Hazelwood Enhanced Memory Care

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

Findings include, but are not limited to:

On 06/24/25 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas:

* Hood vents above cooking equipment – greasy/dusty;

* Shelf above cooking equipment – significant build up of grease/dust/debris;

* Stainless steel wall attached to stove/grill – build up of grease;

* Oven doors/side of oven – drips/spills of food/grease;

* Upper cabinet interiors near stove – food/spice debris on shelving;

* Lower cabinet interiors and exteriors near stove – food debris/dust, food drips/spills;

* Corner cabinet interior near coffee maker – brown sugar debris on shelving;

* Center island exterior cabinet doors and end of island – spills/drips/splatters;

* Large drawer near service window to dining room interior and cabinet below – build of debris; and

* Housing of commercial can opener – build up of black matter.

Other areas of concern included:

* Commercial can open blade – finish worn off;

* Garbage cans uncovered when not in use;

* Window screen above sink – not secure with build up of dust creating potential for flies and dust to enter kitchen;

* Lack of small diameter thermometer;

* Improper food storage:

- Refrigerator and freezer food items not securely closed, labeled and/or dated – waffles, feta cheese and multiple unidentified leftovers: and

- Dry storage – fresh produce and bulk bags of sugar on floor, unknown food item not labeled or dated when opened.

The areas of concern were observed and discussed with Staff 1 and (Cooks/kitchen staff) and discussed with Staff 2 (Life Enrichment Director) on 06/24/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on 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 C240.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

The findings of the change in ownership survey, conducted 02/05/24 through 02/08/24, 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 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 revisit to the change of ownership survey of 02/08/24, conducted on 05/30/24, are documented in this report. The survey was conducted to determine 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.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 revisit to the change of ownership survey of 02/08/24, conducted on 07/18/24, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation, and food service on 02/05/24, between 9:10 am and 12:50 pm, revealed the following:* Upper cabinet doors to the left of the stove had brown matter around the cabinet pulls;* Multiple cabinet shelves had chipped paint, creating an uncleanable surface;* The stainless steel backsplash of the stove had grease/food splatter;* There were no test strips available to staff to use for the sanitizing buckets;* Opened/undated food items were observed in the cabinetry; and* Scoops were observed in the sugar and cereal bins.The areas in need of cleaning and repair were reviewed with Staff 1 (ED) on 02/06/24 at 2:20 pm. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services, included a written description of who should provide the services and what, when, how, and how often the services should be provided for 3 of 6 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia, depression, and mild cognitive impairment.Observations of the resident, staff interviews, and review of the service plan, dated 01/28/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:* How the resident exhibited agitation;* Interventions to redirect when becoming agitated; * The resident's routine relating to carrying a book and having his/her hat on; and * Shower routine. Resident 3 was observed wearing a hat each day during the survey. Observations were made of the resident when an unsampled resident attempted to touch him/her. The resident shook his/her head and stated, "No." When Resident 3 attempted to return to his/her unit, the unsampled resident tried to follow. Staff intervened and redirected the unsampled resident.The need to ensure service plans were reflective of the residents' status and included clear instructions for staff for providing care and services was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24. They acknowledged the findings.2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's, dementia with behavioral disturbance, depression, and post traumatic stress disorder.Observations of the resident, staff interviews, and review of the service plan, dated 01/28/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:* Cueing for activities;* How the resident exhibits anxiety and agitation;* The use of a psychotropic;* Mobility device;* Trust-building with the resident;* Toileting assistance needed;* Usual daytime clothing, including the resident's routine relating to wearing a mask, carrying a word find book, and having his/her hat on;* Shower routine;* Housekeeping routine; and* Laundry routine.Resident 4 was observed wearing a medical grade mask during different times of the survey. Staff 2 (Administrator) verified the resident making statements of having "COVID since 1970" and the preference to wear a mask at times.The need to ensure service plans were reflective of the residents' status, and included clear instructions for staff for providing care and services was discussed with Staff 1 (ED) and Staff 2 on 02/08/24. They acknowledged the findings.
3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including advanced dementia and failure to thrive.Observations of the resident, staff interviews, and review of the service plan, date 11/10/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:* Vocalization with ADL cares;* Repositioning assistance;* Toileting assistance;* Dressing assistance;* Alternating pressure mattress use; and* Hospice.The need to ensure service plans were reflective of the residents' status and included clear instructions for staff for providing care and services was discussed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.

4. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia, hypertension, and mild cognitive impairment.The resident's 01/01/24 through 02/05/24 MARs and physician's orders were reviewed. The following inaccuracy was identified:* The resident had a physician's order for metoprolol (for high blood pressure). There were no parameters for the staff to hold the medication relating to the blood pressure readings.The need to ensure MARs were accurate and included clear parameters for staff was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24. They acknowledged the findings.5. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's, dementia with behavioral disturbance, and hypertension.The resident's 01/01/24 through 02/05/24 MARs, physician's orders, and progress notes, dated 12/10/23 through 02/04/24, were reviewed. The following inaccuracies were identified:* Resident 4 returned from the hospital on 01/11/24 with the following new medications: - Atorvastatin (for lowering cholesterol); - Donepezil (for agitation and dementia); - Fluticasone-Salmeterol (for asthma); and - Olanzapine (for agitation/clear thoughts).Progress notes dated 01/11/24 through 01/15/24 reflected the resident did not receive the above medications due to the facility not having them to administer.Staff initialed the MAR, documenting the medications had been administered on 01/11/24, 01/13/24, 01/14/24, and 01/15/24.* Physician's orders directed staff to hold the metoprolol (for heart failure) for "systolic [blood pressure] less than 110 or heart rate less than 55."The parameters were not transcribed on the resident's MAR.The need to ensure MARs were accurate and included clear parameters for staff was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/08/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for 4 of 6 sampled residents (#s 2, 3, 4, and 5) and contained reasons for use for 3 of 6 sampled residents (#s 1, 2, and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease. Resident 2's signed physicians orders, dated 12/12/23, and MARs were reviewed from 01/01/24 through 02/05/24, and the following was noted:a. Resident 2 had a physician's order for PRN acetaminophen 325 mg every six hours as needed for pain. There was also an order for morphine sulfate 20 mg/ml SOLN 0.25 ml (5 mg) by mouth or under tongue every 15 minutes as needed for pain.There were no resident-specific parameters regarding which PRN should be used first.In an interview with Staff 4 (MA) on 02/07/24, at 10:15 am, it was confirmed that the electronic MAR did not contain any additional information for staff as to which PRN pain medication to use first.b. Multiple medications on the MAR lacked a reason for use.On 02/07/24, the surveyor and Staff 4 reviewed the electronic MAR and confirmed the electronic MAR contained no additional information versus the printed MAR.The need to ensure MARs included reasons for use and all PRN medications had resident-specific parameters was discussed with Staff 1 (Administrator) on 02/07/24. The findings were acknowledged.
2. Resident 5 was admitted to the facility in 12/2023 with diagnoses including dementia and cervical disc disorder. Resident 5's signed physician orders, dated 12/19/23, and MARs were reviewed from 01/01/24 through 02/05/24, and the following was noted:a. Resident 5 had a physician's order for PRN acetaminophen 325 mg, two tablets every six hours as needed for pain. There was also an order for oxycodone-acetaminophen 5-325 mg, one to two tablets every six hours as needed for pain.There were no resident-specific parameters for staff regarding which PRN should be used first.In an interview with Staff 4 (MA) on 02/05/24, it was confirmed the electronic MAR did not contain any additional information for staff as to which PRN to administer first.b. Multiple medications on the MAR lacked a reason for use.On 02/05/24 at 10:24 am, the surveyor and Staff 4 reviewed the electronic MAR and confirmed the electronic MAR contained no additional information versus the printed MAR.The need to ensure all medications on the MAR had reasons for use and included resident-specific instructions for PRN medications was discussed with Staff 1 (Administrator) on 02/07/24. The findings were acknowledged.3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including advanced dementia. Resident 1's signed physician orders, dated 12/27/23, and MARs were reviewed from 01/01/24 through 02/05/24, and the following was noted:* Fluoxetine HCL 40 mg, one capsule once daily lacked a reason for use.On 02/05/24 at 10:28 am, the surveyor and Staff 4 (MA) reviewed the electronic MAR and confirmed the electronic MAR contained no additional information versus the printed MAR.The need to ensure all medications on the MAR included reasons for use was discussed with Staff 1 (Administrator) on 02/07/24. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility, no less than quarterly, and with significant changes of condition. Findings include, but are not limited to:On 02/06/24, the ABST was reviewed with Staff 1 (ED) and Staff 2 (Administrator). The following was identified:* The three newest admissions had not been added to the ABST;* Admission dates were verified with the facility, but the resident data had not been inputted for 15 to 27 days after admission;* Twenty out of the thirty-six residents had not been updated at least quarterly; and* One resident who had a verified significant change of condition had not been updated in the system.The need to ensure the facility updated the ABST before a resident moved in to the facility and no less than quarterly was discussed with Staff 1 and Staff 2 on 02/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) no less than quarterly for 2 of 2 sampled residents (#s 7 and 8) and to use the tool to develop the facility's staffing plan. This is a repeat citation. Findings include, but are not limited to:The facility's ABST was reviewed with Staff 2 (Administrator) at 1:20 pm on 05/30/24. The following was identified:a. Resident 7's ABST did not show evidence of being updated with the service plan dated 05/01/24, and Resident 8's ABST showed the last update was 11/01/23.b. During an interview at 1:20 pm on 05/30/24, Staff 1 stated she included non-direct care staff when using the tool to determine appropriate staffing levels for the facility.The need to ensure each resident's ABST was updated no less than quarterly and the results were used to develop the facility's staffing plan was discussed with Staff 1 on 05/30/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months and document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. Findings include, but are not limited to:Review of fire drill records dated 08/15/23, 10/15/23, and 12/19/23 revealed a lack of documentation of one or all of the following required fire drill components:* Time of day of the fire drill;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and* Evacuation time period needed.Additionally, there was no documented evidence alternate exit routes were used during the fire drills.During an interview on 02/06/23, Staff 2 (Administrator) confirmed the fire drills and fire and life safety instruction to staff had not occurred on alternate months consistently over the last six months.The need to provide fire and life safety instruction to staff on alternate months and to document all required elements for fire drills as required by the OFC was discussed with Staff 1 (ED) and Staff 2 on 02/06/24. They acknowledged the findings.

Based interview and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 361 and Z 142.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:Observations of the facility on 02/05/24 and 02/06/24 revealed the following:* Multiple resident rooms, common bathrooms, and laundry room had scraped doors and/or jambs;* The armrest of a chair outside the nurse's office was missing;* Multiple overhead florescent light fixtures contained dead insects;* A vent outside of Room #29 had dust and debris;* An outdoor vent near the entry to the building had dust and debris;* An outdoor vent in the interior courtyard had dust and debris; and* The hallway entry to the left of the main entrance had scraped paint and baseboards.The surveyor toured the environment with Staff 2 (Administrator) on 02/06/24. She acknowledged the above areas needed to be cleaned and repaired.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 - 120 degrees F. Findings include, but are not limited to: On 02/05/24 and 02/06/24, the surveyor measured water temperatures in occupied resident unit bathrooms and common bathrooms throughout the building. Water temperatures were below 110 degrees F.During an interview on 02/06/24 at 2:35 pm, Staff 2 (Administrator) stated the facility had ongoing issues with water temperatures, especially when dishwashing and laundry tasks were performed simultaneously.The need to ensure hot water temperatures were monitored and maintained within a range of 110 - 120 degrees F was discussed with Staff 2 on 02/06/24. She acknowledged the findings.

