Capital Manor Retirement Community

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 the Food Sanitation Rules, OAR 333-150-000. Facility did not provide accurate textures for residents requiring puree. Findings include, but are not limited to:

Observations were made of the main kitchen, dry food and paper product storage area, memory care unit kitchenette, and the RCF unit dining room kitchenettes on 10/13/25, between 10:00 am and 2:00 pm. The following areas were identified:

1. Main kitchen area

a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following:

* Wall above metal rack storing clean dishes;
* Floor between wall and prep tables;
* Floor under metal racks in dry storage;
* Floor sink in janitor closet;
* Top of hot food storage cart;
* Industrial slicer;
* Table holding slicer;
* Bottom shelf of prep table holding slicer under rack storing cutting boards
* Portable metal baker’s rack;
* Convection ovens;
* Range top;
* Exterior of garbage cans;
* Wall behind range/fryer/conventional oven;
* Flooring between, under, behind equipment;
* Interior of deli cooler;
* Juice machine;
* Fan cages, ceiling and light fixture of walk in cooler;
* Drain under service line/steam table area; and
* Ceiling tiles, vents, smoke detector in/near dishwashing room.

b. The following areas needed were found needing repair;
* Caulking around hand washing sink
* Caulking around industrial ware washing machine

c. Multiple cutting boards were found heavily scored, stained, and/or missing chunks, deep grooves, and needed to be replaced.

d. Cook noted to repeatedly handle RTE (ready to eat) food items with potentially contaminated gloves during tray line service.

e. Multiple kitchen staff observed handling food or clean equipment without hair restraints.
f. Multiple items potentially hazardous food items found without opened/prepared dates.

g. Multiple food items were observed stored uncovered/protected from potential contamination in both walk in cooler and freezer.

h. Food contact surfaces of commercial slicer and single service utensils were stored uncovered/protected from potential contamination. Multiple clean/sanitized dishes and food contact surfaces of equipment were not being stored inverted as required.

i. Multiple staff drink containers were observed in food preparation and/or storage areas that were not of approved styles yielding potential contamination of lip contact surfaces. Staff drinks were observed stored with resident food items.

j. Facility did not have a system to ensure cold food items were at proper temperatures prior to meal service. Facility served a variety of cold items each meal from their deli cooler (tuna salad, deli sandwiches, egg salad, fruit and or vegetable items, etc) and did not ensure the items were at 41 degrees or below when served. Staff 2 was interviewed and confirmed the facility was not checking cold food meal service items prior to service as they were assuming the temperatures were the same as the temperature of the cooler they were stored in.

k. Facility had two residents identified as having puree textures as part of their diets. Observations during meal service found the textures to be served to those residents that was too thin as it flowed through the tines of the fork. This does not meet the criteria of puree.

2. Memory Care kitchenette.

a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following:

* Interior of reach in refrigerator;
* Countertop mixer;
* Interior of oven;
* Interior of bottom cabinet next to oven;
* Interior of reach in drawers; and
* Black utility carts.

b) Food and/or beverage items found in the reach in refrigerator observed uncovered/protected from potential contamination

3. Dining room kitchenette

a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following:

* Interior of microwave
* Interior of drawer storing clean towels
* Exterior/top of small ice machine

b. Reach in cooler and/or freezer door seals were observed damaged/cracked and in need of replacement.

c. Containers of bulk food items were observed with spoons stored inside the container with the handle touching food items causing potential contamination of the food products.

At approximately 1:45pm, the above findings were shared with the Staff 1, Staff 2, and Staff 3 (Director of Dining & Culinary Services), who acknowledged the areas in need of correction.

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

Refer to C240.

C 240: C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules) related to minor cleaning and repair, equipment in good repair, hair restraints and apron use, and food storage.

