Touchmark at Mount Bachelor Village

The findings of the re-licensure survey, conducted 07/29/24 through 07/31/24, 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 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 revisit to the re-licensure survey of 07/31/24, conducted on 09/20/24, 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.

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire drill records from 12/2023 through 06/2024 were reviewed with Staff 1 (Health Services Director) on 07/30/24, and the following was identified:a. The facility lacked documentation fire drills were being conducted on alternating months. b. For fire drills which were completed between 12/2023 and 06/2024, the following required elements were not documented:* Escape route used; and * Evidence alternate routes were used during the fire drills.c. There was no documented evidence fire and life safety instruction for staff had been on alternate months.The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months and document all required elements was discussed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings.

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 C420.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 caregiving staff (#s 6, 8, and 13) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (Health Services Director) on 07/30/24 and 07/31/24.There was no documented evidence Staff 6 (CG), hired 06/04/24, Staff 8 (MA), hired 06/12/24, and Staff 13 (CG), hired 03/11/24, had demonstrated competency all job duties including:* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition; and* Conditions that require assessment, treatment, observation, and reporting.The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings.

The findings of the kitchen inspection, conducted 7/21/22 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 07/21/22, conducted 10/20/22, 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, record review and interview, it was determined the facility failed to maintained the kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 07/21/22 revealed:* Splatters, spills, drips, and debris noted on: - Shelving below the tray line; - Stainless steel shelves; - Food bins; - Dishwashing area; - Warming drawers and oven interior in the Memory Care kitchenette; and - Interior of the cupboards and drawers in the Memory Care kitchenette. * Damaged laminate on the shelving below the tray line creating an un-cleanable surface.* Undated, uncovered, and unlabeled food items were noted in the walk in refrigerator.* At 11:00 am, three plates of breakfast food were in the microwave in the Memory Care kitchenette.* Numerous dented cans were noted in the dry storage closet.* Scoops were left lying in bins of food.* Staff were observed with hair unrestrained.* There was no evidence the operation of the high temperature dish sanitizer was being monitored. The dish machine was observed to operate multiple times and inconsistently registered the required temperatures for sanitation. The repair company was immediately contacted. * Dish racks were stored directly on the floor in the dishwashing room.* A residential dishwasher was being used in the Memory Care kitchenette. Staff 1 (Administrator) was informed of the need to utilize the commercial dish machine based on the facility census. Staff 3 (Sous Chef) and the surveyor toured the main kitchen. Staff 3 acknowledged the above findings.Staff 1 and the surveyor toured the Memory Care kitchenette. Staff 1 acknowledged the findings.The areas in need of cleaning and repair, food storage concerns, and the need for hair to be restrained were reviewed with Staff 1 and Staff 2 (Dining Room Manager). They 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 C 240.

The findings of the re-licensure survey conducted 6/28/21 through 6/30/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 revisit to the re-licensure survey of 6/30/21, conducted 11/30/21 through 12/1/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

3. Resident 6's service plan, dated 6/16/21, failed to reflect the residents care needs and lacked specific instruction to staff regarding memory and cognition. After breakfast on 6/29/21, Resident 6 needed a reminder to where s/he was. The need to ensure service plans were reflective of resident care needs was discussed with Staff 1 (Health Services Coordinator) and Staff 3 (MC RN) on 6/30/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff for 3 of 6 sampled residents (#s 1, 2, and 6) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1's service plan, dated 4/12/21, failed to reflect the residents care needs and lacked specific instruction to staff in the following areas:* Finger foods;* Transfers and use of gait belt; * Cognition, memory and confusion; * Pain, including non-pharmaceutical interventions; and* Emergency evacuation ability. 2. Resident 2's service plan, date 5/30/21, failed to reflect the residents care needs and lacked specific instruction to staff in the following areas:* Shower refusals and interventions;* Cognition, memory and confusion; and* Ability to use the calls system. The need to ensure resident service plans were reflective of current care needs and provided specific instruction to staff was discussed with Staff 3 (MC Nurse Manager) on 6/29/21. She acknowledged the findings.