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, C 361, C 420, C 513, and C 545.

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 361.

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 260 and C 310.

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs, that was individualized and documented in the resident's service or care plan, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, 4, 5, and 6's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.The need to develop a daily meal program for nutrition and hydration based on the resident's preferences and needs and documented in the resident's service or care plan was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24 and 02/08/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate and develop individualized activity plans and provide a meaningful activity program for 2 of 6 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia, depression, and mild cognitive impairment.Although there was some information related to activities Resident 3 may want to participate in, the documentation lacked the following components:* Current abilities and skills;* Emotional and social needs and patterns;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the resident with individualized activities.Resident 3's Life Enrichment Plan identified arts, crafts, and music for his/her preferred activities. The resident's service plan identified arts, crafts, card games, knitting, music, reading, television shows, and walking for his/her preferred activities.Per interview with Staff 3 (MA) on 02/07/24 at 10:44 am, the resident preferred Bingo and watching movies. Although Resident 3 carried a book with him/her, Staff 3 reported the resident was no longer able to focus on reading.Resident 3 was observed during the survey to be in a quiet common area, watching movies.The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24. They acknowledged the findings.2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's, dementia with behavioral disturbance, depression, and post traumatic stress disorder.Although there was some information related to Resident 4's current interests, the documentation lacked the following components:* Current abilities and skills;* Emotional and social needs and patterns;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the resident with individualized activities.Resident 3's Life Enrichment Plan identified music, word puzzles, and word search for his/her preferred activities. The resident's service plan identified arts, crafts, knitting, music, praise and worship, and television shows for his/her preferred activities.Per interview with Staff 3 (MA) on 02/08/24 at 9:24 am, the resident preferred Elvis Presley music, and thought Resident 4 shared the same birthday with Elvis. She reported s/he would play the "air guitar" and dance when Elvis Presley music was being played in the facility.Resident 4 was observed listening to Staff 13 (MA/Activities) talk about Elvis' life in a group setting and join another group where Staff 13 was talking about Dr. Martin Luther King, Jr.The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/08/24. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's and dementia with behavioral disturbance.Review of the resident records and staff interviews during the survey revealed Resident 4 had eloped from the facility three times between 12/24/23 and 01/06/24.The current service plan, dated 01/11/24, and "Life Enrichment Plan" lacked resident-specific information which included how the resident would exhibit agitation and individualized interventions for staff to try when responding to Resident 4's agitation.The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 1 (ED) and Staff 2 (Administrator) on 02/08/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and/or included on the service or care plan for 4 of 5 sampled residents (#s 1, 2, 4, and 6) who had challenging behaviors in the MCC. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease.Review of the resident records and staff interviews during the survey revealed Resident 2 frequently exhibited escalated verbal behavior, including yelling at residents, when agitated and feeling like others were "in [his/her] space."The current service plan, dated 01/12/24, lacked resident-specific information that informed staff of the specific behaviors of concern and lacked individualized interventions for staff to try when responding to the behaviors.The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.2. Resident 6 was admitted to the facility in 08/2023 with diagnoses including dementia with behavioral disturbance.Review of the "Life Enrichment Plan" stated that Resident 6 should be provided with activities that were "tactile and also offers small snacks" as an intervention to Resident 6's behavior of scratching his/her skin. The current service plan, dated 01/20/24, lacked interventions for the behavior of scratching his/her skin. The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.
3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including advanced dementia.Review of the resident's "Life Enrichment Plan" identified that "care staff should always talk to [him/her] first before transferring," as an intervention to Resident 1's behavior of yelling loudly when being touched or transferred. The current service plan, dated 11/10/24, lacked that intervention.The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the fence surrounding the perimeter of the outdoor recreation area was constructed to reduce the risk of resident elopement. Findings include, but are not limited to:The outdoor secured courtyard was toured on 02/05/24 at 9:25 am. The following was observed:The fencing surrounding the perimeter of the outdoor recreation area was constructed of chain link material with slats placed through the gaps in the chain links. The slats placed were flexible and not constructed to reduce risk of resident elopement.Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia with behavioral disturbance. Progress notes, dated 12/10/23 through 02/04/24, were reviewed. The resident eloped from the facility by scaling the fence located in the outdoor secured courtyard area on the following dates:* 12/23/23;* 01/04/24; and * 01/06/24.During an interview on 02/06/24 at 2:30 pm, Staff 2 (Administrator) confirmed the fence construction could potentially aid in resident elopement. A tour of the outdoor recreation area was completed with Staff 2 on 02/06/24. She acknowledged the findings.

The findings of the relicensure survey conducted 04/03/23 through 04/05/23 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

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the relicensure survey, conducted 04/03/23 through 04/05/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in report.

Based on observation and interview, it was determined the facility failed to ensure all required postings were displayed in a conspicuous location for residents, visitors and available for inspection at all times. Findings include, but are not limited to: During a tour of the environment on 04/03/23, a copy of the most recent survey was not in an accessible or conspicuous location. The findings were reviewed with Staff 1 (ED) on 04/04/23. He acknowledged the findings.

Based on interview and record review it was determined the facility failed to ensure incidents and reports of suspected abuse were thoroughly investigated to rule about abuse for 1 of 2 sampled residents (# 3) whose records were reviewed. Findings include but are not limited to:Resident 3 was admitted to the facility in 2018 with diagnoses including senile dementia. The resident's clinical record was reviewed during the survey.On 02/08/23 staff documented on a Change in Service Plan form:* "[Resident] complains of burning in [his/her] private area in [his/her] brief due to incontinence"; and * "[Resident] not getting changed enough."The 03/14/23 service plan indicated the resident was incontinent in both bowel and bladder management and used adult briefs at all times. The service plan also noted the facility would provide perineal care routinely each shift and as needed by his/her request as the resident was at risk for skin breakdown.On 04/04/23, an investigation report was requested. On 04/04/23 at 11:35 am, Staff 1 (ED) confirmed there was no facility investigation completed to rule out neglect of care related to the resident not receiving brief changes timely.The need to ensure reports of suspected abuse were promptly investigated to rule out abuse and neglect was discussed with Staff 1 and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings. The facility was asked to report the incident to the local Seniors and Peoples with Disabilities office. Confirmation was received by the survey team prior to the survey exit.

