Miramont Pointe

Based on interview and record review, conducted during a site visit on 06/10/24 and 06/11/24, it was confirmed the facility failed to review the initial service plan within 30 days of move-in for 2 of 2 sampled residents (#s 5 and 6). Findings include, but are not limited to:Resident 5's initial service plan was dated 07/13/23. Resident 5's next service plan was dated 09/04/23.Resident 6's initial service plan was dated 07/13/23. Resident 6's next service plan was dated 09/04/23.During an interview on 06/13/24, Staff 12 (Administrator) stated when the event occurred, they did not have a Resident Care Coordinator (RCC) and there was a lapse in the responsibility for service plans. The facility failed to review the initial service plan within 30 days of move-in.The findings were reviewed with and acknowledged by Staff 12 on 06/13/24.Verbal plan of correction: The facility now has two fully trained RCCs who are responsible for coordinating all service plan reviews.

Based on observation, interview and record review, conducted during a site visit on 06/10/24 and 06/11/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#1). Findings include, but are not limited to:During an observation and interview on 06/11/24, Resident 1 was observed to engage his/her call pendant. It took staff 13 minutes to respond to the call light.During the interview, Resident 1 stated s/he had been left on the toilet many times and it frequently took staff over 30 minutes to respond to call pendant and that meal times, staff breaks and shift changes were the worst.Resident 1's call light logs for August 2023 were requested, but were unavailable. Call light logs for 06/01/24 through 06/11/24 revealed 10 instances in which Resident 1 waited for more than 15 minutes for assistance. Three of those ten times were greater than 30 minutes.It was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings were reviewed with and acknowledged by Staff 12 (Administrator) on 06/13/24.Verbal plan of Correction: Resident Care Coordinators will run call light log reports for their respective residents no less than weekly. Administrator will review these weekly and follow up with residents and staff on how to reduce wait times.

