Clatsop Care Memory Community

The findings of the re-licensure survey, conducted 04/01/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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. Tag numbers beginning with H refer to the Home and Community Based Services Rules OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 04/04/24, conducted 08/26/24 through 08/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 04/04/24, conducted on 10/18/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 01/20/24 service plan, 01/07/24 through 04/01/24 progress notes, physician communications, and incident investigations were completed. The resident was noted to be independent with most ADLs and ambulated on his/her own. The resident was unsteady on his/her feet and did have occasional falls. The resident could make some needs known and answer simple questions. Review of the resident's records showed the following:* An incident report dated 01/06/24 indicated the resident was in another resident's apartment and was hit with a shoe;* An incident report dated 01/23/24 indicated the resident was found on the floor naked, s/he stated their shoulder was painful, and an abrasion was noted to the right shoulder; and* An incident report dated 03/27/24 indicated the resident was found in the apartment of his/her companion resident. Resident 6 was found with a skin tear to the arm and a red mark under his/her left eye.There was no additional information regarding the incidents and no reports were made to the local SPD unit.Staff 1 (Administrator) was asked to report the incidents and provided confirmation of the reports prior to survey exit.The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1 on 04/04/24. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to promptly investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office, if abuse could not immediately be ruled out, for 3 of 5 sampled residents (#s 3, 4 and 6) with incidents or injuries of unknown cause. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia.Interviews with staff and review of the resident's clinical record were completed, including most recent service plan dated 03/15/24, temporary service plans (TSPs), incident reports and progress notes. The following was identified: * An incident report was completed on 02/15/24 at 11:30 am indicating Resident 4 was found with a skin tear to the left forearm. Staff stated "we are not sure how she acquired this skin tear". When asked, the resident could not explain how the injury occurred. There was no documented evidence the facility immediately reported the injury of unknown cause to the local SPD office. At the request of the survey team, the facility reported the incident to the local SPD and a confirmation was provided to the survey team prior to exit.The need to ensure all injuries of unknown cause were reported to the local SPD office, unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 09/2020 with diagnoses including dementia.The resident's clinical record was reviewed, including progress notes dated 01/05/24 through 03/27/24, incident reports, and temporary service plans, and staff were interviewed.In a 02/18/24 progress note, written at 1:02 pm, staff documented "a red bruised area on the left side of the residents [sic] chin area" was noticed during breakfast. At that time staff wrote it was "unknown at this particular time how it occurred."On 02/20/24 the bruise on the resident's face was investigated by Staff 2 (RN). She noted, "Caregivers on noc [overnight] shift heard and raced to a commotion and saw [resident] standing not too far from [another resident]. They report not seeing any physical activity upon arrival." She documented, "It is possible however inconclusive that [the other resident] hit [Resident 3] prior to the noc caregivers' arrival to the scene." Staff 2 documented abuse and neglect were ruled out.There was no documented evidence the possible resident-to-resident altercation was reported to the local SPD office.On 04/03/24 Staff 1 (Administrator) was directed to immediately report the possible resident-to-resident altercation to the local SPD office, and confirmation of the report was received on 04/03/24 at 10:39 am.The need to ensure all incidents of abuse or suspected abuse are immediately reported to the local SPD office and promptly investigated to rule out abuse was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:During the survey, 04/01/24 through 04/04/24, observations of the facility showed bingo was conducted daily, a bus ride was offered on Tuesday, and ball bounce was played on Wednesday afternoon. No additional activities were observed during survey. Multiple residents were observed throughout the day wandering the halls, asleep in the living room, or watching TV in the living room.Review of the activity calendar showed three to five scheduled activities a day. All scheduled activities noted on the calendar were not observed during survey. Daily activities included snack and hydration pass and men's facial care. The men's facial care was observed to include shaving of male residents while in the living room. In an interview on 04/01/24, Staff 1 (Administrator) indicated the position of the activity aide was recently vacated and they were working to fill the opening. The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. 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' care needs, provided clear direction for staff, and were consistently implemented by staff for 3 of 6 sampled residents (#s 1, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's service plan, dated 03/14/24, and progress notes, dated 01/22/24 to 03/26/24, were completed. Staff indicated the resident was dependent on staff for ADL care and required two staff for transfers.The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not followed by staff in the following areas:* Falls and safety interventions;* Behaviors during care;* Gait belt use and 1 person vs. 2 person transfers;* Toileting;* Activities;* Grooming; and* Mental health diagnoses.The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings.2. Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/20/24, and progress notes, dated 01/07/24 to 04/01/24, were completed. Staff indicated the resident was able to complete several of his/her ADLs on his/her own. The resident required stand-by assist with bathing and occasionally toileting. The resident was able to ambulate and transfer on his/her own.The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not implemented by staff in the following areas:* Falls and safety interventions;* Resident-to-resident altercations;* Relationship with room 9;* PRN assistance with ADLs;* Activities;* Shower assistance; and* Agitation, exit seeking for a "gig," and behaviors related to room 9.The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 03/15/24, and progress notes, dated 01/03/24 through 04/01/24, were completed. Staff indicated the resident was dependent on staff for ADL care and required three staff for transfers.The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not implemented by staff in the following areas:* Three-person transfer assistance;* Two-person assist for bed mobility, dressing, and hygiene cares;* Tilt in space wheelchair with calf support strap;* Pressure reducing boots on both feet at all times;* Rolled blanket next to resident on open side of bed;* Pressure reducing cushion in wheelchair;* Arm protectors on at all times;* Push fluids all shifts;* Daily Foley catheter care instructions;* Elevate heels/feet with pillows in bed;* Ability to use call system;* Straw in drinks;* Fall history; and* Location of pain.The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 03/14/24, and progress notes, dated 01/22/24 through 03/26/24, were completed.a. The resident experienced multiple short-term changes of condition without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas:* New move in;* Injury and non-injury falls;* Wheelchair changes;* Red marks to the face; and* Medication changes.b. Staff indicated the resident had increased confusion and weakness when s/he first came to the facility. The resident came after hip surgery and repeatedly attempted to get up out of the geri chair s/he was seated in. The resident had poor safety awareness and required full assistance with ADL care and transfers. Review of incident reports and investigations showed the following:* An incident report dated 01/24/24 indicated the resident slid out of the chair and was found yelling for help. No injury was noted. * An incident report dated 02/13/24 indicated the resident was found on the floor, with no injuries noted.