4. Resident 3 was admitted to the facility in 08/2018 with diagnoses including senile dementia. a. Review of the resident's 03/14/23 quarterly evaluation and interviews with staff identified the evaluation was not reflective in the following areas:* Recent Falls;* Assistive devices;* Home health PT services received in the past 90 days; and* Weight loss in the last month.b. In addition the 03/14/23 evaluation was not accessible to staff. The need to ensure Resident 3's quarterly evaluation was accurate and made accessible to staff was discussed with Staff 1 (ED) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.
2. Resident 4 was admitted to the facility in 04/20/2023.a. Resident 4's move-in evaluation, dated 02/20/23, lacked information regarding the following required elements:* Customary routines; * Interests, hobbies, social, leisure activities;* Effective non-drug interventions;* Ability to be understood; * Housekeeping and laundry;* List of treatments;* Complex medication regime;* History of dehydration or unexplained weight loss or gain;* Unsuccessful prior placements; and* Environmental factors. b. Resident 4's quarterly evaluation was not accessible to staff.The move-in evaluation was reviewed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia.a. Resident 1's quarterly evaluation, dated 03/14/23, was reviewed and lacked the following required elements:* Assistive devices for transfers and ambulation. b. Resident 1's quarterly evaluation was not accessible to staff.The need for the quarterly evaluation to be used as the basis of the resident's quarterly service plan and the most recent quarterly evaluation, with documented change of condition updates, available in the resident's current record and to staff was discussed with Staff 1 (ED)and Staff 3 (RN) on 04/05/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements and to ensure quarterly evaluations were reflective of the residents' current needs and available to staff for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia. Observations, interviews with staff and review of the quarterly evaluation dated 03/20/23 identified the following:a. Resident 2's quarterly evaluation was not accessible to staff.b. The quarterly evaluation dated 03/20/23 was not accurate in the following areas:* Customary routines including, but not limited to: eating, sleeping and bathing;* Eating and dietary needs;* Number of staff required for incontinent care;* History of dehydration and fluid preferences;* History of skin care issues and interventions;* Home health nursing and PT received in previous 90 days; * Indicators of nursing needs; and* Socialization.The need to ensure the quarterly evaluations were accurate and included sufficient information to be used as the basis of the quarterly service plan was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 08/2018 with diagnoses including senile dementia. Review of the resident's 03/14/23 service plan and temporary service plans (TSP's), observations and interviews with staff during the survey indicated the service plan was not reflective and did not give clear instruction to staff in the following areas:* Assistive equipment, non-slip mat at bed side;* Repositioning assistance; and* Incontinence assistance including resident preferences.In a 04/03/23 interview, Staff 2 (LPN), confirmed the 03/14/23 service plan was not made accessible to staff. The need to ensure service plans were reflective of resident's needs and preferences, gave clear instruction and were accessible to staff was discussed with Staff 1 (ED) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.
2. Resident 1 was admitted to facility in 01/2022 with a diagnosis of dementia. Resident 1's service plan and 03/2023 MAR were reviewed. The service plan, dated 03/14/23, was not reflective of the resident's status, lacked clear instructions to staff or was not followed in the following areas:* Fall mat;* Wheelchair with a tab alarm device; * Side rails; and* Meal monitoring and supplemental shake.The service plan instructed staff to notify MA if Resident 1 did not eat 50% of his/her meal and provide a supplemental shake. In an interview, 04/05/26 at 9:05 am, Staff 7 (CG) stated she had never seen resident offered a supplemental shake.In an interview, 04/05/23 at 9:45 am Staff 18 (MA) stated there was no order to give Resident 1 a supplemental shake.The need to ensure service plans were reflective, included clear direction to staff and were followed was discussed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, reflective of resident's current health status and care needs, provided clear direction to staff regarding the delivery of services and were followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the Memory Care facility in 02/2015 with diagnosis including dementia.Observations, interviews with staff, review of the current service plan dated 03/20/23 and temporary service plans (TSP's) were reviewed during the survey. a. The current service plan dated 03/20/23 was not available to staff.b. Resident 2's current service plan was not reflective and lacked clear direction to staff in the following areas:* Two person bathing and interventions when resident consistently declined bathing;* Instructions for finger and toe nail care;* Incontinent care provided in bed;* History of dehydration and fluid preferences;* History of chronic heel and ankle pressure ulcers and interventions;* Use of pressure alternating mattress and monitoring instructions;* Use of bilateral siderails including risk, precautions and caregiver instructions;* Communication and ability to make needs known;* Seizure protocols, monitoring instructions and who to report to;* Difficulty swallowing and swallow precautions;* Puree and mechanical soft diet; * Ability to make food preferences known; and* Ability to eat independently.The need to ensure service plans were reflective of resident needs, included clear direction to staff was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident's 1, 2 and 3's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to monitor residents consistent with evaluated and service planned needs and short term changes in condition through resolution for 2 of 3 sampled residents (#s 2 and 3) who experienced changes in condition. Resident 3 experienced ongoing discomfort from a skin condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 08/2018 with diagnoses including senile dementia.The resident's current service plan, dated 03/14/23, and temporary service plans (TSP's) were reviewed and revealed the following:* 01/15/23 - Behaviors including yelling out, refusing care, exit seeking;* 01/18/23 - "Skin irritation around [perineal] area, apply barrier cream twice daily for the next seven days and PRN";* 01/25/23 - Med changes, discontinue Lantis Solostar insulin and increase Metformin 500 mg, take two tablets by mouth daily with breakfast and one tablet with dinner daily;* 02/08/23 - "[Resident] complains of burning pain in his/her private area in his/her brief due to incontinence"; and * 03/30/23 - Medication change, start acetaminophen 650 mg take one tablet two times daily, start Memantine five mg, take one tablet by mouth nightly.a. There was no documented evidence of monitoring with progress noted at least weekly through resolution for Resident 3's behaviors and medication changes.b. There was no documented evidence the implemented interventions were evaluated for effectiveness or if new interventions needed to be developed for the resident's skin condition. There was no documented evidence the condition was monitored with progress noted at least weekly through resolution. The resident continued to experience discomfort in his/her perineal area between 01/15/23 and 02/08/23.In an interview on 04/04/23, with Staff 10 (CG), she stated the skin condition had resolved within two weeks prior to the survey.Resident 3's changes of condition, lack of interventions and monitoring were discussed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia. The resident was not able to communicate his/her needs during the survey.Progress notes dated 01/01/23 through 03/08/23, HH provider notes from 12/28/22 through 02/01/23 and 03/01/23 through 04/04/23 MAR's were reviewed and identified the following changes of condition:12/26/22 right ankle pressure wound and bilateral pressure wounds on the heels.On 12/28/22 and 12/29/22, the facility RN assessed the wounds and documented two hour checks for repositioning, use heel/foot protectors, float heels while in bed, increase protein intake and HH wound care would be managing dressing changes. On 01/04/23, the RN documented on a skin impairment sheet "right ankle one inch and left heel two inch with 1/8 inch depth, drainage, pale, reddened, dark, and a one-to-two stage on right ankle and stage two on left heel."On 02/08/23, (26 days later), the RN documented "[one half] inch on left heel, dark scab and "now followed by HH wound care." On 03/05/23, a progress note documented "heels and ankles are looking very good. Nice small scabs on both ...had to do wound dressing. Will continue to keep a close eye on them."There was no documented evidence the wounds were monitored with progress noted at least weekly through resolution. With permission from the resident, ADL care observations were done on 04/04/23 at 12:30 pm. The resident's skin on both ankles and heels were observed to be clean, dry and intact. The need to ensure the facility monitored Resident 2's skin breakdown with weekly progress noted until resolved was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 2 sampled residents (# 3) who experienced significant changes in condition. Residents 3 experienced ongoing severe weight loss. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 02/2018 with diagnoses including senile dementia. The resident was observed to eat independently and was provided a dietary supplement each afternoon. The resident's 03/14/23 service plan instructed staff to offer the resident a peanut butter and jelly sandwich when s/he refused a meal.The resident was observed to consume the following foods during the survey:* On 04/03/05 for lunch, the resident ate one half of a peanut butter and jelly sandwich and a piece of cake; and * On 04/04/23 for breakfast, the resident ate less than 25% of a bowl of hot cereal and a few bites of fruit. S/he refused the offer of an alternative meal. For lunch the resident ate a few bites of pork with gravy, one half of a peanut butter and jelly sandwich and one piece of pie.It was documented Resident 3 weighed 155.6 pounds in 12/2022.In 03/04/2023 Resident 3 was noted to weigh 138.3 pounds a 17 pound, or 11.1%, body weight loss in three months. This constituted a severe weight loss.A current weight for Resident 3 was requested during the survey. Resident 3's weight on 04/04/23 was noted to be 134.8 pounds. Progress notes by Staff 3 (RN) revealed the following:* 01/25/22 -"[Resident] blood sugars have been lower and staff report decreased appetite ...