The findings of the re-licensure survey, conducted 04/22/24 through 04/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 04/26/24, conducted on 10/30/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents due to staffing levels on the overnight shift. Findings include, but are not limited to:At survey entrance on 04/22/24, the facility had 14 residents who resided in the secured memory care unit on floor one of the building, and 125 residents who resided on floors two through eight, for a total of 149 residents on eight floors. During an interview on 04/23/24, Staff 1 (ED) stated the facility currently staffed the overnight shift as follows: * One CG for the locked memory care unit on floor one; * One CG for floors two through eight; and* One MT who floated between the locked memory care unit and floors two through eight. When the CG in the memory care unit took breaks, including a 30-minute lunch break, the float MT stayed in the memory care unit. This left only one staff member to assist 125 residents on floors two through eight. The facility had one resident who required two-person assistance for transfers and incontinence care, and did require assistance at night, as identified in his/her service plan. The resident resided on the second floor. The current staffing plan did not allow for his/her care needs to be met at all times. Additionally, when that resident did get care assistance, that meant no other staff was available to assist with any medication needs, provide additional memory care unit support, or address the needs of the other 124 residents on floors two through eight. When asked whether the current staffing plan allowed for safe evacuation of residents in the case of an emergency, Staff 1 stated they did not have any documentation of evacuation drills or documentation of how staff would ensure the health and safety of residents in the case of an emergency which required evacuation. On 04/25/24, the survey team requested two additional caregivers be added to the overnight shift for floors two through eight. The facility agreed, and provided documentation as to how they would meet this staffing plan. The need for the facility to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, especially as related to sufficient staffing on the overnight shift, was reviewed with Staff 1, Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/25/24. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's dementia.The resident's 03/01/24 through 04/22/24 MARs and physician's orders were reviewed and identified the following:Resident 6 had physician's orders:*03/06/24: Tylenol 325 mg, take 2 tabs (650 mg) four times a day, not to exceed 3,500 mg daily, and the order was changed as follows:*04/16/24: Tylenol 500 mg, take 2 tabs (1000mg) four times a day.A review of the MARs showed from 03/01/24 through 04/22/24 the resident was receiving Tylenol 500 mg, 2 tabs (1000 mg) four times a day for a total of 4,000 mg per day. Interviews with Staff 3 (Director of Nursing) and Staff 18 (RN) showed the MAR was inaccurate. The resident had been receiving Tylenol 325 mg - 2 tabs (650 mg) four times a day on 03/01/24 through 04/16/24 when the physician changed the order to Tylenol 500 mg (1000 mg) four times a day. Staff 3 and Staff 18 determined the order change had been entered into the electronic MAR system incorrectly on 04/16/24. The MAR did not reflect accurately the correct dosage had been administered 03/01/24 through 04/16/24.The need to ensure resident MARs were accurate was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/25/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate related to order transcription and order changes for 2 of 5 sampled residents (#s 2 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 09/2012 with diagnoses including bladder cancer and major depressive disorder.A review of Resident 2's 04/01/24 through 04/21/24 MAR, physician's orders, and Progress Notes dated 01/01/24 through 04/21/24 identified the following:A physician's order dated 04/03/24 stated, "Dermaseptin to buttocks area. After peri care at each brief change, apply dermaseptin [sic] cream to buttocks area. You do not need to completely remove previous layer of barrier cream as it is meant to build up a barrier to moisture over several applications."The order was incorrectly transcribed on the MAR as, " ...After peri care at each brief change, apply dermaseptin cream to buttocks area; remove the previous layer of barrier cream ..."The need to ensure MARs were accurate related to transcribed physician's orders was discussed with Staff 1 (ED), Staff 3 (Director of Nursing/RN) and Staff 21 (Quality Coordinator) on 04/26/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: On 04/23/24, the facility identified their current staffing level during the overnight shift to be: * One CG for the locked memory care unit on floor one; * One CG for floors two through eight; and* One MT who floated between the locked memory care unit and floors two through eight. This was not sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident and to ensure a minimum of two direct care staff were available at all times for a resident who required two person care assistance. The need to have a sufficient number of staff in each building to meet all scheduled and unscheduled needs of residents on the overnight shift, including a minimum of two direct care staff available at all times for a resident who required two direct care staff, was discussed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing) on 04/24/24 and 04/25/25. They acknowledged the findings. Refer to C 160.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) to specify the total number of minutes required to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: The ABST was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/23/24 and 04/24/24. The facility had a census of 149 residents when the survey team entered on 04/22/24. The facility consisted of two segregated areas:* Floor one, a secured memory care unit with 14 residents; and * Floors two through eight with 125 residents. During the acuity interview on 04/22/24, staff identified one resident on floors two through eight who required two direct care staff to assist him/her. Residents on floors four through eight would need to descend stairs to evacuate the facility in the case of an emergency event in which the elevators would be inoperable. During an interview on 04/25/24, Staff 1 and Staff 2 stated they were not currently accounting for evacuation needs, an unscheduled need, on the ABST. The current ABST did not account for staffing two segregated areas and having two direct care staff available at all times for residents who required two direct care to assist them. The need to ensure the ABST specified the total number of minutes required to the meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 and Staff 3 on 04/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written fire drill records were kept that included all required information per the Oregon Fire Code (OFC) and have documented evidence fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:On 04/25/24, fire and life safety records dated 12/12/23 through 03/13/24 were reviewed. Fire drill documentation did not include one or more of the following required elements:* Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drill; * Evacuation time-period needed; and* Number of occupants evacuated.Documentation of fire and life safety training for staff was provided, however the documentation did not include information on the date of the training and staff members who attended or participated in the training.The need to ensure fire drill documentation included required components and documented evidence staff training was completed on alternating months was discussed with Staff 1 (ED), Staff 2 (Regional Director Health Services/RN), Staff 6 (Maintenance Director), and Staff 23 (Maintenance Assistant) on 04/25/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the design of an RCF emphasized a residential appearance while retaining the features required to support special resident needs relating to handrails installed on one or both sides of resident-use corridors. Findings include, but are not limited to:During a tour of the RCF on 04/23/24 at 09:20 am the following was identified:Approximately 40 feet of corridor on the third floor separating the swimming pool on one side, and the beauty salon on the other side, did not include handrails on either side of the corridor. The need to ensure handrails were installed on one or both sides of resident-use corridors was discussed with Staff 1 (Executive Director) on 04/25/24. He acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:During a tour of the facility on 04/23/24 at 9:20 am, the following was identified:a. Common areas in the RCF portion of the facility: * Handrails throughout the facility were worn and had exposed wood, especially on the fourth floor; * Dust was accumulated on the wall behind the dryers in the laundry rooms on the fourth, fifth, and six floors; * Numerous fluorescent light fixtures in the facility stairwells were lacking fixture covers; * Gap in drywall under the air duct in the commercial laundry room; and * Numerous ceiling vent grates were covered with dust.b. Dining area in MCC part of the building: * Various light fixtures with dead bugs inside; * Finish on wood around dishwasher worn off; and * Worn and damaged cabinet frames and doors and missing drawers in the kitchen island cabinets.c. Building Exterior: * The area outside the trash dumpster contained old furniture, appliances, and other discarded items; * The exterior building wall near the trash dumpster had a large, L-shaped hole; * The meditation garden area dirty with rusty firepit and old, soiled furniture; * Third-floor patio grill and grill grates dirty, rusted, and covered with baked-on grease; and * Pan with collected grease on ground next to grill on patio. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) and Staff 6 (Maintenance Director) on 04/23/24, 04/24/24, and 04/25/24. They acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility. Findings include, but are not limited to:The building was toured on 04/23/24 at 09:20 am. Observations and interviews with staff confirmed RCF residents were able to exit the facility from a door on the second floor adjacent to the elevator and which led to an employee entrance. The route did not have a functioning alarm or other system to alert staff when residents exited the building. In the MCC portion of the facility, two doors leading from the dining area to the secured courtyard were observed without a functioning alarm system to alert staff when a resident exited the building into the courtyard. On 04/25/24, Staff 1 (Executive Director) demonstrated a temporary system installed on 04/24/24 in the MCC dining area that included audible door chimes, although the chimes were not loud enough to be widely audible. During the survey, staff ordered a pager-based door alarm system to be installed as a replacement. The need to ensure the facility had an alarm or other acceptable system to alert staff when residents exited the RCF and MCC was discussed with Staff 1 and Staff 2 (Regional Director of Health Services/RN) on 04/25/24. They acknowledged the findings. No further information was provided.