Based on observation, interview, and record review, conducted during a site visit on 08/05/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Findings include, but are not limited to:In an interview on 08/05/24, Staff 1 (Administrator) stated the building consisted of an RCF with two floors named "Manor Care 1 and 2" and a memory care named "Manor Care West."A review of the facility's Posted Staffing Plan stated the following:* Manor Care * Day: seven caregivers, two med techs, and one restorative aide; * Evening: seven caregivers and two med techs; and * Night: four caregivers and one med tech, who was shared with the memory care.* Memory Care * Day: five caregivers, one med tech, and one restorative aide; * Evening: five caregivers and one med tech; and * Night: three caregivers and one med tech, who was shared with Manor Care.In an interview on 08/05/24, when asked how the facility determines the staffing plan, Staff 1 stated this was "the plan the facility has always had."A review of the facility's ABST showed 312 total care hours, requiring 41.6 staff members for day shift.A review of the posted staffing plan and staff schedule revealed the facility was not staffing to the plan required by the ABST.In an interview on 08/20/24, Witness 2 (ABST Corrective Action Coordinator) stated the facility's high frequency count, which generated abnormally high staffing hours, was due to counting single ADL tasks across multiple ADLs in the ABST.Interviews with residents did not reveal any missed needs.The findings were reviewed with and acknowledged by Staff 1, Staff 2 (Director of Nursing), Staff 9 (Facility Compliance Specialist), and Staff 10 (Executive Director).It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool.

The findings of the kitchen inspection, conducted 10/25/23, 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 10/25/23, conducted 01/04/24, 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, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observations were made in the kitchen on 10/25/23, between 10:26 am and 1:15 pm, with facility staff. The following deficiencies were identified:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following:*Industrial and counter top can opener and housing;*Industrial mixer base and dough hook;*Convection oven;*Range top;*Grout behind dishwashing area;*Fans and ceiling in walk in cooler;*Handwashing sink near dishwashing area; and*Bottom two shelves of racks holding clean dishes.b. Heating and cooling system vents in the food prep and tray line areas, as well as in cold storage, had a build-up of visible dust. The ceiling and walls around the vents also had a visible build-up of dust, risking potential contamination of food.c. The coating on the blade of the large can opener was peeling off, leaving an uncleanable surface. The blade needed to be replaced.d. Multiple cutting boards and utility carts were found heavily scored, stained, and/or missing chunks, and needed to be replaced.e. In the dry storage area, multiple cans of food were observed dented/damaged.f. Multiple carts were observed lined up against the wall in a hallway near a dining room at 10:20 am. The carts held covered food and uncovered utensils and were accessible by anyone passing the area, exposing them to potential contamination. The Dining Services Manager reported there was a lack of space in the kitchen area for tray set up, so food delivery carts were kept in the hallway until service.g. Kitchen employee was observed to repeatedly handle RTE (ready to eat) food items with potentially contaminated gloves during tray line service. h. Memory care kitchenette reach in refrigerator was found to be at 49 degrees Fahrenheit. This was the units resident snack fridge. Review of documentation of temperature sheet revealed 10 times since 10/12/23 that the refrigerator temperatures were at higher than 41 degrees (42-48 degrees). Milk and condiments were observed stored in that refrigerator. Facility administrative staff verified they were not informed of any temperature concerns with that refrigerator.The findings were shared with the Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 10/25/23 at 1:00 pm. They acknowledged the findings.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

The findings of the re-licensure survey, conducted 11/07/22 through 11/09/22, 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 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the re-visit to the re-licensure survey of 11/09/22, conducted 03/21/23 through 03/22/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