[physician] discontinued Lantis insulin";* 02/08/23 -"[Resident] has lost five pounds in one month, this is desired weight loss and helping his/her reduce blood sugars, s/he is no longer taking insulin and blood sugars are becoming under control";* 03/20/23 - "[Resident] continues to lose weight (17) pounds in three months. This is desired due to diabetes..."In a 04/05/23 interview with Staff 3, she confirmed the the lack of a timely assessment including resident status and interventions made as a result of the assessment for Resident 3's severe weight loss. The facility's failure to ensure an RN assessment was completed for Resident 3's severe and ongoing weight loss put the resident's health and safety at risk. The need for the facility RN to assess significant changes in condition, document findings, resident status and interventions made as a result of the assessment was discussed with Staff (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View) and Staff 15 (Regional Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed staff. Findings include, but are not limited to:Delegation records for Resident 4, reviewed on 04/03/23, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 13 (MT), Staff 14 (MT), Staff 16 (MT), Staff 17 (MT) and Staff 18 (MT) to include:* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; * Skills, abilities and willingness of unlicensed persons; * That taught task is client specific and not transferable; and* That RN takes responsibility for delegating tasks and ensures supervision will occur for as long as RN is supervising performance. The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an Infection Control Specialist was trained by 07/01/22, as required in OAR 411-054-0050 and failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:1. In an interview on 04/04/23 Staff 1 (ED) was asked to provided training documentation for the facility's designated Infection Control Specialist. Staff 1 confirmed the facility had not designated an Infection Control Specialist who had completed the required training.The need to ensure the facility designated an individual to be the facility's Infection Control Specialist and completed the specialized training in infection prevention and control protocols within the required timeframes was reviewed with Staff 1 and Staff 15 (Regional Director) on 04/05/23. They acknowledged the findings. 2. During meal observations on 04/04/23, Staff 2 (LPN) was observed assisting Resident 3 to his/her unit. Staff 2 touched the resident's walker with her bare right hand and then placed the same hand on the residents waist. Staff 2 walked back to the common area, noting she did not have keys to access the residents unit. She approached the window to the medication room, placed her right hand on the window frame and asked Staff 14 (MA) to borrow her keys. She then walked to Resident 3's unit and unlocked the door, touching the door handle. After assisting the resident into his/her room, Staff 2 walked back to the medication room window with the keys in her hand and handed the keys to Staff 14. She then sat across from an unsampled resident, picked up a spoon and began feeding the resident. Staff 2 was not observed to perform hand hygiene or don gloves prior to assisting the resident with meal assistance. The need to ensure infection prevention and control protocols and practices were maintained to provide a safe, sanitary and comfortable environment was discussed with Staff 1 (ED) on 04/05/23. He acknowledged the findings.
3. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia. Observations of Resident 2 during the survey revealed s/he was dependent on two staff for all bowel and bladder care and needed assistance with incontinent care while in bed. On 04/04/23 from 12:30 pm to 12:47 pm, the surveyor obtained permission and observed two CGs provide bowel care for Resident 2. Both CG's failed to change gloves after removing soiled clothing, soiled incontinent brief and wiping urine and fecal matter from Resident 2's perineum. The CGs touched the resident's clean clothing, clean incontinent brief, their uniforms, keys, a door handle, the resident's bed linens, heel protectors, the resident's lower legs and both sides of the resident's body when assisting the resident to roll from side to side for staff to place a clean incontinent brief on Resident 2. After care was provided, one caregiver proceeded to change the bed linens and place a clean chux pad on the bed. Both staff removed their soiled gloves, one CG gathered the incontinent trash bag and took soiled gloves from the second caregiver with an ungloved hand and walked into the dining room. The other CG wheeled the resident down the hallway and into the dining room to wait for lunch. No hand hygiene was observed during ADL care or prior to entering the dining room and before handling the resident's wheelchair. The CG carrying the incontinent trash bag stopped to get keys from the housekeeper, touched the keys and doorknob to the laundry room, all before performing hand hygiene. The CG did perform hand hygiene in the laundry room sink before walking back to the dining room, picked up a tray of food from the kitchen and proceeded to provide one-on-one meal assistance for Resident 2 without using a barrier (apron) to prevent potential cross contamination from the staff's uniform. The need to ensure the facility established and maintained infection prevention and control protocols to provide a safe, sanitary and comfortable environment was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View) during the exit interview on 04/05/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications administered to the residents for 2 of 4 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia. The resident's 03/01/23 through 03/31/23 MARs and physician's orders were reviewed. There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following medications and treatments that the facility was responsible to administer:* Ferrous sulfate;* Setraline (for mood);* Acetaminophen (for pain);* Atorvastatin (for cholesterol);* Benzonatate (for cough);* Loperamide (for loose stool);* Oxycodone (for pain);* Alum & Mag Hydrox-simethicone (for upset stomach); * Polyethylene Glycol (for constipation);* Acetaminophen PRN (for pain);* Risperidone (for agitation);* Boost very high calorie supplement;* Milk of magnesia (for constipation);* Triamciolone ointment (for rash);* Sodium fluoride (for teeth);* Inzo antifungal cream:* Eye itch relief drops;* Miconazole cream (for peri area); and* Bisacodyl suppository (for constipation).The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia.A review of the resident's clinical record identified the following:There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications and treatments that the facility was responsible to administer. The need to ensure the facility had a system in place to ensure current signed physician orders were available in the residents record was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN) on 04/05/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions and had specific parameters for PRN medications for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2022 with a diagnosis of dementia. Resident 1's 03/01/23 through 03/31/23 MAR was reviewed.Resident 1's MAR revealed two PRN pain medications, Oxycodone and acetaminophen lacking specific indications and parameters for use. There were also three bowel care medications, milk of magnesia, polyethylene glycol and bisacodyl suppository, lacking specific indications and parameters for use. In an interview with Staff 2 (LPN) at 11:45 am on 04/04/23, she acknowledged the lack of parameters for PRN pain and 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 (ED) and Staff 3 (RN) on 04/05/23. They acknowledged the MARs were not accurate.
2. Resident 2 was admitted to the facility in 02/2015 with diagnosis including dementia. Review of Resident 2's 03/01/23 through 04/04/23 MAR identified the following inaccuracies: * Treatment for wound care to heels;* Gently wash [heels] with baby shampoo;* Paint ulcers with betadine liquid using a cotton ball and apply to ulcers, cover with dry gauze, tape to secure; and* Change dressing every other day and as needed. With permission, observation of ADL care on 04/04/23, showed the resident's heels were clean, dry and intact. The heels were not painted with betadine and were not covered with dry gauze and tape. During an interview on 04/04/23, Staff 14 (MA) stated she thought the order was discontinued. The MA further confirmed the treatment wasn't done and she was not able to locate the betadine in the med cart or the resident's room. The MAR's reviewed showed MA's had initialed that the betadine treatment, dry gauze and tape was administered, daily. On 02/01/23, a HH provider note documented Resident 2's heel wounds were resolved, however there was no documented evidence the wound orders were clarified, needed to be discontinued and the treatment removed from the MAR. The need to ensure MARS were accurate to include clarified wound orders, clear instructions for unlicensed staff to follow and MA's only initialing the MAR for medications and treatments that were administered was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions and documentation of the use of the device in the resident's evaluation and service plan for 1 of 2 sampled residents (#2) who had bilateral siderails on their hospital bed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia. On 04/04/23 the resident's bed was observed to have bilateral half-length siderails in the down position while the resident was laying in the bed.There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the device in the resident's evaluation and service plan.The above information was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (LPN, Clackamas View) on 04/05/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care, and failed to have an accurate and effective Acuity Based Staffing Tool (ABST) that defined an appropriate number of caregivers and general staff based on resident acuity and service needs. Findings include, but are not limited to:Observations, interviews and record review, during the survey revealed the following:* At the time of the relicensure survey, the facility was a single level home to 18 residents with memory care diagnoses. * During the acuity interview on 04/03/23, the facility was noted to have numerous residents with high ADL care needs which included four residents who required two staff transfers with mechanical lift assistance, multiple residents who required one to two person incontinent care or toileting, three residents who needed meal oversight and/or eating assistance, and six residents who were identified as having behaviors. * According to the UDS (Uniform Disclosure Statement), the facility used Medication Aides and Universal Workers (whose job duties included providing care and services to residents in addition to having other tasks, such as housekeeping, laundry and activities.) The UDS indicated the facility would schedule five staff (one MA and four universal workers) between 7:00 am - 11:00 pm (day and evening shifts), and one MA and one universal worker from 11:00 pm - 7:00 am the following morning.During an interview with Staff 11 (Housekeeper) on 04/04/23, reported "I always provide direct care for [an unsampled resident] because [the resident] doesn't like anyone else. I'm able to help [him/her] shower, bring him food, everything." I do everything around here, I clean the bathrooms, cook, help with feeding residents, do showers, yeah, I do it all, all except meds."* Review of the posted staffing plan and interview with Staff 1 (ED) during the survey revealed the facility scheduled one MA and two CG from 6:00 am - 2:00 pm and 2:00 pm - 10:00 pm shifts, and one MA and one CG at night (10:00 pm - 6:00 am). * Observations during meal service on 04/05/23 at 8:52 am, multiple residents were in the dining room. The facility cook, the only staff member present, was seated at a table supporting a resident with their meal. A resident who was seated in a large recliner in the sitting area adjacent to the dining room, made contact with a tall wooden stand next to his/her chair and an artificial plant fell off the top of the stand onto the residents right shoulder. A few moments later the resident stood up from the recliner and pushed the back of the chair until it flipped over. The resident then walked to the front of the chair, bent forward and lifted it until it landed in it's normal position. No facility staff responded to either incident until a surveyor brought the incidents to the MA's attention. * On 04/03/23, the surveyor requested the facility's ABST and the defined number of staff that the tool had generated. Upon review of the ABST, multiple residents that had been entered into the ABST had no minutes of caregiver time spent on care that was observed to be needed and/or that they were service planned to receive. The need to increase staffing levels to compensate for increased staff duties when utilizing universal workers and to ensure unscheduled resident needs could be met was discussed with Staff 1 on 04/05/23. He acknowledged the need for increased staff. Refer to C 361