Concerns were identified and the facility was provided with technical assistance in the following area:H 1515: OAR 411-004-0020 (2) Physical Setting: Individual Accessible (b) The setting is physically accessible to an individual.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 160, C 360, C 361, C 420, C 511, C 513, C 555.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 9, 11, 12 and 22) completed all required pre-service orientation and dementia training topics; 3 of 3 newly-hired direct care staff (#s 9, 11 and 12) completed all additional pre-service dementia training topics; and 2 of 2 long term non-care staff (#s 5 and 24) completed annual infectious disease training. Findings include, but are not limited to:Staff training records were reviewed on 04/23/24 through 04/25/24. 1. There was no documented evidence Staff 11 (MT), hired 12/24/23, Staff 12 (CG), hired 03/04/24, Staff 9 (CG), hired 03/11/24 and Staff 22 (Housekeeping Assistant), hired 03/04/24, completed one or more of the following pre-service orientation and dementia training topics:* Infectious Disease Prevention;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach.2. There was no documented evidence Staff 9, Staff 11 and Staff 12 completed one or more of the following pre-service dementia training topics required of direct care staff:* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and* Use of supportive devices with restraining qualities in memory care communities.3. There was no documented evidence Staff 5 (Activities Director), hired 07/12/21, and Staff 24 (Assistant Chef), hired 06/04/14, completed the required annual infectious disease training. The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules was discussed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN), Staff 3 (Director of Nursing/RN), Staff 19 (RCC) and Staff 21 (Quality Coordinator) on 04/25/24. They acknowledged the findings.

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

Based on observation and interview, it was determined the facility failed to ensure access to secured outdoor space and walkways allowed residents to enter and return without staff assistance. Findings include, but are not limited to:During a tour of the RCF on 04/23/24 at 09:20 am the following was identified:In the MCC portion of the facility, two doors leading from the dining area to the secured courtyard were observed to be difficult for residents to open from the courtyard side, requiring the assistance of staff to allow residents to return to the dining area.The need to ensure access to secured outdoor space and walkways allowed residents to enter and return without staff assistance was discussed with Staff 6 (Maintenance Director) on 04/23/24 and Staff 1 (Executive Director) on 04/25/24. They acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, and outdoor furniture was of sufficient weight, stability, and design not to aid in elopement. Findings include, but are not limited to:During a tour of the RCF on 04/23/24 at 09:20 am the following was identified:The fence surrounding the secured courtyard was missing one board and had numerous other smaller gaps, the gate separating the secured courtyard from the exterior area was only five feet, eight inches high, and the secured courtyard contained various chairs that could aid in resident elopement. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, and outdoor furniture was of sufficient weight, stability, and design not to aid in elopement was discussed with Staff 6 (Maintenance Director) on 04/23/24, and Staff 1 (Executive Director) and Staff 2 (Regional Director of Health Services, RN) on 04/24/24 and 04/25/24. They acknowledged the findings. No further information was provided.