2. On 11/09/22 at approximately 7:30 am, the surveyor observed a caregiver provide incontinent care to Resident 2. During the process, Staff 17 (CG) removed the resident's soiled incontinent brief, which was saturated with urine, and tossed it on the floor near the garbage can. Staff 17 changed gloves after removing the brief. The resident was assisted from the toilet, bottom wiped and barrier cream applied all over the resident's bottom. Staff 17 did not change gloves prior to pulling up the residents brief and pants. This left large white sections of barrier cream along the waist band and back of the resident's pants. Staff 17 bagged up all soiled items, washed hands and wheeled the resident out of his/her room. When no attempt had been made to disinfect the floor prior to leaving the resident room, the surveyor asked the staff member to disinfect the floor where the brief had been. Approximately 15 minutes later housekeeping was observed in the resident's room.The need to ensure staff consistently used proper infection control and universal precautions when incontinent care was provided was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.
3. Resident 1 was admitted to the facility in 07/2016 with diagnoses including dementia. Review of the current service plan, dated 08/18/22, as well as interviews with staff, revealed s/he required full assistance with all ADLs.On 11/08/22 care staff were observed providing incontinence care for the resident. Care staff removed the resident's soiled brief, provided perineal care, disposed of the brief, put on a clean brief, and transferred the resident to his/her wheelchair without changing gloves. After care staff removed their gloves, they did not perform hand hygiene.The need to follow proper infection control and hand hygiene procedures was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:Observations were made during the survey to determine adherence to universal precautions for infection control.1. On 11/09/22 at 11:10 am the surveyor obtained permission and observed Staff 12 (CG) provide toileting assistance to Resident 7. During the observation Staff 12 failed to change gloves after wiping urine from Resident 7's perineum. Staff 12 touched the resident's clothing and multiple areas on the resident's wheelchair while wearing the same soiled gloves. The need to ensure staff exercised universal precautions and infection control standards was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), and Staff 3 (Compliance Specialist) on 11/09/22. 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 and were completed prior to the resident being admitted to the facility for 1 of 2 sampled residents (#4). Findings include, but are not limited to:Resident 4 was admitted to the facility on 07/08/22. The resident's move-in evaluation was dated 06/08/22. The following elements were not addressed in the move-in evaluation:* Skin conditions;* Treatment needs;* Emergency evacuation ability;* Elopement risk or history; and* Environmental factors which impact the resident's behavior, including, but not limited to, noise, lighting, and room temperature.The need to address all elements of a move-in evaluation prior to a resident being admitted to the facility was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and were followed by staff for 5 of 11 sampled residents (#s 1, 2, 3, 4 and 7) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in October 2018 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 07/25/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Behaviors including disrobing; * Falls, frequent checks, tab alarm and low bed;* Supervision in the dining room;* Incontinent care and toileting assistance; and* One vs two person transfers and gait belt use.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.2. Resident 4 was admitted to the facility in July 2022 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 08/12/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Behaviors including physical aggression towards staff;* Falls, frequent checks, motion alarm and bed height;* Incontinent care, toileting assistance and frequency of assistance;* Keeping the resident's door open;* Fluids within reach and refilled throughout day;* Activities and television use;* Staff assistance with bathing, toileting and dressing; and* One vs two person transfers and gait belt use.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.3. Resident 7 was admitted to the facility in October 2021 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff and review of the service plan dated 09/05/22, showed the service plan was not reflective of the resident's current care needs in the following areas:* Level of required meal assistance; and* Refusal of gait belt use.The need to ensure service plans were reflective of resident care needs was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), and Staff 3 (Compliance Specialist) on 11/09/22. They acknowledged the findings.
