Advocate Care

?Based on interview and record review, it was determined the facility failed to ensure residents were evaluated, referred to the facility nurse, changes were documented, and the service plan was updated for 1 of 1 sampled resident (#2) who experienced a significant weight gain, and failed to ensure actions or interventions were determined, documented, communicated to staff on each shift and weekly progress was noted to resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 11/2015 with diagnoses including inappropriate antidiuretic hormone secretion (a condition that causes water retention).

The resident’s progress notes and service plan addendums dated 01/01/25 to 03/31/25, service plan dated 03/13/25, 03/01/25 to 03/31/25 MAR, and six months of weights were reviewed. The following was identified:

Resident 2’s recorded weights were as follows:

* 02/15/25 – 113.7 pounds;

* 03/09/25 – 115.8 pounds;

* 03/11/25 – 131.8 pounds;

* 03/15/25 – 131.7 pounds; and

* 04/01/25 – 127 pounds (taken during survey).

From 03/09/25 to 03/11/25, the resident gained 16 pounds or 13.8% of his/her bodyweight, which was a significant change of condition. Subsequent weights confirmed the significant weight gain, which required the facility to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed.

There was no documented evidence the above was completed. At 12:32 pm on 04/01/25, Staff 3 (Director of Nursing Services) stated she had not been notified of the significant weight gain.


The need to ensure significant changes of condition were referred to the facility nurse, evaluated, documented, and the service plan was updated as needed was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 04/02/25. They acknowledged the findings, and no further information was provided.

?2. Resident 3 was admitted to the facility in 01/2019 with diagnoses including schizophrenia.

The resident's 01/01/25 through 03/30/25 progress notes, 03/13/25 service plan, evaluations, incident reports, and service plan addendums were reviewed. The following changes of condition were identified:

* An addendum to service plan, dated 03/21/25, indicated post surgical instructions which included “Staff will need to monitor [his/her] incision sight on [his/her] head.”

There was no documented evidence the facility monitored the resident at least weekly to resolution.

The need to ensure short-term changes of condition was monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff

3. Resident 1 was admitted to the facility in 03/2023 with diagnoses including anxiety due to PTSD.

A review of the resident's clinical records dated 01/01/25 through 03/31/25 indicated the following changes of condition:

* 02/14/25 – Resident returned from emergency room visit;

* 03/05/25 - Resident had a non-injury fall;

* 03/24/25 – RN/LPN noted “bruise above left eyebrow”’ and

* Resident experienced nine non-injury falls between 01/05/25 and 03/26/25.

There was no documented evidence the facility had evaluated these changes to determine actions and interventions or provided written instructions to staff related to fall interventions.

The need to ensure resident-specific instructions or interventions were developed, implemented, and reviewed for effectiveness were discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager), and Staff 3 (Director of Nursing) on 04/02/25 at 12:30 pm. They acknowledged the findings. A new fall evaluation form was provided to survey team on 04/02/25 at 1:45 pm.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed that included resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#3) who had a significant weight loss. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2019 with diagnoses including schizophrenia.

The resident’s 10/20/24 through 01/19/25 facility weight records, 01/01/25 through 03/30/25 progress notes, 03/13/25 service plan, evaluations, interoffice memos, and service plan addendums were reviewed. Interviews with staff were conducted.

On 03/21/25 Staff 3 (Director of Nursing Services) completed an RN assessment for a significant change of condition regarding “Res [Resident 3] return from the hospital for SDH [subdural hematoma] after a fall. Has some significant changes.” The RN assessment noted weight loss of “27#’s [pounds]” but no additional information about the resident’s status or interventions related to the weight loss were noted.

The most recent facility weight records revealed Resident 3 weighed 223.4 pounds on 01/29/25. On 04/02/25 Staff 3 confirmed Resident 3 was last weighed in the hospital and was “approximately 200 pounds.” Between approximately 01/29/25 and 03/21/25, Resident 3 lost 23.4 pounds, or 10% of his/her total body weight in less than two months, which was considered severe and triggered a significant change of condition. There were no additional weight records to review, and Staff 3 confirmed there was no documented evidence the facility had taken Resident 3’s weight since returning from to the facility. Resident 3 was weighed during survey on 04/01/25 and was 211 pounds.