The findings of the kitchen inspection, conducted 10/19/23, 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 Service - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 10/19/23, conducted 12/28/23, 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 second revisit to the kitchen inspection of 10/19/23, conducted 03/29/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practice and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 10/19/23 at 11:00 am, the facility kitchen was observed and the following areas were in need of cleaning: a. Food spills, splatters, debris, dust and/or black matter were observed on or underneath the following: * The outside of food bin containers holding oatmeal, panko, flour, rice, powdered sugar and brown sugar; * The lower shelves throughout the entire kitchen, areas included the steam table, prep counters, Hobart mixer, shelf with large cooking pans and tubs, counter holding blender and waffle maker;* The ceiling and vent in the area near the dishwashing room; * The ceiling vent outside of dry storage; * The wall above the dish racks;* The wall behind the spray nozzle in the dishwashing room; * The walls beneath dishwashing counter; * Fan in dishwashing room;* The flooring throughout entire kitchen; * The equipment throughout the kitchen including refrigerators on the service line, ice machine, deep fat fryer, drawer refrigerator, hot box, stove, grill, steamer and convection oven;* The interior of refrigerators on the service line; * The walls behind the stove/grill and the stand alone freezers; and* The fan on wall in the dishwashing room.b. Cutting boards on service line refrigerators had gouges and dark matter build up, creating uncleanable surfaces.c. Missing cove base tiles in the area of the dishwashing room and chemical storage area were in need of repair. d. Improper food storage included: * An open box of blueberries garden burgers in the freezer and an uncovered pan of unidentified food product; * Dry storage: scoops/cups were in bins of panko crumbs, flour, rice; and* Two tubs of ice cream were uncovered in the freezer in the beverage station area. The areas of concern were discussed with Staff 1 (Executive Director) and Staff 2 (Culinary Director) on 10/19/23. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:The kitchen was toured on 12/28/23 at 12:44 pm.a. Food spills, splatters, debris, dust and/or black matter were observed on or underneath the following: * Hobart mixer including cart and equipment in the bin that was stored on the shelf underneath the mixer;* Shelf underneath the prep table where the cutting boards were stored;* The meat slicer and stainless steel cart; and * Multiple service carts were not cleaned and sanitized after use. b. The following areas required repair:* The ceiling and vent in the area near the dishwashing room was discolored brown and the vent was falling down;* The ceiling vent outside of the dry storage was discolored brown; * The wall behind the sink with a spray nozzle in the dishwashing room, the walls above and beneath the dishwashing counter had black and brown matter buildup;* Multiple small holes in the wall above the spray nozzle sink, dishwashing area and the wall above the hand wash sink in the dishwashing area;* Multiple areas of broken tile, including cove base tiles and missing grout around the cove base tiles;* Cutting boards on the service line above the salad refrigerator and chef refrigerator had gouges and dark matter build up, creating uncleanable surfaces; and* The hand wash sink (located at the entrance of the kitchen and in between a food warmer and a prep table that housed the waffle maker) didn't have a splash guard. c. Improper food storage included: * Open bag of garden burgers, pepperoni and a box of open biscuits in the walk-in freezer;* Open bag of cranberries and leftover chili in the walk-in refrigerator;* Multiple food products in the walk-in refrigerator and the salad line refrigerator were not labeled and dated, including onions, mixed fresh cut vegetables, fresh cut cucumbers, breakfast patties and links, shredded hashbrowns, and an unidentified sauce mixture;* Scoops/cups were in bins of sugar; and* Open packages of chocolate chips, coconut flakes, pancake mix, rice and potato chips. The kitchen was toured and the areas requiring cleaning or repair was discussed with Staff 1 (ED), Staff 2 (Dining Services Director) and Staff 3 (Dining Room Supervisor) on 12/28/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C240 and Z142.

Based on observation 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 C 240.

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

The findings of the on-site investigation, conducted 06/14/22 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, during a site visit conducted on 06/14/23, it was confirmed that the facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (# 2). Findings include, but not limited to:During an interview on 06/13/23 Staff 1 (Executive Director) stated, he completed a "grievance form" form when the money was reported stolen. He stated this was not what the facility typically used to investigate abuse or neglect. The facility reported that matter to the police, but did not report to APS. He felt it was "too murky" to consider it as abuse or neglect and warrant an investigation because the resident had left the facility with their purse for outside appointments. Staff 1 explained they have a process in Service Minder (care-planning platform) called risk management for abuse and neglect investigations. He stated they interviewed staff, family, and Resident 2 but did not document the interviews.No documentation of an investigation was provided by the facility other than a grievance form dated 02/15/23. The bottom of the form had instructions to "Attach investigative process, copies of in services held and attendance sheet" though no attachments were included.The findings were reviewed with and acknowledged by Staff 1 on 06/14/23. The facility failed to promptly investigate a report of stolen property of abuse and suspected abuse, and take measures necessary to protect residents and prevent the reoccurrence. Verbal plan of correction: A copy of the ODHS abuse investigation and reporting guide was provided by email on 06/15/23. Staff 1 and Staff 2 (Director of Nursing) to review and will investigate and document investigations for any claims of financial abuse and exploitation in addition to their normal risk management form or other forms of alleged abuse and neglect.