* An incident report dated 03/02/24 indicated the resident scooted out of the chair and tipped forward. The resident repeatedly attempted to get out of the chair on that day. There were no injuries noted.* An incident report dated 03/14/24 indicated the resident was found on the floor in the lobby. The resident fell out of the wheelchair, no injury was noted. A new cushion for the wheelchair would be ordered to help keep the resident from scooting forward.* An incident report dated 03/19/24 indicated the resident was found on the floor in another resident's apartment. There was no injury noted, and staff were able to assist the resident out the apartment.* An incident report dated 03/21/24 indicated the resident was found on the floor in his/her room, next to the bed. The bed was in the low position, and no injuries were noted to the resident.There was no documentation in the resident's record the facility had completed investigations of the incidents to determine the cause, minimize reoccurrence, develop and implement interventions and to re-evaluate existing interventions for appropriateness and effectiveness.In interview on 04/01/24, the resident was unable to answer questions regarding the falls. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, interventions were evaluated for effectiveness and provided clear resident-specific directions to staff was discussed with Staff 1, Staff 2, and Staff 3 (RCC) on 04/03/24 and 04/04/24. The staff acknowledged the findings.4. Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/20/24, and progress notes, dated 01/07/24 through 04/01/24, were completed. The resident experienced multiple short-term changes of condition without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas:* Resident-to-resident altercations;* Body aches;* Sexual behaviors in common areas;* Relationship and agitation with another resident; and* Medication changes.The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. The staff acknowledged the findings.
2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia, cerebral vascular accident, and post-polio syndrome.The resident's clinical record, including progress notes, dated 01/13/24 through 04/01/24, and incident reports, were reviewed, and interviews with staff were conducted. The following was identified:* An incident report dated 02/12/24 reported Resident 4 had a fall from bed and sustained a skin tear to the left elbow and a red mark on his/her left cheek bone. A rolled blanket intervention was determined to be placed on the side of the resident to help remind him/her of where the edge of the bed was; and* An incident reported dated 03/14/24 reported the resident had sustained a skin tear to the left leg during a transfer from bed to the wheelchair.There was no documented evidence staff had evaluated the effectiveness of interventions and/or determined if additional actions or interventions were indicated, communicated actions or interventions to staff on all shifts, or monitored progress and effectiveness of interventions weekly through resolution.The need to ensure interventions were evaluated for effectiveness, additional actions or interventions were determined as indicated and communicated to staff on all shifts, and any new interventions were monitored for effectiveness weekly through resolution for short-term changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure there was documented monitoring at least weekly to resolution for short-term changes of condition, interventions were evaluated for effectiveness, and resident-specific interventions were determined, communicated to staff on all shifts, and implemented for 4 of 6 sampled residents (#s 1, 4, 5, and 6) reviewed with changes of condition.1. Resident 5 was admitted to the facility in 01/2024 with diagnoses including dementia.The resident's service plan, dated 02/16/24, progress notes, dated 01/02/24 through 04/01/24, temporary service plans, and incident reports were reviewed. Staff were interviewed. The following was identified:The resident experienced multiple changes of condition:* 01/04/24 and 01/05/24 - multiple medications refused;* 01/11/24 - new diet;* 01/17/24 - report of a person entering his/her room when s/he was sleeping, laying next to him/her on the bed, and having "fought" the person;* 01/21/24 - medication refusals;* 02/16/24 - placed on alert charting upon returning to the facility the morning following an overnight visit with family;* 02/26/24 - medication change; and* 03/04/24 - medication changes.There was no documented evidence these short-term changes of condition were monitored through resolution.In addition, the resident experienced a severe weight gain, which was identified on 02/15/24. The significant change of condition was assessed by the facility RN, who determined the resident would be weighed weekly to monitor the weight gain.There was no documented evidence weekly weights were implemented for the resident.The need to implement determined interventions and monitor changes of condition through resolution, with progress noted at least weekly, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure they staffed based on their Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to:Review of the ABST, the March and April 2024 staffing schedule, and the posted staffing plan was completed on 04/01/24 and 04/02/24. The facility was not staffing to or exceeding the indicated number of staff calculated by the tool for the day and evening shifts.The need to ensure the facility was staffed according to the ABST generated staff hours was discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted on alternating months, for all shifts, and that all required components were documented on the fire drill form in accordance with the Oregon Fire Code. Findings include, but are not limited to:Fire and life safety records, reviewed between 10/2023 and 03/2024, showed documentation was lacking in the following areas:* The escape route used;* Problems encountered;* Evidence of alternate routes used;* Evacuation time-period needed; and* The number of occupants evacuated.The fire drills were not completed at least every other month on alternating shifts.The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months, for all shifts, was discussed with Staff 1 (Administrator) and Staff 17 (Maintenance Director) on 04/02/24. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months of fire drills or conduct fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:Fire and life safety records, reviewed between 06/03/24 and 08/26/24, revealed the following:* Fire and life safety instruction was not consistently provided to staff on alternating months; and * There had been no fire drills completed between 06/03/24 and 08/26/24.In an interview on 08/26/20, Staff 17 (Maintenance Director) and Staff 1 (Administrator) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months and fire drills were not conducted according to the OFC. On 08/27/24 at 3:59 pm Staff 17 conducted a fire drill which included documentation of all required components.
Fire drills will be happening monthly for nine months and fire and life safety instructions every other month. All fire and life safety drills will be evaluated monthly for nine months and brought to quarterly Q.A.P.I. meetings. Maintenance Director is responsible to see that this is completed. Administrator to review documentation monthly.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to:Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 04/02/24. There was no documentation of annual training conducted with residents related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire.In an interview on 04/02/24, Staff 1 indicated the facility had not been conducting annual training with residents. She acknowledged there were residents currently in the facility who would be able to participate with fire and life safety training. Staff 1 further indicated they would implement a plan to address annual training with the residents who were able to understand.

Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 420.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:Observations of the facility on 04/01/24 showed the following areas in need of cleaning or repair:* Multiple walls, doors, and door frames in the living room, dining room, and activity room had scrapes, dings, chips, missing pieces of plaster, spills, and/or black streaks;* A cupboard in the Jacuzzi room was damaged and the side was pulled apart, and a wall was scraped and chipped;* Walls in the laundry room had scrapes, splatters, and dings. The flooring in the east laundry room had a large section of missing linoleum around the drain. The west laundry room had small pieces of linoleum that were chipped and/or missing;* Numerous black scratches, deep gouges, and dings were noted on the flooring in the living room near the fireplace area;* Multiple areas of the laminate floor throughout the two front halls were pulling apart at the seams, creating a gap in the flooring. Several entry ways to bedrooms had no transition between the hall and bedroom flooring, which created a large gap between the two flooring types;* Numerous chairs located in the dining room, activity room, and hallway had missing vinyl, which left an exposed fabric layer. A sofa in the entryway of the building had a large tear in the left arm rest, with exposed stuffing. A recliner chair near the dining room had food spills and debris and dining room chairs had spills and debris on the seats and lower arms;* Window sills in the dining room had splatters, debris, and dead insects;* Strong, pervasive urine odors were present in Room 7 and the nearby hallway and alcove; these odors did not dissipate during the survey;* Courtyard doors and the facility's front door had significant scrapes and dings to the lower portions of the door; and* Two unused nurse's stations had scrapes, splatters, chips, and dings on the outer walls, inner walls, and/or corners were chipped with pieces of missing plaster.The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings.