During an interview on 04/01/25 at 1:00 pm, Staff 3 acknowledged Resident 3 had a significant weight loss while in the hospital related to not eating. “[S/he] had childhood trauma and won’t eat around people. I expected that [s/he] would gain weight once [s/he] was back and I would just watch to see if [s/he] was eating.” Staff 3 acknowledged the RN assessment lacked information regarding resident status and interventions. Prior to exit, Staff 3 completed a progress note that included additional information regarding resident status and identified and communicated interventions to staff.

The need to ensure an RN assessment was completed which documented resident status and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 3 on 04/02/25 at 1:15 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 11/2015 with diagnoses including traumatic brain injury and was identified in the acuity interview as having behaviors.

The resident’s 03/01/25 to 03/31/25 MAR, progress notes, and current physician orders were reviewed. The following was identified:

The resident had an order for clonazepam 1 mg, give 1 tablet as needed for anxiety prior to medical appointments or procedures. The MAR showed staff administered the medication on 03/08/25 and 03/23/25 for behaviors.

At 12:32 pm on 04/01/25, Staff 3 (Director of Nursing Services) confirmed the medication was to be given for anxiety prior to medical appointments and not for behaviors.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 04/02/25. They acknowledged the findings, and no further information was provided.

?2. Resident 3 was admitted to the facility in 01/2019 with diagnoses including schizophrenia.

The resident's 03/01/25 through 03/31/25 MARs, 03/21/25 physician orders and the 03/21/25 After Visit Summary from a hospital discharge were reviewed and noted the following:

1. The MAR showed the resident had an order for oxycodone 5 mg, administer half to 1 tablet every 6 hours PRN for moderate to severe pain. The After Visit Summary noted it was available to be picked up at the hospital pharmacy. On 04/02/25 at 10:10 am the surveyor attempted to review the Substance Distribution log and the oxycodone with Staff 2 (Resident Care Manager). Staff 2 acknowledged the medication was not in the facility. Staff 2 indicated when a medication is filled at the hospital “we have them fax over the prescription to [facility’s] pharmacy or we would send someone over to the hospital to pick it up.” On 04/02/25 at 12:15 pm, Staff 3 (Director of Nursing Services) indicated she requested the medication be delivered urgently.

2. A treatment order for white petroleum ointment was to be applied to a skull incision twice daily for 5 days between 03/21/25 through 03/26/25. The MAR revealed the 8 PM dose was not administered on 03/25/25 and 03/26/26 because “the drug/item was not available.” The treatment was administered at 8:00 am on 03/26/26. On 04/02/25 Staff 2 (Resident Care Manager) acknowledged the same medication was also available in the supply closet.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 and Staff 3 on 04/02/25 at 1:15 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure PRN medications given to treat resident's behavior were used only after non-pharmacological interventions were tried with ineffective results and then documented for 2 of 2 sampled residents (#s 1 and 3) who had PRN psychotropic medications prescribed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 03/2023 with diagnosis including anxiety due to PTSD.

Review of the resident's service plan, physician orders, and 03/01/25 through 03/31/25 MAR revealed the following:

Resident 1 was prescribed Quetiapine 25 mg (anti-anxiety medication), administer one tablet three times daily PRN for anxiety.

The facility failed to ensure the resident's MAR and clinical record included the following required information:

* Non-pharmacological interventions to attempt prior to administration of the medication on seven of the eleven occasions given between 03/04/25 and 03/30/2025.

The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager), and Staff 3 (Director of Nursing) on 04/02/25 at 12:30 pm. They acknowledged the findings.

?2. Resident 2 moved into the facility in 11/2015 with diagnoses including traumatic brain injury and was identified in the acuity interview as having behaviors.