Based on observation, interview and record review, during a site visit conducted on 06/14/23, it was confirmed the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents for 1 of 1 sampled resident (#3). Findings include, but not limited to:During an observation and interview, Resident 3 engaged their call light at 12:38 pm. A caregiver responded to the call light at 1:00 pm (22 minutes) and assisted Resident 3 to the bathroom.During the interview on 06/14/23, Resident 3 stated s/he regularly has to wait a very long time for help from a caregiver, sometimes up to 45 minutes. Resident 3 thinks his/her bladder infections are caused by having to hold urine for so long while waiting to get assistance. S/he further stated, it is really stressful when s/he has to wait, and weekends are the worst time for staffing related to the the facility being short-staffed. S/he reported sometimes they have to call the front desk to get someone to help.During interviews on 06/14/23, Staff 4 (caregiver), Staff 5 (LPN) and Staff 6 (Medication Technician) stated call lights should be responded to within 15 minutes. Staff 4, Staff 5 and Staff 6 all stated "there is not enough staff to meet resident needs sometimes", especially if there are multiple residents using their call lights at the same time.Resident 3's call light logs for 05/15/23 through 06/14/23 revealed 36 occasions when Resident 3 waited longer than 15 minutes for a response to his/her call light. Ten of those occasions were longer than 45 minutes.The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 06/14/23.The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Verbal plan of correction: Staff 1 to review call light logs weekly and discuss in the health services meeting. S/he will review the ABST process with the home office to develop a consistent staffing process. The facility was currently undergoing a transition with the staffing coordinator who stepped down. The facility was actively recruiting for two staffing coordinators and direct care staff.

Based on interview and record review, during a site visit conducted on 06/14/23, it was confirmed that the facility failed to implement an Acuity-Based Staffing Tool (ABST). Findings include, but not limited to:During interviews on 06/14/23, Staff 1 (Executive Director), Staff 2 (Director of Nursing), and Staff 3 (Quality Care Coordinator) stated their care-planning platform, Service-Minder tool had their ABST built-in. The document used was called "Summary by Provider". They entered the residents data into the tool to generate how many hours of care was needed per day to figure out the facilities staffing plan. The process was completed once a month. If a resident had a service plan change, it would be reflected immediately in the summary by the provider, but not on the ABST. If residents had changes of conditions that required service plans updates and increased level of care, they stated they would discuss that in the morning meeting, and Staff 3 would update the schedule for the week. A review of the May 2023 ABST documents provided lacked residents' names. The Compliance Specialist requested the ABST for June 2023 or any current ABST documentation. Staff 1 was unable to provide documentation of the June 2023 ABST, as it had not yet been completed, and would not be until July 2023. The facility was unable to provide documentation of their ABST review process for new move-ins, updates with service planning or changes of conditions. There was no documented evidence the facility changed their staffing plan to reflect resident care needs. The finding were reviewed with and acknowledged by Staff 1 on 06/14/23.The facility failed to fully implement an ABST.Verbal plan of correction: Staff 1 will contact the home office for regarding the facilities ABST and staffing. Until that time, they will review their "summary by provider" report and staffing schedule in daily health services meeting and document the review for new move-ins, changes in service planning/care needs, and changes of conditions, and implications for staffing needs.