Based on observation, interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment accurately for each resident to develop the facility's staffing plan based on the ABST. Findings include, but are not limited to:In a interview on 04/03/23, Staff 1 (ED) confirmed the facility utilized the Oregon Department of Human Services ABST.The ABST tool showed all 19 residents had information entered into the system and generated a staffing plan. Observations, interviews with the staff and review of the ABST indicated it was not reflective of current ADL needs for Resident 2, Resident 3 and three unsampled residents in the following areas:* Transferring in or out of bed or chair;* Repositioning in bed or chair;* Ambulation, escorting to and from meals and activities;* Supervising, cueing or supporting while eating;* Cueing or redirecting due to cognitive impairment or dementia; and* Monitoring behavioral conditions or symptoms.The generated staffing plan did not reflect the total of weekly minutes required to meet the scheduled and unscheduled needs of the residents.In addition, the ABST had not been updated at least quarterly and with changes of condition for Resident 2, Resident 3 and the three unsampled residents.Staff 1 acknowledged the tool was not reflective of resident's current ADL needs and had not been updated at least quarterly and with changes of condition.The need to complete an accurate assessment of each resident, update the information at least quarterly and with changes of condition into the ABST to generate a staffing plan was reviewed with Staff 1, Staff 4 (LPN, Clackamas View) and Staff 15 (Regional Director). No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure direct care staff were trained in the use of abdominal thrust and First Aid within 30 days of hire for 2 of 2 sampled direct care staff (#s 7 and 12) whose training records were reviewed. Findings include, but are not limited to:On 04/04/23, staff training records and interview with Staff 1 (ED) identified the following deficiencies:There was no documented evidence that Staff 7 (CG) and Staff 12 (MT) had completed training on First Aid and abdominal thrust within 30 days of hire.The need to ensure direct care staff had completed First Aid and abdominal thrust within 30 days of hire was discussed with Staff 1 on 04/05/23. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Fire drill and fire and life safety training records from 10/03/22 to 04/03/23 were reviewed on 04/04/23. The following deficiencies were identified:1. The facility failed to conduct fire drills every other month. 2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED), Staff 4 (LPN, Clackamas View) and Staff 15 (Regional Director) on 04/05/23. Staff 1 acknowledged the facility did not conduct and record unannounced fire drills every other month and did not consistently provide fire and life safety instruction to staff.