The resident’s 03/01/25 to 03/31/25 MAR and current physician orders were reviewed. The following was identified:

The resident had an order for haloperidol lactate 2 mg/ml, administer 1 ml by mouth every 6 hours as needed for agitation. Staff administered the medication on 03/01/25, 03/02/25, 03/03/25, 03/13/25, and 03/30/25. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administering the medication.

The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 04/02/25. They acknowledged the findings, and no further information was provided.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

?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. Findings include, but are not limited to:

Fire and life safety records from 11/2024 and 03/2025 were reviewed and showed fire drill 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

* Evidence of alternate routes used.

Additionally, staff interviewed did not know the designated point of safety.

The need to ensure all required components were addressed and documented for each fire drill was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 3 (Director of Nursing Services) on 04/02/25 at 1:15 pm. The staff acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 02/28/25, the facility's failure to fully implement an acuity-based staffing tool was substantiated for 1 of 2 (#2) sampled residents. Findings include, but are not limited to:In an interview Staff 1 (Resident Care Manager Assistant) stated Staff 4 (Administrator) updated the ABST and confirmed the facility used the ODHS ABST.A review of the facility's resident roster indicated the facility is home to 30 residents. A review of the facility's ABST "Facility Section Details" indicated there were 32 residents entered. A review of the facility's ABST exported data indicated there were six current residents' whose profiles had not been updated at least quarterly; three residents listed in the tool no longer resided in the facility, and one resident (Resident 2) was not entered into the tool.Resident 2's service plan dated 01/23/25, indicated s/he was dependant on staff to provide assistance with ADLs including two-person transfer and did not have an ABST profile.In an interview Staff 1 stated Resident 2 moved into the facility on approximately 01/26/25.A review of the ABST care times indicated the facility needed approximately 11 staff on day shift, 9 staff on swing shift and 4 staff on night shift.A review of the posted staffing plan indicated the following:· Day shift 6:45 am to 3:00 pm: 1 nurse, 1 medication aide and 7 caregivers;· Swing shift 2:45 pm to 11:00 pm: 1 nurse, 1 medication aide and 7 caregivers; and · Noc shift 10:45 pm to 7:00 am: 1 nurse/ medication aide and 6 caregivers.A review of the facility's staffing schedule for 02/22/25 - 02/28/25 indicated the facility was not staffed according to the posted staffing plan for eight of 56 shifts and the facility was not staffed to the ABST time for nine of 56 shifts reviewed.The facility failed to implement and update and Acuity Based Staffing Tool.Findings were reviewed and acknowledged by Staff 1 (Resident Care Manager Assistant) and Staff 2 (Administrators Assistant) on 02/28/25.

Based on interview and record review, conducted during a site visit on 02/28/25, the facility's failure to fully implement an acuity-based staffing tool was substantiated for 1 of 2 (#2) sampled residents. Findings include, but are not limited to:In an interview Staff 1 (Resident Care Manager Assistant) stated Staff 4 (Administrator) updated the ABST and confirmed the facility used the ODHS ABST.A review of the facility's resident roster indicated the facility is home to 30 residents. A review of the facility's ABST "Facility Section Details" indicated there were 32 residents entered. A review of the facility's ABST exported data indicated there were six current residents' whose profiles had not been updated at least quarterly; three residents listed in the tool no longer resided in the facility, and one resident (Resident 2) was not entered into the tool.Resident 2's service plan dated 01/23/25, indicated s/he was dependant on staff to provide assistance with ADLs including two-person transfer and did not have an ABST profile.In an interview Staff 1 stated Resident 2 moved into the facility on approximately 01/26/25.A review of the ABST care times indicated the facility needed approximately 11 staff on day shift, 9 staff on swing shift and 4 staff on night shift.A review of the posted staffing plan indicated the following:· Day shift 6:45 am to 3:00 pm: 1 nurse, 1 medication aide and 7 caregivers;· Swing shift 2:45 pm to 11:00 pm: 1 nurse, 1 medication aide and 7 caregivers; and · Noc shift 10:45 pm to 7:00 am: 1 nurse/ medication aide and 6 caregivers.A review of the facility's staffing schedule for 02/22/25 - 02/28/25 indicated the facility was not staffed according to the posted staffing plan for eight of 56 shifts and the facility was not staffed to the ABST time for nine of 56 shifts reviewed.The facility failed to implement and update and Acuity Based Staffing Tool.Findings were reviewed and acknowledged by Staff 1 (Resident Care Manager Assistant) and Staff 2 (Administrators Assistant) on 02/28/25.