The findings of the kitchen inspection conducted on 9/20/2022, are documented in the this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities fro Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection survey of 09/20/22, conducted 11/16/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure food preparation and service, storage, and dish machine temperatures were in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:On 9/20/2022, between 10:35 am to 12:10 pm, the following areas of concerns were observed in the kitchen:*The powdered sugar container had a paper cup in it and a container of brown rice was open without anything covering it.* Five containers of cold cereal were stored with paper cups in them. In the same area a container of brown sugar had a scoop in it and was uncovered, a container of raisins was also uncovered. The area was a high traffic area for kitchen staff. * At 10:45 am and 12:00 noon, the reach in refrigerator within the kitchen, which had access to the dining room staff had a temperature of 52.5 degrees F and 56.5 degrees F respectively. During observations the refrigerator indicated it was in a defrost cycle. Kitchen staff had documented the "closing check" temperatures on the temperature log 9/19, 9/18 and 9/17/2022 as 64 degrees F, 61 degrees F and 62.5 degrees F. Morning temperatures were less than 41 degrees F. Staff 1 (Executive Director), Staff 2 (Dining Room Supervisor) and Staff 3 (Kitchen Supervisor) were advised of findings and will address with maintenance staff immediately. Staff 2 indicated the rolling carts in the refrigerator were moved into the walk in refrigerator every night. * Pork loin was observed in a container of cold water, the faucet was not running cold water at the time of the observation. Staff 3 stated the water had been running previously. * Breakfast food items were observed in the steam table during the inspection, per Staff 3 breakfast was served from 8:00 am to 12:00 noon daily. Sausage patties were observed on the counter in a steam pan, food prep staff stated patties and the food in steam table would be disposed of and not served again. Diced chicken in a container being prepped for a lunch salad was not being held in an ice bath to keep chilled. * The dishwashing machine had a data plate indicating both high and low temperatures for its usage. Observed temperatures included wash at 147 degrees F and rinse at 168 degrees F. Staff 1, 2 and 3 were advised of the situation. * Dishwashing staff was observed to handle clean dishes without handwashing or rinsing after handling soiled dishes.*Walls by and above the three compartment sink in the dishwashing room had food drips/splatter. * A fan operating above the clean dish area had significant accumulation of dust. The top shelf of a rack in the dish room had significant accumulation of dust.* The floor under the stove and range top had buildup of black matter/grease. The above areas of concern were discussed with Staff 1, Staff 2 and Staff 3. The findings were acknowledged.

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

Based on interview and record review it was confirmed that the facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident. Findings include but not limited to:During an unannounced site visit on 6/23/22, Staff #3 (S3) indicated that Resident #3 (R3) was left on the toilet for 30 minutes which caused her pain on 8/29/2021.Compliance Specialist (CS) requested and reviewed all incident reports dated 7/21/2021 through 6/12/2022 related to R3 and an incident report for the above incident was not included. The facility was unable to produce an incident report for this event and could not confirm that an investigation of this event had been completed and was not self-reported to Adult Protective Services (APS).These findings were reviewed with and acknowledged by Staff #1-#3 (S1-S3)Facility Plan of Correction: Review of Abuse reporting guide by Executive Director and Resident Care Coordinators. Facility will report any incidences involving medication errors, injuries of unknown origin to Adult Protective Services for them to rule out abuse/neglect in addition to conducting their own investigations in both RCF and endorsed memory care unit.