4. Resident 1 was admitted to the facility in 07/2016, and Resident 3 was admitted in 05/2014, both with diagnoses including dementia.Current service plans and quarterly resident evaluations were reviewed, observations were made, and staff were interviewed. The following was identified:Information about the residents' food and beverage preferences and/or leisure activity interests were on the evaluation, but had not been included in the service plan. Staff 1 (Administrator) stated, in an interview on 11/09/22, caregiving staff do not have access to residents' evaluations, only to their service plans.The need to ensure information on the quarterly resident evaluation is included in the residents' service plans and available to caregiving staff was discussed with Staff 1, Staff 2 (Director of Nursing), Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and the condition was monitored to resolution at least weekly for 3 of 9 sampled residents (#s 2, 3 and 4) who experienced changes of condition. Resident 2 experienced repeated falls with significant injury, and Resident 3 experienced ongoing weight loss. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in October 2018 with diagnoses including dementia. Interviews with staff and review of the resident's 07/25/22 service plan, 08/01/22 through 11/07/22 progress notes, incident investigations and physician communications were completed.Observations between 11/07/22 and 11/09/22 revealed the resident had a tab alarm in place while in bed and in the wheelchair. The resident was noted to pull on the clip and move the alarm when s/he was in bed. A fall mat was in place when the resident was in bed. The resident's bed was intermittently in the lowest position. The resident was unable to move himself/herself from the bed to wheelchair or wheelchair to bed safely. The resident was observed to be weak and unable to stand securely with support during toileting assistance. The resident could not initiate care from staff, utilize the call light or understand his/her safety limitations. The dining room was inconsistently monitored by staff throughout the day and the resident's apartment door was frequently closed while the resident was in bed.a. The resident experienced multiple injury and non-injury falls as follows:* On 08/01/22, a note indicated the resident had a fall on 07/30/22, the resident was found on the floor with a skin tear noted. Intervention to implement was a tab alarm at all times.* On 08/13/22, the resident's tab alarm alerted staff who found the resident on the floor in his/her room with no clothing or brief on. No injury was noted. Intervention to be implemented was offer the resident to come to dining room when awake. * On 08/14/22, the resident was found on the floor in his/her room with no clothes or brief in place. The resident stated s/he tried to go to the bathroom. A skin tear was found on the resident's left elbow. Intervention implemented was to keep the resident in the dining room before, during and after meals. An X-ray was completed on 08/24/22 related to ongoing pain and transfer difficulties. The resident was found to have a pelvic fracture.* On 08/25/22, the resident's tab alarm sounded and the resident was found on the ground in the dining room with a skin injury to the right shin, area was noted as both an abrasion and a skin tear. Intervention implemented was not to leave the resident unattended after meals.* On 09/04/22, the resident's tab alarm sounded and the resident was found on the floor in his/her room in a pool of blood. The resident had a wound to the back of his/her head but extent of injury was not visible due to blood. The resident was transported to the emergency room for evaluation. The resident returned with staples to the back of his/her head. Intervention implemented was provide toileting assistance before putting the resident to bed.