Washington Gardens Memory Care

The findings of the kitchen inspection, conducted 11/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 11/21/23, conducted 03/01/24, 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.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 11/21/23 at 11:00 am, the kitchen was observed to need cleaning in the following areas: * Interior and exterior of the microwave; * Lids of food storage containers in the dry storage area; and* The exterior doors of reach in refrigerators and freezer. Items in the refrigerator were not sealed closed to prevent potential cross contamination, including an open bag of peeled garlic and a block of butter. One staff was not using any type of beard restraint. During food preparation observations there was a lack of appropriate glove use including the failure to wash hands when changing gloves. The areas were discussed with Staff 1 (Executive Chef) and Staff 2 (Executive Director) on 11/21/23. The findings were acknowledged.

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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 05/23/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 05/23/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 10/27/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it was confirmed the facility failed to orient direct care staff to the resident. Findings include:Review of facility Incident Report and Investigation Worksheet dated 09/15/2022, Investigation, and witness statement reveal that Staff # 3 was unaware of Resident # 1 having a POLST with DNR in place and direct care staff started CPR against resident wishes. Interview with Staff # 1 and Staff # 2 on 10/27/2022 with both stating that Staff # 3 did not know that Resident # 1 had a POLST with DNR. Facility Correction Plan: Facility provided in-service training on 10/25/2022 on POLST and CPR to staff.

The findings of the re-licensure survey, conducted 10/10/22 through 10/13/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit survey to the re-licensure survey of 10/13/22, conducted 02/22/23 through 02/28/23, 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 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 second revisit to the re-licensure survey of 10/13/22, conducted 06/20/23 through 06/21/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:Resident 2 was admitted to the MCC facility in November 2020. During the acuity interview on 10/10/22, staff reported the resident had a catheter. Observations were conducted during the survey to determine adherence to universal precautions for infection control. * Multiple observations during the survey, revealed Resident 2's catheter bag was hanging off the side of the resident's hospital bed and was touching the floor. * On 10/11/22 two CGs provide ADL care to Resident 2. During the observation, one of the CGs noted the tip on the catheter drain tube had become disconnected and was touching the floor. She reconnected the drain tube and failed to ensure the tube was sanitized prior to reconnecting. * On 10/12/22 at 10:38 am, Staff 16 (MT) provided ADL care which included catheter care and incontinent care. Staff 16 was observed to place the catheter bag on the floor and repeatedly stepped on the catheter bag while ADL care was provided. When the task was completed, the catheter bag was picked up from the floor and placed on the bed, laying flat, level with the resident's bladder. The need to ensure proper infection control protocols were followed during ADL care was discussed with Staff 1 (ED), Staff 3 (Health Service Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in February 2020 and was dependent on staff for all ADL care needs. A review of the resident's clinical record identified the following: On 10/02/22, staff documented on a progress note that the resident had a purple colored bruise to the pubis area.On 10/05/22 (three days later), Staff 3 (Health Services Director/RN) documented on a progress note that the bruise appeared to be consistent with a bruise from a transfer and abuse and neglect was ruled out. There was no evidence the facility conducted an immediate and thorough investigation which included the following required components: * Time, date, place and individuals present; * Description of the event as reported; * Response of staff at the time of the event; * Follow-up action; and * Administrator's review.In an interview on 10/12/22, Staff 3 stated she had self-reported the injury on 10/10/22. Verification the injury of unknown cause was reported to the local SPD office was received on 10/12/22.The need to ensure injuries of unknown cause were investigated promptly and reported as necessary was discussed with Staff 3 on 10/12/22 . She acknowledged the findings.
2. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia. The clinical record revealed:On 08/04/22 and 08/05/22, the resident experienced two falls. A review of the incident and investigation reports showed no documented evidence the facility thoroughly investigated the falls in order to rule out abuse or neglect or reviewed the service plan to determine if it was being followed. The need to ensure a thorough investigation of falls and injuries in order to rule out abuse or neglect was completed and ensure service plans were being followed to prevent further injury was discussed with Staff 1 (ED) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to conduct investigations that included information to rule out abuse or neglect. The facility failed to conduct investigations for injuries of unknown cause and report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:1. Resident 2 was admitted to the MCC facility in 11/2020 and was dependent on staff for all ADL care needs. His/her clinical record revealed the following injuries of unknown cause:* On 08/01/22 a bruise to left forearm;* On 08/11/22 a skin tear to left forearm;* On 09/12/22 a yellowish bruise to left shin;* On 09/18/22 a skin tear/ scrape to right forearm; and* On 09/26/22 bruises to bilateral lower extremities and right hand.There was no documented evidence the facility immediately investigated and documented the injury was not the result of abuse or neglect. The facility did not report the injury to the local SPD office as suspected abuse/neglect.The need to ensure injuries of unknown cause were investigated promptly to rule out abuse and neglect or reported if necessary was discussed with Staff 3 (Health Services Director/RN) on 10/11/22. She acknowledged the facility had not investigated to rule out abuse/neglect. Verification the facility reported the five injuries of unknown cause to the local SPD office was received on 10/12/22.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen on 10/10/22 through 10/12/22 showed the following:* The dish machine faceplate indicated that it used high temperature water and the rinse cycle were required to reach 180 degrees F (Fahrenheit) to sanitize the dishes. Observation with Staff 8 (Executive Chef) showed the rinse cycle reached only 171 degrees F. Staff acknowledged the failure to reach the required temperature and used disposable plates and cups for all meals until the dish machine was serviced on 10/11/22, when a technician confirmed the water temperature was 188 degrees F., and a replacement gauge was ordered.* The back room sink leaked water around the faucet, and was loose. Staff 8 stated it had not been usable for months; * The freezer doors' center post had a build up of ice between the two doors, preventing it from sealing completely. The temperature was observed at 10 degrees F. and all food was frozen hard; and* The wall base next to the refrigerator was missing, exposing drywall and metal framing.The need to ensure the kitchen and equipment was kept in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 2 (Regional Director), Staff 6 (Executive Chef), and Staff 8 (Environmental Services Director) on 10/12/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia and was dependent on staff for all care. Resident 1's quarterly evaluation, dated 08/29/22, reviewed during the survey was not reflective of the resident's current needs and preferences in the following areas:* referred to use of a sling for a humerus fracture;* stated "attends meals with reminders";* activity preferences and accommodations needed;* recent history of falls;* dressing assistance needed in relation to hip precautions;* bathing instructions for staff to follow, hospice services;* toileting needs;* hip/leg pain and current interventions;* mobility status and needs;* nutrition and hydration needs, including meal assistance;* current skin wounds;* included wandering behavior; and* evacuation assistance needs. The need to ensure quarterly evaluations were reflective of the resident's current care needs was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) and failed to ensure quarterly evaluations were reflective for 3 of 3 sampled residents (#s 1, 2, and 3) whose quarterly evaluations were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 09/2022 with diagnoses including dementia. Resident 5's new move in evaluation, dated 09/07/22, and initial service plan, dated 09/17/22, were reviewed on 10/11/22. The following required elements had not been answered, were not reflective, or were missing from the initial evaluation:* Environmental factors that impact the resident's behavior including noise, lighting, and room temperature;* Skin condition;* Emergency evacuation ability;* History of weight loss or dehydration;* Elopement risk or history;* Smoking;* Presence of depression, thought disorders, behaviors, and mood; and* How the resident copes with change or challenging situations.The need to ensure new move in evaluations address all required elements and were reflective of the residents status was discussed with Staff 1 (Executive Director) and Staff 3 (Health Services Director/RN) on 10/12/22. They acknowledged the findings.
3. Resident 3 was admitted to the facility in February 2020 with diagnoses which included dementia. Observations of the resident on 10/11/22 and 10/12/22, interviews with staff, and review of the resident's current service plan and evaluation dated 08/30/22 revealed the resident was dependent on staff for all ADL care and was a two-person transfer with a Hoyer lift. The quarterly evaluation was not reflective in the following areas:* Speech ability, the resident was primarily non-verbal;* Current skin and wound care status;* One-to-one meal assistance; * Toileting assistance needed and frequency; and* Emergency evacuation ability noted the resident would need one caregiver to exit the community in the event of an emergency with a wheelchair; however, the resident required a two-person transfer with a Hoyer lift. On 10/13/22, the need to ensure quarterly evaluations were reflective of the resident's health status, current needs and conditions was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). They acknowledged the findings.