The findings of the kitchen inspection, conducted 06/11/24, 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.

The findings of the re-visit to the kitchen inspection of 06/11/24, conducted 08/14/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: Observation of the main kitchen on 06/11/24 at 09:30 am through 11:55 am revealed the following:a. An accumulation of food spills and splatters were visible underneath the stand mixer.b. The following areas were found in need of repair:* Loose fluorescent light cover;* Burned out fluorescent light; * Accumulation of water under the dish washing area with saturated towel on the floor;* A gap with exposed wood and putty in between the wall and door frame on the inside of the kitchen entry door;* The main entry door had paint chips, exposing the surface of the door; and * The wooden door to the dry storage area had chips.c. Multiple food items in the refrigerators, freezers, and dry storage area were found without dates when opened and/or prepared. d. Multiple cutting boards were found to be heavily scored and/or stained. Staff 1 (Dietary Manager) and Staff 2 (Resident Care Manager/Designee) toured the kitchen areas with the surveyor on 6/11/24. They acknowledged the findings.

The findings of the kitchen inspection, conducted 06/07/23, 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 Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 06/07/23, conducted 08/17/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 06/07/23 at 11:15 am, the following concerns were observed: * The ceiling vent and fan in the dry food storage area had an accumulation of dust; * In the walk in refrigerator: - A stack of three cardboard boxes were siting on directly on the floor, the top box contained hard boiled eggs; - A cardboard box containing individual portion cartons of milk were sitting directly on the floor; * In the dishwashing room: - The ceiling light was uncovered; - A box fan was operating that had an accumulation of dust; and * One staff was not wearing any type of hair restraint. The areas of concern were discussed with Staff 1 (Dietary Manager) and Staff 2 (Manager in Charge) on 06/07/23. The findings were acknowledged.

The findings of the re-licensure survey conducted 02/07/22 through 02/09/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.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 relicensure survey of 02/09/22, conducted 11/02/22, 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. 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 02/09/22 conducted, 02/01/23, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents and implement effective methods of infection control. Findings include, but are not limited to:1. On 02/07/22 at 9:30 am, care staff were observed providing linen changes for a resident on the unit. Care staff were observed carrying soiled linens through the hallway without placing the linens in a plastic bag. A blanket was observed dragging along the floor as care staff took the linens to the laundry room.2. On 02/07/22, soiled incontinent products were observed in an open trash can in room 30. The soiled products were not properly bagged for disposal. The sheets on the bed were observed to be stained. 3. On 02/07/22, staff were observed transporting a resident from the shower room using a shower chair. A trail of liquid was on the floor from the shower room to the resident room and there was a strong odor of urine.4. On 02/09/22 at 11:50 am, staff were observed placing a bag of soiled incontinent supplies on the floor in the hallway. The bag of soiled supplies remained on the floor for more than 10 minutes.5. During the survey, multiple hand washing stations throughout the facility did not have paper towels. 6. Multiple staff were observed wearing visibly soiled face shields.The need to implement effective infection control practices was reviewed with Staff 1 (Administrator) on 02/09/22. No additional information was provided.