* On 09/29/22 at 11:00 am, the resident was witnessed to stand, set off tab alarm, lose his/her balance and fall on his/her bottom. The investigation indicated the resident seemed to be worried about a bloody nose from earlier in the day and attempted to get something for his/her nose. No injury noted. Intervention to implement was noted if the resident's nose was bleeding then staff were to attempt to stop the bleed by pinching bridge of the nose and provide the resident a towel to catch the blood. * On 09/29/22 at 9:09 pm, the resident was found on the floor in the common area bathroom near the dining room. Tab alarm was not in place, resident stating in "agony," hip pain expressed repeatedly as well as bruising and swelling to the right hip. Intervention to implement was for staff to ensure the tab alarm was in place and attached between the resident's shoulder blades. The resident was transported to the emergency room for evaluation and admitted to the hospital with a fracture which required surgery. The resident returned on 10/10/22.* On 10/23/22, the resident was found partially on the fall mat next to his/her bed. The resident's tab alarm was not sounding. The resident stated s/he was "trying to go pee." No injury was noted. Intervention to be implemented was to offer the resident frequent toileting after meals.There was no documentation to show ongoing evaluation of existing interventions, determination and implementation of any new interventions and monitoring of those interventions for effectiveness after each of the resident's falls. The investigations did not indicate what may have contributed to the falls, nor did they address interventions to prevent future occurrences.Resident 1 had repeated falls with and without injury, including two fractures and a laceration to the head, without sufficient evaluation, monitoring and intervention by the facility to prevent further injuries and falls.b. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:* Bruising, skin tears and excoriation;* New medications and medication changes;* Falls: injury and non injury; * Weights, snacks and fluid intake;* Behaviors including disrobing and brief removal;* Bloody nose; and* Sutures.The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.2. Resident 4 was admitted to the facility in July 2022 with diagnoses including dementia.Observations of the resident, interviews with staff and review of the resident's 08/12/22 service plan, 08/02/22 through 11/04/22 progress notes, incident investigations and physician communications were completed.The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:* Falls with and without injury and safety interventions;* Behaviors including urinating on the floor, refusal of care and striking out at staff;* Skin tears, edema and pannus rash;* New medications and medication changes.The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.
3. Resident 3 was admitted to the facility in 05/2014 with diagnoses including dementia, anxiety disorder, and depression.The resident's clinical record was reviewed, including the service plan, resident evaluations, incident reports, interim service plans (ISPs), progress notes, MARs, and weight records, and staff were interviewed.Weight records from 05/2022 through 11/2022 indicated the resident weighed:* 05/01/22: 149.2 lbs.;* 08/06/22: 137.6 lbs.; and* 11/01/22: 108.4 lbs.The resident lost 11.6 pounds from 05/01/22 to 08/06/22, which was a 7.7% loss of his/her total body weight. This represented a significant weight loss in 30 days and constituted a significant change of condition.The resident lost 29.2 pounds between 08/06/22 and 11/01/22, or 21.2% of his/her total body weight. This was a severe weight loss in 90 days and constituted a significant change of condition.A 40.8 lb. loss in six months, from 05/01/22 to 11/08/22, or 27.3% of his/her total body weight, represented a severe weight loss, which was also a significant change of condition.There was no documented evidence the facility RN was notified of the resident's weight loss; actions or interventions were determined, communicated to staff on all shifts, and implemented; or interventions were monitored for effectiveness. The resident continued to lose weight.Observations from 11/07/22 through 11/09/22 revealed Resident 4 was asleep in bed while the surveyor was in the facility. S/he was not observed to eat or drink anything. Staff indicated s/he had been admitted to hospice on 11/05/22.In an interview on 11/09/22, Staff 2 (Director of Nursing) stated the documented weights were incorrect because staff had not been weighing the resident correctly. Staff 2 was unable to provide any documentation indicating the resident's documented weights were incorrect or staff had not weighed him/her according to the facility's procedure.The need to ensure all changes of condition were evaluated and referred to the RN if indicated; had actions and/or interventions developed, implemented, and communicated to staff on all shifts; and interventions were monitored for effectiveness was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings. No additional information was provided.