4. Resident 2 was admitted to the facility in 11/2020 with diagnoses including dementia. Resident 2's quarterly evaluation, dated 09/20/22, reviewed during the survey identified the following:a. The evaluation was not reflective of the resident's current needs in the following areas:* Activities, level of participation and activities of interests;* Two person repositioning while in bed;* Bathing assistance;* Outside providers noted incorrect provider information;* One to one dining assistance and preference to eat in room while in bed;* Nutrition and hydration preferences (none listed);* Ability to use call light system;* Two person fire evacuation assistance; and* Recent falls and current fall interventions were not listed. b. Resident 2's clinical record lacked documented evidence the use of a "body suit" was evaluated. The need to ensure quarterly evaluations were accurate and reflective of the resident's current care needs and interventions with potentially restraining qualities were evaluated and made part of the resident's record was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 09/2022 with diagnoses including dementia. On 10/10/22, Resident 5's initial service plan was requested from the facility, and could not be located.On 10/11/22 review of the service plan binders kept in the staff break room revealed no initial evaluation or service plan for Resident 5 available for staff. In an interview at 11:10 am on 10/11/22, the Med Tech and caregiver for Resident 5 both stated there was no information available.On 10/11/22, Staff 4 (RCC) printed a new copy of the initial service plan, but acknowledged that the copy for caregivers to use was missing.The requirement that service plans must be readily available to staff was reviewed with Staff 2 (Regional Director), Staff 3 (Health Services Director/RN), and Staff 4 (RCC) on 10/11/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, readily available to staff, provided clear caregiving instructions or were followed for 4 of 4 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in February 2020 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the clinical record and the most recent service plan dated 08/30/22, revealed the service plan was not reflective of the resident's care needs, was not followed by staff, and did not provide clear direction to staff in the following areas:* Customary routines related to getting up for meals and then going back to bed; * Home health service for wound care, including schedule; * Incontinence care provided in bed;* Repositioning throughout the day;* Foot rests to be used while in the wheelchair;* Geri sleeves to be placed on the resident in the morning and removed at night;* Shower schedule;* Right arm supported while in the wheelchair and bed; * One-to-one meal assistance;* Fluid and snack assistance between meals; and* Non-verbal indicators of pain.On 10/11/22 a review of the service plan binders kept in the staff break room revealed there was no service plan available for Resident 3. Resident 3's current service plan was requested from Staff 4 (RCC) and provided on 10/11/22. The need to ensure residents' service plans reflected current care needs, provided clear direction to staff, were available to staff and followed was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC).
4. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia.a. On 10/11/22, a review of the service plan binders for direct care staff revealed the quarterly evaluation/service plan for Resident 1 available for staff was dated 05/29/22.Upon request, Staff 4 (RCC) provided a copy of an updated evaluation/service plan, dated 08/29/22. During an interview with Staff 4, it was determined the most current service plan had not been accessible to direct care staff.b. Resident 1's service plan, dated 08/29/22, was not reflective of the resident's current status and did not provide clear instructions to staff in the following areas:* referred to use of a sling for a humerus fracture;* stated "attends meals with reminders";* activity preferences and accommodations needed;* recent history of falls;* dressing assistance needed in relation to hip precautions;* bathing instructions for staff to follow, hospice services;* toileting needs;* hip/leg pain and current interventions;* mobility status and needs;* nutrition and hydration needs, including meal assistance;* current skin wounds;* included wandering behavior; and* evacuation assistance needs.The need to ensure service plans were accessible to direct care staff, reflective of residents current needs and provided clear directions to staff was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.
3. Resident 2 was admitted to the facility in November 2020 with diagnoses including dementia.Resident 2's service plan, dated 09/20/22, was not reflective of the resident's current status, did not provide clear instructions to staff and/or staff did not follow the service plan in the following areas:* Monthly weights;* One-to-one dining assistance and preference to eat in room while in bed;* Hospice services provided bathing, incontinence care, dressing, grooming, personal hygiene and housekeeping;* Clear instructions for catheter care;* Activities, level of participation and activities of interests;* Behaviors and behavior interventions;* Two person assistance with repositioning while in bed;* Two person fire evacuation assistance;* Recent falls and current fall interventions* Use of a "body suit" lacked clear instructions that included who, when and how frequently staff were to use the body suit; and* Dietary needs to avoid lactose was not followed. The need to ensure service plans were reflective of residents' current needs, provided clear directions to staff and were followed was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed at least quarterly 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 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:Residents' 2 and 3 most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.On 10/13/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). They acknowledged the findings.