2. Resident 2 was admitted to the facility in August 2021 and had diagnoses including neuropathy and hypertension.Observations and interviews on 02/07/22 and 02/08/22 showed the resident had two half-rails in the "up" position on either side of the bed and was wearing a nasal cannula with oxygen flowing via concentrator. The resident had an over-the-bed table with a lunch meal and was feeding him/herself a sandwich.The current service plan, dated 01/04/22, and temporary service plans were reviewed. The service plan did not provide clear instructions to staff in the areas of:* Use of side rails; and* Use of oxygen/concentrator.The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator) on 02/08/22. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services 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 1 was admitted to the facility in August of 2020 with a diagnosis of pain. Resident 1's service plan was reviewed. The service plan, dated 11/09/21, was not reflective of the resident's status and lacked clear instructions to staff in the following areas:* Pain and pain related to behaviors; and* Side rail use as a mobility device.The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.
3. Resident 3 was admitted to the facility in June 2021 with diagnoses including Type 1 Diabetes Mellitus and below the knee amputation.A review of the current service plan dated 01/18/22, check in guidelines dated 06/16/21 and interviews with the resident and staff were conducted during the survey.The service plan did not provide clear instructions to staff in the areas of:* Catheter care instructions, including steps for proper infection control; and* Pain, including non-pharmaceutical interventions for pain and how the resident expresses pain.The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 2 and 3) whose medication records were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in August 2021.Resident 2's MARs, reviewed from 01/01/22 - 02/07/22, revealed the following inaccuracies:Reasons for use was not indicated for the following medications administered by unlicensed staff:* aspirin;* Calcium + D3;* ibuprofen;* sennosides - docusate sodium; and* extra strength Tylenol.On 02/08/22, the need to ensure all medications on the MAR included reasons for use was discussed Staff 2 (Director of Nursing) and Staff 1 (Administrator). They acknowledged the findings.
2. Resident 3 moved into the facility in June 2021.Resident 3's MARs, reviewed from 01/01/22 - 02/07/22, revealed the following inaccuracies:Reasons for use was not indicated for the following medications administered by unlicensed staff:* acidophilus;* cetirizine; and* multiple vitamin-minerals.On 02/09/22, the need to ensure all medications on the MAR included reasons for use was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills and fire and life safety instruction was provided on alternate months in accordance with Oregon Fire Code (OFC). Findings include, but are not limited to:Review of fire drill and fire and life safety records from August 2021 through December 2021 identified the following:* The facility failed to provide fire and life safety instruction to staff on alternate months: and * Failed to provide evidence that fire drills were conducted every other month. The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 513.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit, all exterior pathways and accesses to the facility's common use areas were maintained, and exterior grounds were orderly, free of litter and refuse. Findings include, but are not limited to:The facility grounds were toured on 02/07/22 with Staff 1 (Administrator) and Staff 5 (Maintenance Supervisor). The following was observed:* A janitor's closet, located in a hallway near resident rooms, was observed to be unlocked and contained cleaning chemicals;* Rubbish was observed on the ground near the front entrance, near both smoking sections, and throughout the parking lot;* Cigarette butts littered the parking lot and planter boxes; * The interior courtyard (off the dining room) had piles of leaves, tree branches and an improperly stored hose laying on the pathway; and* Interior courtyard (near boiler room) had unmanaged landscaping, overturned containers, window screens on the ground, refuse and litter in piles on the ground. The need to ensure all toxic materials were maintained in locked storage, exterior pathways did not have potential tripping hazards and exterior grounds were kept free of litter was discussed with Staff 1 and Staff 5 on 02/07/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair and the interior of the facility was free from unpleasant odors. Findings include, but are not limited to:The interior and exterior of the facility was toured on 02/07/22 with Staff 1 (Administrator) and Staff 5 (Maintenance Supervisor). a. The following interior areas of the facility needed cleaning and/or repair:* Gouges, dark brown splatter and black marks on the white walls beneath the handrails through the entire building;* Handrails throughout the facility had large spots where the finish had worn off;* Multiple lights not working in the dining room, common hallways, and in resident rooms 19 and 21;* Multiple ceiling lights were missing covers;* Exposed electrical wires in room 30's bathroom ceiling;* Exposed electric wires in the laundry room ceiling;* Multiple ceiling tiles were broken and had