Based on observation and interview, it was determined the facility failed to ensure an effective pest control system was in place and that any toxic materials were properly stored in locked storage. Findings include, but are not limited to: A review of the facility environment was conducted on 04/03/23. The following was identified:* There were ants present in the TV room next to the dining room; and* Chemical disinfectant was observed in unlocked cupboards in the common bathrooms. The bathrooms were observed to not be consistently locked throughout the day. On 04/05/23, in an interview with Staff 1 (ED), the need to ensure an RCF takes measures to prevent the entry of rodents, flies, mosquitoes, and other insects, and all poisons, chemicals, rodenticides and other toxic materials were contained in a locked storage unit was discussed. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:Observation of the facility on 04/03/23 revealed:* The carpet throughout the facility had multiple stains and was worn;* There was paint missing on the wall under the soap dispenser in the shower room (next to room 17);* The doors and/or frames to all three shower rooms and rooms 22, 28, nurses station and shower rooms were scratched, gouged and missing paint;* The arm chair outside nurses station had fabric that was torn;* The couch in the back TV/lounge area had ripped seams and stuffing protruding;* The shower room (next to room 28 and 21) had broken tiles and missing grout in the shower; and* The transition strip to the laundry room was missing.A walk through of the facility was completed on 04/04/23 with Staff 1 (ED). On 04/04/23, the surveyor discussed and reviewed the areas requiring cleaning and repair with Staff 1. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:The facility laundry rooms were observed on 04/03/23. The following was identified:The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent. The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) on 04/04/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to:On 04/04/23 the surveyor measured water temperatures in occupied resident unit bathrooms and common bathrooms throughout the building. Water temperatures were below 110 degrees Fahrenheit. The need to ensure hot water temperatures were monitored and maintained within a range of 110 - 120 degrees F was discussed with Staff 1 (ED). He acknowledged the findings. He stated he would inform maintenance staff to adjust the water heaters on 04/05/23.