2. Resident 3 was admitted to the facility in February 2020 with diagnoses including dementia.Observations of the resident, interviews with staff, review of the service plan, dated 08/30/22, temporary service plans, "wound assessment" sheets, and progress notes dated 07/13/22 through 10/07/22 were reviewed and showed the following:* An 08/12/22 progress note documented the resident had an abdominal wound to the right side that was open and bleeding. Staff had cleaned and applied triple antibiotic ointment; and * An 08/20/22 progress note documented an "opened rash on breasts, cleaned and triple antibiotic ointment was applied." The skin conditions were not documented on the wound assessment sheets provided for Resident 3. There was no documented evidence the facility evaluated the resident's skin condition, consistently monitored or determined actions or interventions specific to each change of condition at least weekly until resolved.On 10/13/22, the resident's short-term changes of condition related to skin and compliance guidelines for changes of condition and monitoring were discussed with and provided to Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident changes of condition were evaluated, resident specific interventions were determined, documented and monitored for effectiveness with weekly progress noted to resolution for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Resident 1 had multiple falls and sustained a hip fracture. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in January 2020 with a diagnosis of dementia. Resident 1's clinical records revealed s/he had a history of falls with a humerus fracture in February 2022.The service plan, dated 05/29/22, identified Resident 1 as having a risk of falls and listed current interventions as "staff will need to check [him/her] frequently and when they see [him/her] awake and starting to stir, assist to get up ... safety checks 4x per shift".The record indicated Resident 1 fell on 08/04/22 while up early in the morning walking in the common area and sustained abrasions to his/her face. An Interim Service Plan (ISP), dated 08/04/22 listed fall interventions of "cue and remind resident to call for assistance ..., remind the resident to use a walker or wheelchair for mobility...". The incident and investigation reports, dated 08/04/22, did not include information on when the resident was last checked.Resident 1 experienced another fall on 08/05/22 when s/he was found face down on the floor in a hallway. The incident and investigation report, dated 08/05/22, did not include information on when the resident was last checked and did not identify any additional interventions to try and prevent falls.There was no documented evidence of new interventions being developed and implemented or a determination of the effectiveness of current interventions on the service plan following each of the falls.On 08/19/22, the record indicated Resident 1 was found on the floor in the common area and showed signs of pain and was unable to bear weight to stand. Resident 1 was sent to the hospital and diagnosed with a hip fracture. There was no documented evidence of whether the current fall interventions (assisting the resident up when awake, safety checks four times per shift) were being followed at the time of the fall and were effective, or whether new interventions needed to be developed.The facility failed to identify and document fall interventions after multiple falls and the resident sustained a hip fracture. The need to ensure changes of condition were monitored, interventions identified and implemented, and monitored for effectiveness was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.
3. Resident 2 was admitted to the MCC facility in 11/2020 with diagnosis of vascular dementia. A review of the service plan, dated 09/20/22, temporary service plans, and progress notes dated 07/13/22 through 10/07/22 identified the following short-term changes of condition:* On 07/18/22 - missed medication (Spironolactone);* On 07/20/22 - missed medication (Spironolactone);* On 08/08/22 - skin tear to the right lower arm;* On 08/11/22 - skin tear to the right lower arm;* On 09/14/22 - yellowish bruise on left shin;* On 09/18/22 - scrape on right forearm;* On 09/23/22 - resident was found unresponsive; and* On 09/24/22 - resident was found unresponsive.There was no documented evidence the facility evaluated and determined what action or intervention was needed for the resident, and communicated interventions or monitoring instructions to staff. The need to evaluate and determine actions need for residents following short term changes of condition and communicate clear instructions to staff was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, service plan updated, and referred to the RN for 1 of 1 sampled resident (#8) who experienced unplanned significant weight loss. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the facility in 02/2020 with diagnoses including advanced frontal lobe dementia.During the survey, Resident 1 was observed to receive meal cues and consumed approximately 85-100 percent of his/her meals.The most recent evaluation and service plan (dated 12/07/22) noted Resident 8's weight as 169 lbs.Between 12/07/22 (169 lbs.) and 01/01/23 (154 lbs.) s/he lost 15 lbs., or a decrease of 9% of his/her total body weight, in 25 days.There was no documented evidence Resident 8's significant weight loss had been evaluated, referred to the facility nurse, or the service plan updated to reflect the change of condition.The facility's lack of a system in place to evaluate changes of condition, update the service plan, and refer the significant change to the RN for assessment was discussed with Staff 1 (Executive Director) and Staff 4 (RCC) on 02/27/23. They acknowledged the findings.