The findings of the re-licensure survey conducted 7/6/21 through 7/7/21 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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
The findings of the first re-visit to the re-licensure survey of 7/7/21, conducted 10/27/21 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 07/07/21, conducted 01/12/22, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation that reasonably concluded and documented a physical injury of unknown cause was not the result of abuse or neglect, for 1 of 1 sampled resident (#1) with documented injuries of unknown cause. Findings include, but are not limited to:Resident 1 resided in the Memory Care Community and had diagnoses which included dementia. The record indicated Resident 1 was discovered to have three injuries for which the resident was unable to tell staff how they occurred:* 5/8/21: two abrasions on the left upper shin just below the knee;* 5/28/21: a scratch on the right side of the neck; and* 6/30/21: a skin tear on the left upper shin just below the knee.The facility did not complete the investigations until between four and seven days after the injuries were identified - these were not considered "immediate" investigations.The need to conduct more timely investigations of injuries of unknown cause was discussed with Staff 5 (RCC) on 7/7/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an incident of suspected abuse was immediately reported to the local SPD office for 1 of 1 sampled resident (# 10) reviewed with a resident to resident verbal altercation. This is a repeat citation. Findings include, but are not limited to:During the acuity interview on 10/27/21, Resident 10 was identified to be involved in a resident to resident verbal altercation.Review of Resident 10's record revealed the following:* An incident report dated 10/06/21 identified Resident 10 was upset with another resident attempting to get into his/her apartment. The residents were separated. Later in the day that same resident was found trying to open Resident 10's apartment door. Resident 10 engaged in a verbal altercation with the resident and attempted to throw a punch but made no physical contact. The residents were separated and escorted to separate activities. Resident 10 was placed on alert charting and interventions were developed; however, there was no documented evidence the incident had been reported to the SPD office. During an interview on 10/27/21 with Staff 1(ED), he stated he had not reported the incident to the SPD office . The surveyor requested the incident be reported to the local SPD office. The surveyor received confirmation of the report to the SPD office on 10/27/21.The need to ensure resident to resident verbal altercations were investigated and reported to the local SPD office as appropriate was discussed with Staff 1(ED), Staff 3 (Quality Coordinator), Staff 4 (RCC) and Staff 5 (RCC) on 10/27/21. They acknowledged the findings.
Additional training provided to all staff members at an all staff meeting on November 16, 2021. In this training the abuse reporting requirements were reviewed and acknowledged by staff. We have provided copies of the abuse reporting requirements to all staff. Any allegations of abuse will be brought to the attention of the supervisor, Executive Director and Director of Nursing (as needed). The allegation will be reported to APS as required by rule. An internal investigation will be done by the executive staff. This abuse reporting will be reviewed for all newly hired employees upon hire, and at least anually for all existing staff members. The Executive Director will be responsible for the completion and monitoring of this requirement.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 4 sampled residents (#3) who received home health or hospice services. Findings include, but are not limited to:Resident 3 was admitted to the Memory Care Community in March 2021 with diagnoses including Parkinson's disease. The record revealed the following: *On 6/16/21 the resident was sent to the emergency department for a fall with hip dislocation, HH, OT and HH, PT were ordered;*On 6/20/21 the resident was sent to the emergency department for symptoms related to the 6/16/21 fall, HH, OT and HH, PT were ordered; and*On 6/23/21 the resident was sent to the emergency department for a fall with head injury. During an interview on 7/6/21, Staff 5 (RCC) revealed the recommended services had not been started, and that there was no documented evidence of contact to coordinate with the outside providers. At the time of survey, Resident 3 was not receiving HH, OT or HH, PT. The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1 (Executive Director), Staff 2 (Director Of Nursing /RN), Staff 4 (RCC), and Staff 5 (RCC) on 7/7/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 1 sampled resident (# 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed. Findings include, but are not limited to:Resident 4 was admitted to the facility in November 2016. The resident's current physician orders directed staff to administer Xanax 0.25 mg every 8 hours as needed for severe anxiety and Tramadol 50 mg every 6 hours as needed for severe pain.Resident 4's Controlled Substance Disposition logs and MARS were reviewed from 6/1/21 - 7/6/21. The following deficiencies were identified:* On 6/19/21, Xanax 0.25 mg was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR;*On two occasions, 6/21/21 and 6/22/21, Xanax 0.25 mg was documented as being removed from storage on the disposition log at 6:41 am and 6:45 am, but it was documented as being administered on the MAR at 8:42 am, two hours after being dispositioned and at 1:04 pm, 6 hours 19 minutes after being dispositioned;* On 6/21/21, Tramadol 50 mg was documented as being removed from storage on the disposition log at 6:41 am, but it was documented as being administered at 8:42 am on the MAR, two hours after being dispositioned; and * On 6/27/21, Tramadol 50 mg was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 7/7/21 with Staff 1 (Executive Director) and Staff 3 (Quality Coordinator). The staff reviewed the documentation and acknowledged the discrepancies.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications, for 2 of 4 sampled residents (#s 6 and 7) who administered their own medications. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 2019 with diagnoses including cancer with metastasis and kidney failure.The service plan indicated Resident 6 administered their own medications, however, the 4/20/21 self-medication evaluation did not include information to determine the resident's ability to safely self administer medication. The resident's 6/1/21 through 6/30/21 MARs indicated Resident 6 was self administering all medications, including prn morphine (narcotic pain medication), prn Lorazepam (psychotropic medication), and other scheduled prescription medications. The need to complete evaluations of a resident's ability to self administer medications at least quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Quality Coordinator), Staff 4 (RCC) on 7/7/21. They acknowledged the findings.
2. Resident 7 was admitted to the facility in March 2018 with diagnoses including hyperlipidemia.The resident's 6/1/21 through 6/30/21 MARs and physician communications from 5/13/21 indicated the resident had an order for Atorvastatin. The order indicated the resident could self administer this medication.The 5/28/21 self-medication evaluation did not accurately reflect the resident's ability to self administer this medication. In an interview on 7/6/21, Staff 5 (RCC) indicated she had not complete the evaluation of the resident's ability to self administer medications thoroughly.The need to complete evaluations of a resident's ability to self administer medications at least quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Quality Coordinator), Staff 4 (RCC) and Staff 5, on 7/7/21. They acknowledged the findings.

