties of a medication aide.4. Staff 7, 8 and 9 either had no date of when they received Abdominal Thrust training or there was no staff signature of who performed the training. The need to document demonstrated competency in job duties, complete all required trainings and complete First Aid training within the first 30-days of hire was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 9/22/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:During the entrance conference on 09/21/21, the surveyor requested Fire and life safety training records from February 2021 through August 2021. There was no consistent documented evidence of the following areas:* Evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Evidence of the number of occupants who were evacuated.On 09/22/21 the above areas were reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:During the entrance conference on 09/21/21, the surveyor requested Fire and life safety training records from February 2021 through August 2021. The following was identified:* No documentation of fire and life safety training for residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and * A written record of fire safety training, including content of the training sessions and the residents attending. The need to ensure all general fire and life safety requirements were discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 9/22/21. They 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 240, C 260, C 310 and C 513.
Based on observation and interview, 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 C513.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the garden area were maintained in good repair and garbage was stored in covered containers. Findings include, but are not limited to:The exterior garden courtyard of the RCF was toured on 09/21/21. There were drop-offs of up to approximately six inches from the concrete landing to the planting bed at the bottom of the stairway. This represented a fall risk for residents.The facility's refuse container was observed to be more than half full with the lid off multiple times throughout the survey. This could allow the entry of rodents and other pests. The need to ensure walkways were maintained and safe for residents and garbage was stored in covered containers was reviewed with Staff 1 (ED) on 9/21/21. She acknowledged the drop-offs.

Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair and free of unpleasant odors. Findings include, but are not limited to:Observations of the RCF conducted 09/21/21 through 09/23/21 showed the following:* Gouges in the flooring in front of the patio doors in the dining area;* Black and brown stains in the carpeting throughout the facility; and* Persuasive odor of urine in Resident 1's bedroom and bathroom that did not dissipate throughout the day.The need to maintain the interior of the facility and all surfaces and to be free from unpleasant odors, was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 9/23/21. They acknowledged the findings. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the facility was clean and in good repair. This a repeat citation. Findings include, but are not limited to:Observations of the RCF conducted 01/27/22 showed the following:* Black and brown stains in the carpeting throughout the facility.The need to maintain the interior of the facility and all surfaces, was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/27/22. They acknowledged the findings. An extension for the carpet replacement, which was currently underway, was granted until 01/31/22.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility on 04/07/22 showed the following areas were in need of cleaning and/or repair:* The carpet in Resident Room 2 was stained near the bathroom, and had a strong urine odor that did not dissipate;* The hallway outside Resident Room 1, 2, 3 and 4 had only a carpet pad with no flooring material. A resident in a wheelchair was observed navigating over the carpet pad to come and go to their room;* The activity room was missing crown molding and finish paint due to ceiling water damage; and* All thresholds between the hallway and resident rooms carpet were missing, creating an abrupt edge, and the seams between flooring material sections in the hallways were connected with grey duct tape.The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure operable resident windows above the second floor with sill heights lower than 36 inches were designed to prevent accidental falls. Findings include, but are not limited to:The interior of the facility was toured on 04/07/22 at 10:20 am. During the tour, observation showed resident rooms both on the ground floor and some rooms above the ground floor on a hillside. Resident Room 2 was observed with the window open approximately 36 inches wide. Upon inspection, the window was found to lack any means of limiting how wide the window could be opened to prevent accidental falls, with a drop off of approximately 12 feet to the ground on a steep slope. The height of the window sill was 24 inches above the floor. Another second-floor unsampled resident's window was inspected and was also found to lack any means of limiting how wide the window could be opened. All resident window sills were approximately 24 inches above the floor.Review of the facility license showed the RCF was constructed in 1995. Further observations showed Resident Room 1, 2, 3, 4, 11, 16, and 17 had windows above the ground floor, with no safety devices, and with sills 24 inches above the floor.The need to ensure resident windows above ground level were designed to prevent accidental falls was reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations ) on 04/07/22. No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure all 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:Observations on 9/21/21 and 9/22/21 showed exit doors to the resident balcony, and patio area did not have an alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) on 9/22/21. She acknowledged the findings.