RN and ED to audit chart notes of residents at least weekly to monitor for change of conditions.At Daily stand up meetings residents with change of conditions or possible change of conditions will be discussed.Resident # 8 change of condition was completed on her.RN and ED to oversee and monitor

2. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia. The resident sustained a hip fracture with surgical repair in August 2022 and returned to the facility with two pressure wounds, was admitted to hospice services and required two person, mechanical lift for transfers and extensive assistance with all ADL's. The resident was observed during the survey to be non-ambulatory and required meal assistance to complete meals. The fracture and decline in mobility and ADL functioning constituted a significant change in condition.A review of the resident's clinical record, including progress notes from 08/19/22 through 10/10/22 showed an "RN note" dated 09/02/22. The RN assessment note documented the resident's admission to hospice, use of a Hoyer lift for transfers and an assessment of the wounds. However, the assessment lacked the following:* information on findings: the resident's current level of ADL ability;* interventions developed as a result of the assessment; and* evidence the service plan was updated to reflect the changes in the resident's care needs. The need for an RN assessments to include findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 3 (Health Services Director/RN) on 10/12/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by the RN and included findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 2) who experienced significant changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in November 2020 with diagnoses including dementia. The resident was admitted to hospice on 07/12/22 which constituted a significant change of condition. Observations made during the survey showed staff provided full assistance with all ADL care while the resident remained in bed. There was no documented RN assessment of the significant change of condition, nor was the service plan updated to reflect the resident's changes in care needs. The need for significant change of condition RN assessments, which included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#8) who experienced a significant change of condition related to weight loss. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the facility in 02/2020 with diagnoses including advanced frontal lobe dementia. During the survey, Resident 8 was observed to receive meal cues and consumed approximately 85-100 percent of his/her meals. The most recent evaluation and service plan (dated 12/07/22) noted Resident 8's weight as 169 lbs.Between 12/07/22 (169 lbs.) and 01/01/23 (154 lbs.) s/he lost 15 lbs., or a decrease of 9% of his/her total body weight, in 25 days. The unplanned severe weight loss constituted a significant change of condition.There was no documented RN assessment completed for the weight loss which included findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Executive Director) and Staff 4 (RCC) on 02/27/23. They acknowledged the findings.

Weights to be audited by RN and ED at least weekly to capture and change of condtions that may be required as well as developing interventions for weight loss and weight gain as needed for residents with signficant weight loss or weight gain.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits was maintained in the residents' records or that recommendations were implemented for 2 of 3 sampled residents (#s 2 and 3) who were receiving services from outside providers. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia. Resident 3 was identified as receiving outside provider services related to wound care. A review of the resident's records showed on 09/26/22, home health skilled nursing provided wound care and left instructions and information for the facility that home health would visit two times per week. There was no documented evidence of outside providers' visits between 09/26/22 through 10/10/22. In an interview with Staff 3 (Health Services Director/RN) on 10/12/22, she confirmed that home health had not been leaving visit notes routinely.The need to ensure on-going coordination of care was maintained and documented was discussed with Staff 1 (ED), Staff 3 and Staff 4 (RCC) on 10/13/22. They acknowledged the findings.