2. Resident 3 was admitted to the facility in 05/2014 with diagnoses including dementia, anxiety disorder, and depression.The resident's clinical record was reviewed, including the service plan, resident evaluation, incident reports, interim service plans (ISPs), progress notes, MARs, physician orders, hospice notes, and weight records, and staff were interviewed.a. Weight records from 05/2022 through 11/2022 indicated the resident weighed:* 05/01/22: 149.2 lbs.;* 08/06/22: 137.6 lbs.; and* 11/01/22: 108.4 lbs.The resident lost 11.6 pounds from 05/01/22 to 08/06/22, which was a 7.7% loss of his/her total body weight. This represented a significant weight loss in 30 days and constituted a significant change of condition.The resident lost 29.2 pounds between 08/06/22 and 11/01/22, or 21.2% of his/her total body weight. This was a severe weight loss in 90 days and constituted a significant change of condition.Between 05/01/22 and 11/01/22, the resident lost a total of 40.8 pounds, or 27.3% of his/her total body weight. This represented a severe weight loss, which was also a significant change of condition.There was no documented evidence the facility RN had completed a significant change of condition assessment for the resident's severe, ongoing weight loss.b. During the acuity interview on 11/07/22, Resident 3 was identified as having been admitted to hospice "within the last few days."A progress note dated 10/21/22 indicated the resident's physician had referred him/her to hospice. Progress notes from 10/21/22 through 11/04/22 revealed nursing staff were communicating with hospice related to when the resident would be admitted.There was no documented evidence the facility RN had completed a significant change of condition assessment when the resident was admitted to hospice on 11/05/22.In an interview on 11/09/22, Staff 2 (Director of Nursing) stated the resident was "put on a significant change of condition," but she had not completed a significant change of condition assessment.The need to ensure an RN assessment was completed in a timely manner for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings. No additional information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 6 sampled residents (#s 2 and 3) who experienced significant changes of condition related to weight loss. Residents 2 and 3 experienced severe weight loss. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in October 2018 with diagnoses including dementia. The resident's 07/25/22 service plan, 08/01/22 through 11/07/22 progress notes, investigations and physician communications were reviewed and staff interviews were conducted. In an interview on 11/09/22, Staff 3 (Compliance Specialist) indicated monthly weights were to be completed by the 5th of each month and re-weights done by the 10th.a. Weight records documented from May 2022 through November 2022 indicated the resident experienced a 10.6 pound weight loss from June to September 2022. This constituted a 10.01% severe weight loss in three months. The resident experienced a fall on 09/29/22 and sustained a head injury and a fracture. The resident was hospitalized from 09/30/22 to 10/10/22 and surgery was completed. The resident had no documented weight in October upon his/her return to the facility. The resident's weight in November 2022 was documented as 97.8 pounds.The resident's intake varied and s/he received a regular texture diet. The resident required full assistance from staff for his/her ADLs but could feed himself/herself once meal items were delivered. Multiple observations of the resident between 11/07/22 and 11/09/22 showed the resident was independent with his/her meal once it was delivered. The resident ate in the dining room, received cut up foods and 2-3 cups of fluid, usually a juice, coffee and/or water. The resident ate 25-100% of the meals observed. The resident was observed both to be alert and eating well and pushing plate away and taking no bites. Observations of the resident with no meal intake showed staff sat with the resident, fed him/her a bite, left the table and did not return. The resident did not initiate any further bites on his/her own and the plate was cleared approximately 20 minutes later. Additional observations showed the resident accepted fluids when offered throughout the day, if up in the dining room. The resident was not observed to receive a snack when in the dining room or offers/assistance with fluids when in his/her room. The resident did require intermittent cueing to continue with his/her meal and fluids. The resident was not offered additional helpings of any of the meal items when his/her meal was fully eaten. The resident spent 20-40 minutes at the table eating, which varied by the time of day.In interviews on 11/07/22, Staff 8, Staff 13 and Staff 32 (CGs) indicated the resident's intake was fair to good. The staff indicated the resident was able to eat on his/her own and enjoyed coffee. The resident required reminders to continue to eat and drink. b. The resident experienced a fall on 08/14/22 with a skin tear. On 08/16/22 progress notes indicated the resident had increased hip pain, significantly decreased mobility, pain with transfers and decreased physical therapy participation.A progress note dated 08/18/22 indicated the resident's physician was called for follow up on fax of 08/16/22 regarding hip pain. A message was left for the physician requesting an X-ray of the resident's left hip.A progress note dated 08/19/22 indicated family was contacted to inform them a request was made for an X-ray, but the physician had not responded yet. The family was advised they could take the resident to urgent care. The family indicated they would contact the resident's physician first before considering transport to urgent care. A progress note dated 08/23/22 indicated the resident's family called the facility for an update on the X-ray request related to the resident's problems with transfers. The physicians office was contacted again and order obtained for an X-ray to be completed on 08/24/22.A progress note dated 08/24/22 indicated staff were to keep the resident in bed and as comfortable as possible, non-ambulatory and non-weight bearing. Transfers were to be completed with a mechanical lift.A progress note dated 08/25/22 completed by Staff 2 (Director of Nursing Services), indicated the resident recently had a couple of falls and a recent X-ray showing a pelvic fracture. The physician indicated the resident's fracture was a common one and s/he could be weight-bearing as tolerated. The resident would continue to work with PT and appeared to be in no pain. The facility failed to ensure a thorough RN assessment was completed for the fracture which documented findings, resident status and interventions made as a result of the assessment. The resident continued to experience falls with a head laceration and an additional fracture. The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.