4. Resident 5's 6/20-6/28/21 MAR was reviewed and revealed more than one PRN bowel medication available to use without parameters of when and which medication to administer first.The lack of parameters was discussed with Staff 5 (ALF RN) on 6/29/21 who verified the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs contained reason for use, resident-specific parameters for PRN medications and clear instructions to staff for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3's 6/1/21 through 6/28/21 MAR was reviewed. Resident 3's MAR revealed multiple PRN bowel care medications that lacked parameters for use and clear instructions to staff. In an interview with Staff 2 (Nurse Manager) at 11:20 am on 6/29/21, she acknowledged the lack of parameters for PRN bowel care medications.The need to ensure there were clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (Health Services Director), Staff 2 and Staff 5 (AL/MC RN) on 6/30/21. They acknowledged the MARs were not accurate.
5. Resident 4's 6/1/21 through 6/28/21 MAR was reviewed. Resident 4's MAR identified multiple PRN bowel care medications that lacked parameters for use and clear instructions to staff on when to administer. In an interview with Staff 1 (Health Services Director) on 6/29/21, she acknowledged the lack of parameters for PRN bowel care medications.On 6/29/21, the need to ensure there were parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1, Staff 2 (Nurse Manager), and Staff 5 (AL/MC RN). They acknowledged the findings.
2. Resident 1's 6/1/21 through 6/28/21 MAR was reviewed on 6/29/21.The following medications lacked a reason for use: * Routine Estradiol (vaginal cream);* PRN Amlodipine (blood pressure medication); and * Aspercreme lidocaine patch 4% for pain. The following PRN medications lacked clear parameters for administration: * Docusate sodium for constipation.The need to ensure MARs were accurate and included reasons for use and clear parameters for PRN medication was discussed with Staff 3 (MC Nurse Manager) on 6/29/21. She acknowledged the findings. 3. Resident 2's 6/1/21 through 6/28/21 MAR was reviewed on 6/29/21.The following medications lacked a reason for use: * Risperidone (for behaviors);* Vitamin B12 (supplement); and* Vitamin D3 (supplement). The following PRN medications lacked clear parameters for administration: *Docusate and Polyethylene Glycol (to treat constipation) lacked clear parameters on when to administer one versus the other and in what order; * Meloxicam and Acetaminophen (for pain) lacked clear parameters on when to administer one versus the other; and * Guaifenesin and Mucinex (for cough and congestion) lacked clear parameters on when to administer one versus the other.The need to ensure MARs were accurate and included reasons for use and clear parameters for PRN medication was discussed with Staff 3 (MC Nurse Manager) on 6/29/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 veteran staff (#s 12 and 13) completed the minimum required 12 hours of annual in-service training. Findings include, but are not limited to:Facility training records were reviewed on 6/29/21 and revealed the following:* Staff 12 (CG) hired on 7/13/11 and Staff 13 (CG) hired on 3/12/09 did not have documented evidence of completing the required 12 hours of annual in-service training. The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (Health Services Director) on 6/30/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months. Findings include, but are not limited to:Fire and life safety records from 1/14/21 to 6/29/21 were reviewed and revealed fire and life safety instruction was not consistently provided to staff on alternating months.In an interview on 6/29/21 at 2:45 pm Staff 1 (Health Services Director) and Staff 6 (Assistant Executive Director) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months.

Based on observation and interview, it was determined the facility failed to ensure the door that exited to an interior courtyard was equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:On 6/28/21, observation of exit doors to an enclosed courtyard in the endorsed memory care failed to have an alarm or other acceptable system to alert staff when residents exited. On 6/28/21, the need to ensure doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Health Services Director). She 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 C 374, C 420 and C 555.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled direct care staff (#s 10 and 11) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:Training records were reviewed on 6/29/21. The following deficiencies were identified:* Staff 10 (CG) hired on 8/24/16 and Staff 11 (CG) hired on 2/27/20 did not have documented evidence of completing the required 16 hours of annual in-service training. The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (Health Services Director) on 6/30/21. She 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. This is a repeat citation. Findings include, but are not limited to:Refer to C 260 and C 310

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 3 of 3 sampled residents (#s 1, 2 and 6) whose service plans were reviewed. Findings include, but are not limited to:Resident's 1, 2 and 6's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 3 (MC Nurse Manager) on 6/29/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 6) whose records were reviewed. Findings include, but are not limited to:Though Resident 1, 2 and 6's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's: * Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. No individualized activities were observed during the survey. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 3 (MC Nurse Manager) on 6/29/21. She acknowledged the findings.

The findings of the Health and Safety Monitoring survey conducted 2/2/21 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. 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 re-visit to the Health and Safety Monitoring survey of 02/02/21 conducted 3/11/21 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Community Based Service Regulations.

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. Failure to follow infection control guidelines to prevent the spread of COVID-19 put residents in serious risk. Findings include, but are not limited to:During the Health and Safety Monitoring survey of the Residential Facility, conducted 2/2/21, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. At the time of the COVID-19 Infection control review, there were residents who had either tested positive for or were showing symptoms of COVID-19. Deficiencies that were identified included, but were not limited to:*Multiple staff engaged in conversation with residents with face shields on top of their head;*Multiple staff removed masks and shields to eat and drink in high traffic common areas;*Face shields were located on the third floor in the staff shift change room. Staff had to travel through the facility to the third floor to access their face shields; and*Staff wore their surgical masks home and reused them for their next shift the following day.During an interview on 2/2/21, the facilities failure to follow infection control practices were reviewed with Staff 1 (Assisted Living Administrator). She acknowledged the need for increased oversight of infection control practices in the facility.