2. Resident 2 received hospice services. The following recommendations for supplemental care from outside providers were not added to the resident's service plan and were not implemented:a. On 09/15/22 hospice left a written outside provider note to "please off- load bilateral heels to prevent skin breakdown." Observations made during the survey noted a box of medical supplies in the resident's room that included blue foam heel protectors.During an interview on 10/12/22, Staff 16 (MT) stated she was unaware if the resident was supposed to be wearing them. There was no documented evidence the recommendations were added to the resident's service plan.b. On 09/26/22, the resident was seen by the hospice RN due to the episodes of unresponsiveness. The hospice RN requested a change in the care plan that included new instructions for transferring from bed to wheelchair and new "monitoring" instructions during bed to wheelchair transfers. There was no documented evidence the change in care plan and new monitoring instructions were updated in the resident's service plan. The facility's failure to effectively communicate the new instructions from the outside provider and update the service plan was reviewed with Staff 1 (ED), Staff 3(Director of Health Services/ RN) and Staff 3 (RCC) on 10/12/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a physician or other legally recognized practitioner were carried out as prescribed for 1 of 3 sampled residents (#2) whose records were reviewed. Findings include, but are not limited to:Review of Resident 2's 09/01/22 through 10/10/22 MAR/TAR's, weight records and signed physician orders, dated 07/12/22 and 09/28/22, identified the following orders were not carried out as prescribed:* Monthly weights; and* Fluid enhancement: Assist and encourage to drink additional eight ounces of fluid between meals and with every medication pass.Multiple observations made during the survey, which included medication pass on 10/11/22 and 10/12/22, showed staff were not consistently following the fluid enhancement order. The need to ensure all orders for medications from a physician or legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:1. During the entrance conference and acuity interview on 10/10/22 the following was identified: * The memory care facility had 39 residents divided into two units;* Nine residents were identified as requiring 2-person care with transfers and/or use of mechanical lift device;* Caregivers' duties included serving meals, cleaning up after meals (floors, tables, kitchenettes), conducting daily activities and some laundry in addition to direct caregiving duties, which qualified them as "Universal Workers".Observations and interviews with staff during the survey and the facility's posted staffing plan for 10/10/22 to 10/12/22 was as follows: * During the day and swing shifts, there were four caregivers and one Medication Technician scheduled on duty; and* During the night shift, there were two caregivers and one Medication Technician scheduled on duty.The facility used an ABST (Acuity Based Staffing Tool) which determined a staffing plan. However, the facility failed to provide the number of direct caregivers as designated by the staffing tool. Refer to C 361.2. During the survey, a review of medication administration times for three sampled residents was completed. Medication administration times, reviewed from 10/05/22 through 10/12/22 were in excess of one hour past the scheduled administration time as follows:* Resident 1: experienced 47 medication passes that were in excess of one hour;* Resident 2: experienced 82 medication passes that were in excess of one hour; and* Resident 3: experienced 34 medication passes that were in excess of one hour. The need to ensure the facility provided enough direct care staff to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 10/13/22. No additional information was provided.

Based on interview and record review, the facility failed to use the results of an acuity-based staffing tool to develop and routinely update the facility's staffing plan. Findings included, but are not limited to:Record review on 10/11/22 of the posted staffing plan, the facilities own Acuity Based Staffing Tool (ABST), the staffing schedule for 10/09/22 to 10/13/22 and service plans for Resident 1, 2 and 3 revealed the scheduled staffing plan was not reflective of the ABST. Service plans for Residents' 1, 2 and 3 were not reflective of the residents care needs and the acuity tool, therefore, did not accurately measure the residents care needs.In an interview on 10/11/22 with Staff 2 (Regional Director) and on 10/12/22 with Staff 1 (ED) and Staff 4 (RCC) it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST. In addition, service plans were required to be updated to be included in the ABST tool staffing plan. The need to ensure a staffing plan was generated by the ABST, included accurate resident information and was followed was discussed with Staff 1, Staff 2 and Staff 4. They acknowledged the findings.

The Department imposed a condition on the facility on 12/02/22 and issued a continuance for the condition on 02/23/23. The facility has been working with the Department to resolve the condition. They remain out of compliance with C 361 until the condition is lifted.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code, and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:Fire and life safety records, reviewed for the period between 04/2022 and 10/10/2022, revealed the following:1. The facility failed to relocate or evacuate residents during fire drills; and the documentation was lacking in the following areas: * The escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* The number of occupants evacuated.2. Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Executive Director) and Staff 8 (Environmental Services Director) on 10/12/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who can follow instructions received instruction at admission and re-instruction in fire and life safety training, at least annually after admission. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:There was no documentation that residents who were able to follow instructions were provided with fire and life safety training at admission, or fire and life safety training at least annually following admission.The need to ensure residents who could understand instructions receive fire and life safety instructions at admission, and annual re-instruction was discussed with Staff 1 (Executive Director) and Staff 3 (Health Services Director/RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to Z 142, Z 162, C 270 and C 280.

Based on interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to 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. This is a repeat citation. Findings include, but are not limited to:Refer to C 270 and C 280.