Based on and interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as prescribed in OAR 411-054-0050 Infection Prevention and Control. Findings include, but are not limited to:In an interview on 11/09/22, Staff 1 (Administrator) reported Staff 27 (Environmental Services Director) was the facility's designated Infection Control Specialist. Review of Staff 27's infection control training revealed she had not completed the required specialized, Department-approved training in infection prevention and control protocols for a Residential Care Facility infection control specialist.The need to ensure the designated Infection Control Specialist completed all required training was reviewed with Staff 1 and Staff 27 on 11/10/22. They acknowledged training had not been completed as required.

Based on interview, observation, and record review, it was determined the facility failed to ensure controlled substances were logged and administered accurately for 1 of 3 sampled residents (#3) whose PRN narcotics and psychotropic medications were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 05/2014 with diagnoses including dementia, anxiety disorder, and depression.A review of the resident's clinical record, including the 10/01/22 through 11/07/22 MARs, physician orders, and the controlled substance disposition log, revealed the following:a. The resident had a physician's order for morphine (a narcotic) 20mg/ml sol 15 ml, take 0.25 ml (5 mg) by mouth every hour as needed for pain or shortness of breath.* Two entries in the controlled substance disposition log for PRN morphine were not listed on the MAR as having been administered to the resident:- 11/05/22 at 7:37 pm; and- 11/07/22 at 10:00 pm.* One administration of PRN morphine was listed on the MAR for 11/06/22 at 12:19 pm but was not listed in the controlled substance disposition log.b. Resident 3 had an order for Ativan (a psychotropic) 0.5 mg, take one tab (0.5 mg) "every two hours as needed for anxiety, restlessness, insomnia."* One administration of Ativan (for anxiety and agitation) was logged in the controlled substance disposition log, but not on the MAR:- 11/05/22 at 10:22 pm.The need for entries in the narcotic disposition log and entries on the MAR to correspond was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure specific reasons for use of PRN psychotropic medications were included on the MAR, and non-pharmacological interventions had been documented as attempted and ineffective prior to administration, for 1 of 1 sampled resident (#6) who were prescribed and were administered PRN psychotropic medications. Findings include, but are not limited to:Resident 6 was admitted to the facility in 08/2022 with diagnoses including anxiety. The resident's 10/01/22 through 11/07/22 MARs were reviewed, and the following deficiencies were identified:* PRN Ativan 0.5 mg (for anxiety) was administered on 8 occasions from 10/01/22 through 11/07/22. The facility failed to document non-pharmacological interventions as ineffective prior to administering the medication; and * PRN Haloperidol Lactate 2MG/ml (for hallucinations) failed to include non- pharmacological interventions for staff to attempt prior to administration of the medication and to specify how the resident exhibited signs and symptoms of hallucinations. On 11/09/22, the need to include resident-specific parameters on the MAR for PRN psychotropic medications and documented evidence of non-pharmacological interventions were attempted prior to administering psychotropic medications was discussed with Staff 1 (Administrator) and Staff 3 (Compliance Specialist). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 5 of 5 newly hired direct care staff (#s 9, 10, 20, 24 and 33), demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:Training records were reviewed with Staff 28 (Staffing Development Coordinator) 11/07/22 through 11/09/22. The following deficiencies were identified:There was no documented evidence Staff 9 (CG), hired 09/14/22, Staff 10 (CG), hired 09/07/22, and Staff 33 (MT), hired 08/24/22, demonstrated competency in all required areas within 30 days of hire including:* Changes associated with normal aging; and* Abdominal thrust.There was no documented evidence Staff 20 (MCC) (CG), hired 05/18/22, and Staff 24 (MCC) (CG), hired 06/13/22, demonstrated competency in abdominal thrust within 30 days of hire. The need to ensure newly-hired direct care staff demonstrated satisfactory performance in all required areas within 30 days of hire was discussed with Staff 1 (Administrator), Staff 5 (Memory Care Coordinator) and Staff 28 on 11/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and Life Safety records from 05/2022 through 11/2022 were reviewed on 11/08/22. The fire drill records did not include the following required information:* Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* Number of occupants evacuated.The need to ensure fire drills were conducted according to the Oregon Fire Code, and all required information was documented, was discussed with Staff 1 (Administrator) and Staff 26 (Director of Facilities) on 11/08/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. Findings include, but are not limited to:Fire and Life Safety records from 05/2022 through 11/2022 were reviewed on 11/08/22. There was no documented evidence of a written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.The need to ensure residents were provided instruction as required by the Oregon Fire Code was discussed with Staff 1 (Administrator) and Staff 26 (Director of Facilities) on 11/08/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the doors that exited to the interior courtyards were equipped with an operational alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:The interior of the facility was toured on 11/07/22 and 11/08/22. There were three exit doors in the memory care unit through which residents could enter the secured MCC courtyard, and two exit doors in the residential care facility (RCF) through which residents could enter the RCF courtyard. When the surveyor exited through these doors, no audible alert was heard.Interviews on 11/08/22 with Staff 26 (Director of Facilities) and Staff 1 (Administrator) confirmed there was no system that alerted staff when a resident exited into the courtyards of the memory care unit and RCF. Staff 1 acknowledged the facility needed to install a system that alerted staff when a resident exited the building.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Please refer to C 372, C 420, C 422, and C 555.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly-hired direct care staff (#s 20 and 24) completed all required pre-service orientation, pre-service dementia training and demonstrated competencies within required timelines. Findings include, but are not limited to:Training records were reviewed with Staff 28 (Staffing Development Coordinator) 11/07/22 through 11/09/22. The following deficiencies were identified:a. Staff 24 (CG) was hired 06/13/22. There was no documented evidence Staff 24 completed the required pre-service orientation in resident rights and values of CBC care prior to beginning job duties and completed the following required pre-service dementia care training topics prior to providing care and services independently:* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being;* Family support and the role the family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in MCCs prior to working independently.There was no documented evidence Staff 24 demonstrated competencies in the following required areas within 30 days of hire:* Role of the service plan in providing individualized care;* Providing assistance with ADL's;* Changes associated with normal aging;* Identification, documentation and reporting changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.b. Staff 20 (CG) was hired 05/18/22.There was no documented evidence Staff 20 demonstrated competencies in the following required areas within 30 days of hire:* Providing assistance with ADL's; and* Changes associated with normal aging. The need to ensure newly-hired direct care staff completed all required pre-service orientation, pre-service dementia training and demonstrated competencies within required timelines was discussed with Staff 1 (Administrator), Staff 5 (Memory Care Coordinator) and Staff 28 on 11/09/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Please refer to: C 160, C 252, C 260, C 262, C 270, C 280, C 302, and C 330.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked out of their rooms. Findings include, but are not limited to:During the survey, observations of the memory care unit showed all apartment doors had an electronic locking system in place.The doors remained locked at all times when closed and required a key fob for every entry into the room. Any individual who wanted or needed to enter an apartment with a closed door had to utilize a key fob to do so. Caregiving staff each carried a key fob which could open residents' rooms. Six residents were observed with key fobs on their person or attached to walkers. The residents were unable to state what the key was for or what it did. An additional eleven residents were observed with no key fob. Four residents were observed attempting to open their apartment doors, the doors were locked and residents were unable to enter. A non-sampled resident stated it made him/her "so angry," as s/he repeatedly pulled on the door knob.Observations of Resident 2 and 4 and additional non-sampled residents, who required staff assistance to get out of bed and leave the apartment, showed visitors were unable to access the residents without staff intervention. The surveyor knocked on Resident 2 and 4's doors on 11/07/22. The residents yelled out "come in" repeatedly but the surveyor was unable to open the doors as they were locked. Once a staff was located they were able to temporarily unlock the residents' doors to allow the surveyor access. Additional observations of Resident 4 on 11/07/22 showed the resident yelling out for help, moaning and groaning. The resident responded to the surveyor's knock and questions through the door. The resident said come in and replied s/he needed help. The surveyor told the resident help was on the way and to stay seated. A staff member was located and the resident's door was opened. The resident was seated in his/her recliner and told staff s/he needed help. During interviews with multiple memory care staff between 11/07/22 and 11/08/22, the staff stated the doors would open with a key fob but were not unlocked. Staff stated some of the residents in the unit did have key fobs for their apartments but only a few of the residents understood how to use them. The staff further indicated a resident or a visitor just needed to locate a staff member to let them into apartments. The need to ensure residents were not locked out of their apartments and that those visiting the resident could access the resident when the resident requested they enter was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.