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 150, C 152, C 231, C 295, C 360, C 361, C 372, C 420 , C 510, C 513, C 530 and C 545.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation, pre-service dementia training and competency demonstrated within 30 days of hire was completed and documented for 2 of 2 newly hired direct care staff (#s 7 and 12) and annual in-service training was completed and documented for 3 of 3 long term direct care staff (#s 9, 10 and 13). Findings include, but are not limited to:On 04/04/23 training records were reviewed with Staff 1 (ED).1. Staff 7 (CG), hired on 01/27/23 and Staff 12 (MA), hired on 01/06/23 lacked documented evidence of completing all required pre-service or competency training in the following areas: a. Pre-service orientation prior to performing any job duties:* Resident rights;* Abuse reporting requirements;* Infectious disease prevention;* Fire safety and emergency procedures;* If preparing food, food handler's card; and* Written job description.b. Pre-service dementia training prior to providing care and services independently:* Dementia disease process including progression of the disease, memory loss, psychiatric and 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, and 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 memory care communities.c. Demonstrated competency training within 30 days of hire:* Changes associated with normal aging; and* Identification, documentation and reporting changes of condition.2. Staff 9 (CG), hired on 10/23/15, Staff 10 (CG), hired on 03/19/19 and Staff 13 (MT), hired on 12/20/16 failed to complete 16 hours of annual in-service training which included six hours related to dementia care.The need to ensure all newly hired staff completed pre-service orientation, pre-service dementia training, demonstrated competency within 30 days of hire and all long-term direct care staff completed 16 hours of annual in-service training was discussed with Staff 1 on 04/05/23. 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: C 252, C 260, C 262, C 270, C 280, C 282, C 303, C 310 and C 340.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed, followed and included in the service plan for 1 of 3 sampled memory care residents (#2) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2015 with diagnoses including dementia. The resident was unable to make his/her needs and food preferences known. Observations during the survey identified Resident 2 preferred to eat breakfast in his/her room every day, needed two-person mechanical lift transfer and wheelchair escorts to attend meals and snacks offered in the dining room. During the acuity interview on 04/03/23, Staff 10 (CG), reported Resident 2 needed a puree diet. Review of outside provider notes from 01/01/23 through 03/08/23, identified Resident 2 had a speech therapy evaluation due to difficulty swallowing. The evaluation recommended mechanical soft and/or puree diet. The current service plan dated 03/20/23 offered the following information:* [Resident] is able to make [his/her] food preferences known;* [S/he] may not sit through the meal if there are no sweets with the meal;* [Resident] requires one-on-one supervision while eating and drinking for safety reasons;* Staff to prop up right arm with a rolled towel or pillow when sitting in wheelchair at meals; * Staff to offer fluids and snacks between meals; * Staff to offer alternate menu items if s/he expressed s/he didn't like the food or staff notice s/he isn't eating; and* Staff to offer coffee with each meal.Observations throughout the survey noted the following: * Resident 2 would nod his/her head yes or no at intermittent times when responding to staff, otherwise was non-verbal. * On 04/03/23 Resident 2 was offered whole cooked vegetables and a whole bread roll during lunch. The resident ate less than 50 % of the meal. Staff 10 (CG) who provided one-on-on meal assistance failed to offer alternate menu items. * On 04/03/23, snack pass between breakfast and lunch was offered to residents who were out in the community. Resident 2 remained in his/her room and was not offered the snack or fluids. * On 04/04/23 at 10:50 am, a snack pass was offered to residents who were out in the community, Resident 2 remained in his/her room and was not offered the snack or fluids.* Resident 2 was observed in a tilt back wheelchair during lunch on 04/03/23 and 04/04/23 without the use of a rolled towel or pillow propped under the right arm. On 04/05/23, the need for an individualized nutrition and hydration plan was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 4 (LPN, Clackamas View). They 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, and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2 and 3's service plans offered some information about the residents' interests, however, the facility had not fully evaluated the residents: * 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 were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities.Observations and interviews indicated the residents were dependent on staff to initiate activities.On 04/05/23 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED), who acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:Observations during the survey between 04/03/23 and 04/05/23 indicated the doors to the interior courtyard were locked and did not allow residents to exit and return without staff assistance.During a tour of the building on 04/04/23 at 12:15 pm with Staff 1 (ED). He acknowledged the courtyard doors were locked and there was no inclement weather policy.Refer to Z 173.

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:During the survey, between 04/03/23 and 04/05/23, the doors to the interior courtyard were observed to be locked.During a tour of the building on 04/04/23 at 12:15 pm with Staff 1 (ED), he acknowledged the facility did not have a written policy which described under what circumstances the doors to the courtyard would be locked.

Based on observation and interview, it was determined the facility failed to ensure residents' rooms were unlocked. Findings include, but are not limited to:During environmental observations on 04/03/23 and 04/05/23, it was noted seven residents' rooms were locked. The need to ensure residents were not locked out of or inside of their rooms at any time was discussed with Staff 1 (ED) on 04/04/23. He acknowledged the findings.