Based on 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 231.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair and courtyard pathway edges did not contain drop offs to prevent tripping hazards for residents. Findings include, but are not limited to:The facility's outdoor courtyard/patio area was toured with Staff 8 (Maintenance Director) on 7/7/21. Drop off's, up to three inches in depth, were observed along both sides of the cement pathway edges creating a possible trip hazard to residents.The need to ensure all exterior pathways were maintained in good repair was discussed with Staff 1 (Executive Director) and Staff 8 on 7/7/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident was maintained in clean and good repair. Findings include, but are not limited to:The facility was toured on 7/7/21. The following areas needed cleaning and/or repair:a. General common use areas:*The two common use elevators had chipped or missing floor tiles, chipped and gouged wall paneling with exposed wood material and the electrical panels had cracked floor selection buttons and the floor selections were not legible;*Multiple stairway exit doors throughout the facility had chipped paint, scuffs and gouges; *The entrance/exit doors and multiple storage room doors on the memory care unit had chipped paint, scuffs, gouges, and discoloration;*The stairwell between the seventh and eight floor had a musty odor and the floor, ceiling and walls had discolored areas related to a previous roof leak;*Tables and the refrigerator in the seventh floor lounge had gouged and chipped wood or paint; and*A hallway bench on the fifth floor and a chair in the lounge on the seventh floor had ripped and torn upholstery.b. The second floor:*Carpet throughout the common use hallway was discolored and stained with areas of fraying and broken flooring transition materials;*The floor in the dining room, near the piano, had deep scratches and gouges;*Multiple table bases in the dining room had a buildup of dirt/dust and food debris;*Multiple table bases were in disrepair and had folded napkins or paper towels placed under the base's legs;*The kitchenette's island and cabinets had broken or missing wood paneling along the lower edges;*The stove in the kitchenette was missing the bottom paneling;*The doors and walls in the food prep area had chipped paint, scuffs and gouges;*The interior of the cabinet under the juice machine had large cracks on the bottom shelving and the cabinet was cluttered with miscellaneous trash, clothing, and linen items;*The floor and drain under a cabinet had a buildup of dirt/dust and food debris;*The perimeter of the floor in the food prep area had a buildup of dirt/dust and food debris; and*The bottom edge of the refrigerator and floor under and around the refrigerator had a buildup of thick dirt/dust and food debris.The need to ensure the facility was maintained in clean and good repair was discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director) on 7/7/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:The following observations were made on 7/7/21:The windows at the end of the hallway on the second floor, in the lounge on the seventh floor, in room 704, and room 705 had window sill heights lower than 36 inches. The windows opened to the full window height and were not designed to prevent accidental falls.During an interview on 7/7/21, with Staff 1 (Executive Director) and Staff 8 (Maintenance Director) they stated only the windows on the first floor memory care unit had stopping mechanisms to prevent the windows from fully opening. All other windows in the facility did not have these stopping mechanisms installed to prevent accidental falls.The need to ensure windows above the first floor were designed to prevent accidental falls was discussed with Staff 1 and Staff 8 on 7/7/21. They acknowledged the findings.

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 7/7/21, showed exit doors in the main lobby, main dining room, memory care dining room and the second floor dining room did not have an alarm or other acceptable system to alert staff when residents exited the building.During an interview on 7/7/21 Staff 1 stated the facility did have alarms on several exit doors but not all alarms were working.The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Executive Director) on 7/7/21. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C231, C510, C513, C515 and C555.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 231.

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C290, C302 and C325.

Based on observation, interview and record review, it was determined the facility failed to evaluate each Memory Care Community resident for activities and develop an individualized activity plan for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to:There were 13 residents who were diagnosed with dementia who resided in the MCC at the time of the survey. The residents' ability to participate in the activities that were offered on the unit during the survey varied. Some residents stayed in their rooms and did not participate in any scheduled activities while others joined group activities but needed some degree of assistance to understand and participate in the activities.The activity information that was documented and included in Resident 1 and 2's service plans consisted of a list of activities the residents currently enjoyed or enjoyed in the past. There was no documentation the following areas had been evaluated:* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions.The facility had not developed an individualized activity plan for either resident based on a comprehensive activity evaluation.This surveyor met with Staff 7 (Activity Assistant) on 7/7/21 and asked her to explain the current status of activity evaluations and activity plans for the residents in the MCC. Staff 7 reported that several months ago the facility acquired a number of new activity evaluation forms. She showed the surveyor the various forms and they appeared to address the information noted as lacking above. However, Staff 7 reported the activity staff had not yet completed comprehensive evaluations of each resident using the new forms. She also reported that she did not develop written activity plans for the residents and had not contributed to the activity information included in the residents' current service plans. She acknowledged the facility needed to complete an evaluation of each resident using all the new forms and then develop a plan as to who would be responsible for developing a written activity plan for each resident.The above information was discussed with Staff 5 (RCC) on 7/7/21. She indicated she agreed that the MCC residents hadn't been fully evaluated and the facility hadn't developed a written activity plan for each resident based on the information gathered in the evaluation.