brown stains throughout the building;* Multiple ceiling vents had buildup of dust debris;* Multiple cold air return vents on the walls had buildup of dust, debris;* Gouges in multiple resident doors throughout the building;* Black fabric storage bin in the dinning room had dried tan-colored stains;* Multiple brown chairs in the dinning room and living room had torn fabric; and* Fire doors on the north and south side of the building had multiple gouges.b. North shower room needed the following repairs: * Caulking around the sink was peeling and the sink was pulled away from the wall; * Transfer pole near the toilet had peeling paint and exposed rust;* Seal between floor and shower stall was worn with exposed subfloor underneath; * Linoleum floor had dark gray stains and was peeling with exposed subfloor underneath;* Door was splintered and had multiple gouges in the wood; and* Door frame had peeling paint and exposed rust areas.c. South shower room needed the following repairs:* Caulking around the sink was peeling and the sink was pulled away from the wall; * Seal between floor and shower stall was worn with exposed sub floor underneath; * Linoleum floor had dark gray stains and was peeling with exposed subfloor underneath;* Wallpaper (above the shower stall) was peeling with exposed sheet rock underneath;* Ceiling vent had buildup of dust debris; and* Ceiling support beam (south side of the building, near the shower room) had gouges in the wood and broken trim.d. From 02/07/22-02/09/22, there was a pervasive odor of marijuana throughout the facility.e. The following exterior areas of the facility needed cleaning and/or repair:* Multiple windows were missing screens or the screens were torn;* Several of the screens had a buildup of cobwebs and insects between the screens and windows;* Multiple window seals were worn and aluminum window frames were broken;* Multiple areas of the gutter system were damaged at the roof line and multiple down spouts were disconnected; and* UV protectant on multiple windows was peeling off.The need to maintain the interior and exterior of the facility in clean condition and in good repair was discussed with Staff 1 and Staff 5. They acknowledged the areas that needed cleaning and repair.
Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:The interior and exterior of the facility was toured on 11/02/22 with Staff 5 (Maintenance Supervisor). a. The following interior areas of the facility needed cleaning and/or repair:* Multiple ceiling vents had build-up of dust debris; and* Multiple brown chairs in the dinning room and the couch in the living room had torn fabric.b. South shower room needed the following repairs:* Sink was pulling away from the wall; and* Door frame had areas of paint missing.c. The following exterior areas of the facility needed cleaning and/or repair:* Multiple windows were missing screens; and* The down spout on the corner of the building by the smoking area was damage and disconnected.The need to maintain the interior and exterior of the facility in clean condition and in good repair was discussed with Staff 4 (Administrative Assistant) and Staff 5. They acknowledged the areas that needed cleaning and repair.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals and provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Findings include, but are not limited to:1. Observations during the survey from 02/07/22 through 02/09/22 revealed temperatures inside the building were consistently below 70 degrees during daytime hours. Temperatures obtained included the following:* 02/07/22 at 12:15 pm, room 18 was 64 degrees;* 02/09/22 at 9:00 am, the hallway near room 19 was 65 degrees;* 02/09/22 at 9:15 am, the common area TV room was 65 degrees. In separate interviews on 02/09/22, Residents 2 and 3 stated their rooms were cold. 2. During interviews on 02/07/22, care staff reported multiple resident rooms did not have heating devices. The facility was providing space heaters for the resident's use to heat the rooms as needed. On 02/09/22, a space heater was observed in use on the floor in room 18, near the resident's bed. The surface temperature of the heater was obtained and was 214 degrees Fahrenheit. The need to ensure resident areas could be maintained at a minimum of 70 degrees and that any covers, grates or heating elements on heating devices did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) on 02/09/22. She acknowledged the findings and stated the facility planned to have PTAC units installed in resident rooms.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:Observations on 02/07/22 through 02/09/22 revealed the following exit doors failed to have an alarm or other acceptable system to alert staff when residents exited the building.:* North and south side exit doors (exit doors required a code to exit). The exit door code was posted on the wall by each door and multiple non-sampled residents were observed to enter and exit the coded doors.* Door off the main hallway (near the kitchen), led through a small corridor, to an exit door that was not alarmed; and* Interior courtyard exit doors (near boiler room and off the dining room) were not alarmed. During an interview with Staff 6 (CG), s/he confirmed there were not alarms on the north exit door, south exit door, or courtyard exit doors, however there were alarms on other exit doors. The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.