3. Resident 5 was admitted to the facility in September 2022 with a diagnosis of dementia.Observations during the survey from 10/10/22 through 10/12/22, showed Resident 5 was not able to obtain food or fluids for themselves due to cognitive impairment and relied on staff.Resident 5's service plan, dated 09/20/22, lacked individualized information. The section for diet and nutrition documented the resident did not have any food likes or dislikes and could self select all food and beverage choices. An interview on 10/11/22, Resident 5's family provided information about food preferences and dietary needs that were not documented on the service plan.The need for individualized nutrition and hydration plans was discussed with Staff 1 (ED) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.
4. Resident 3 was admitted to the facility in February 2020 with diagnoses including dementia.Resident 3's 08/30/22 service plan instructed staff to provide snacks and fluids throughout the day. Observations of meals on 10/11/22 and 10/12/22 identified the resident needed full assistance from staff with eating and drinking. The resident was not observed to be provided snacks or fluids between the morning and noon meals. The need to ensure the facility implemented and followed residents' individualized nutritional plans was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/13/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed, followed and included in the service plan for 4 of 4 sampled memory care residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia. During observations of the resident on 10/10/22 through 10/12/22, it was revealed the resident was dependent on staff to attend meals, used a geri-chair for positioning during meals, required assistance from staff to complete eating meals, needed assistance to drink liquids and was dependent on staff for snacks and hydration.Resident 1's service plan, dated 08/29/22, had no individualized hydration and nutrition plan identified for the resident. The service plan did not include clear instructions to staff for ways to meet the resident's nutrition and hydration needs.The need for individualized nutrition and hydration plans was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/12/22. They acknowledged the findings.
2. Resident 2 was admitted to the MCC facility in November 2020 with a diagnosis of dementia. Resident 2 was admitted to hospice on 07/12/22.Resident 2's service plan, dated 09/20/22, lacked staff instructions or was not followed related to the resident's individual nutritional and hydration needs. Observations during the survey from 10/10/22 through 10/13/22, revealed Resident 2 was unable to obtain food or fluids for him/herself due to cognitive impairment. Staff were not observed to consistently follow Resident 2's physician orders to provide fluid enhancement between meals and with every medication pass. During an interview on 10/12/22, Staff 12 (CG) reported "snacks were passed between meals, the first snack pass is usually around 10 am and again before the end of my shift [2:00 pm]."On 10/11/22, the scheduled snack pass after lunch was not completed and on 10/12/22, the scheduled snack pass after breakfast was not completed.The need for individualized nutrition and hydration plans was discussed with Staff 1 (ED) and Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:Residents 1, 2, 3 and 5's service plans offered information relating to the resident's past interests; however, the facility had not thoroughly evaluated the following:* Current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. Observations of the residents from 10/10/22 through 10/12/22 revealed the lack of activity programs that included the residents in one to one or group interaction.There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities.The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 5 (Life Enrichment Director) on 10/13/22. They acknowledged the findings.

Resident 5 was admitted to the facility in September 2022 with the diagnosis of dementia.Resident 5's record documented behaviors including:* Directing profanity toward staff and residents;* Exit seeking;* Sexual behaviors toward and statements to other residents; and* Threatening caregivers with violence.Observations on 10/10/22 and interviews revealed staff did not have access to a copy of Resident 5's service plan. The survey team requested a copy of the service plan, and Staff 4 (RCC) provided a copy.The current service plan lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 10/12/22, the need to develop individualized behavior plans for residents with behavioral symptoms and provide the information to staff on all shifts was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services/RN). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to provide and update an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 2 and 5) with documented behaviors. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 11/2020 with diagnoses including vascular dementia and chronic urinary tract infections. A review of Resident 2's record and interviews with staff noted behaviors related to pulling on the catheter and "fecal smearing". The resident's service plan, dated 09/20/22, referenced behaviors related to pulling out his/her catheter and "fecal smearing". The service plan further noted Resident 2 wore a body suit to reduce the frequency of the behaviors. Observations and interview with Resident 2 on 10/12/22 noted the resident was not wearing the body suit and was pulling at the catheter tubing. In an interview with Staff 16 (MT) on 10/12/22 it was reported all his/her body suits were in the laundry. Staff 16 was unaware of any other interventions for redirecting or minimizing the resident's behavior. The service plan lacked clear instructions for staff on the use of the body suit; when to assist the resident to wear it, when it should be removed, risks and what to report, and lacked effective interventions to attempt prior to the use of the body suit. The need to ensure resident's with known behaviors have an individualized behavior plan was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.