Technical assistance was provided in the following area:(2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Technical assistance was provided in the following area related to H1518:(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C231, C242, C361, C420, C422, and C513.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 420.
Refer to C 420

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 3, 13, and 20) completed all required pre-service orientation and dementia training topics; 3 of 3 staff (#s 13, 16, and 20) demonstrated competency in all assigned job duties within 30 days of hire; 2 of 2 long term staff (#s 4 and 14) completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training on dementia care; and 2 of 2 long term non-care staff completed annual infectious disease training. Findings include, but are not limited to:Staff training records were reviewed on 04/03/24. The following was identified:1. There was no documented evidence Staff 3 (RCC), hired 02/22/24, Staff 13 (CG), hired 01/31/24, and Staff (20), hired 01/11/24, completed one or more of the following pre-service orientation and dementia training topics:* Infectious Disease Prevention;* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.2. There was no documented evidence Staff 13 (CG), hired 01/31/24, Staff 16 (MT), hired 08/08/23, and Staff 20 (CG), hired 01/11/24, demonstrated competency in one or more of the following areas within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.3. There was no documented evidence Staff 4 (CG), hired 07/31/20, and Staff 14 (MT), hired 04/07/21, had completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training related to dementia care.4. There was no documented evidence Staff 5 (Dietary Aide), hired 09/21/18, and Staff 19 (Dietary Manager), hired 11/16/15, completed the required annual infectious disease training.The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 24, 25, and 26) completed all required pre-service dementia training topics and 3 of 3 staff (#s 24, 25, and 26) demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 08/27/24 with Staff 1 (Administrator). The following was identified:1. There was no documented evidence Staff 24 (CG), hired 07/08/24, Staff 25 (CG), hired 05/23/24, and Staff (26), hired 06/21/24, completed the following pre-service orientation and dementia training topic:* Use of supportive devices with restraining qualities in memory care communities.2. There was no documented evidence Staff 24 (CG), hired 07/08/24, Staff 25 (CG), hired 05/23/24, and Staff 26 (CG), hired 06/21/24, demonstrated competency in one or more of the following areas within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.The need to ensure the required pre-service training was completed by staff in the time frames specified in the rules, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire, was discussed with Staff 1, Staff 3 (RCC) and Staff 9 (Administrative Assistant) on 08/27/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C260 and C270.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 6 sampled residents (#s 3 and 5) whose records were reviewed. Findings include, but are not limited to:Resident 3 and 5's current service plans, dated 03/19/24 and 02/16/24, respectively, were reviewed. Both service plans were found to be lacking information and staff instructions related to an individualized nutritional plan.The need to develop an individualized nutritional plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop individualized activity plans from the evaluations completed, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 5 of 6 sampled residents' (#s 1, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:A review of service plans for Residents 1, 3, 4, 5, and 6, and interviews with Staff 1 (Administrator) and Staff 21 (Activity Director) and during survey, revealed the following:1. There was no documented evidence an individualized activity plan had been developed for Residents 1, 3, 4, 5, and 6 based on their activity evaluation that was reflective of the resident's activity preferences and needs.2. There was no documented evidence a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate and based on the resident's evaluation.The need to ensure the facility developed an individualized activity plan based on the evaluation for each resident, and provided daily structured and non-structured activities based on the evaluation, was discussed with Staff 1, Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

The findings of the re-licensure survey, conducted 05/17/22 through 05/18/22, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 05/18/22, conducted 10/26/22 through 10/27/22, 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 57 for Memory Care Communities.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 re-visit to the re-licensure survey of 05/18/22, conducted 03/23/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.

Based on interview and record review, it was determined the facility failed to ensure unwitnessed falls were thoroughly investigated to rule out abuse/neglect and reported to the local SPD office, as appropriate, for 1 of 1 sampled resident (# 2) with incidents. Findings include, but are not limited to:Resident 2 was admitted to the facility in 04/2019 with diagnoses including dementia.Review of the resident's clinical records, including progress notes, incident reports, investigations, and temporary service plans, dated 02/17/22 through 05/17/22, revealed the resident had an unwitnessed fall and sustained bruising and skin tears to the left shoulder and left upper arm on 05/10/22. There was no documented evidence the unwitnessed fall with injury had been investigated to rule out abuse, and the facility did not report to the local SPD office. The need to ensure resident incidents were thoroughly investigated and reported to the local SPD office when indicated was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RN Consultant) on 05/18/22. They acknowledged the findings. Verification the facility had reported the incident to the local SPD office was received on 05/18/22.

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:On 05/17/22 at 2:20 p.m., the facility's main kitchen was observed to need cleaning or repair in the following areas:* Floors throughout the kitchen had black matter build-up and food debris in corners, around perimeter edges, under equipment and inside floor drains. Floors additionally had large scratches, gouges and large sections with scraped and missing paint;* Shelving throughout the kitchen, including the refrigerator and freezer, and shelving in the dry storage, had food spills, white/gray accumulation, dust, and/or debris hanging from edges; * Ceiling vents had an accumulation of lint and dust on the grates;* Ceiling lights throughout the kitchen had dead insects and debris inside;* Two floor fans had caked-on dust and cobwebs; and* Doors frames and walls had splatters, dust/cobwebs, spills and/or chips.On 05/17/22 the two kitchenettes were observed to need cleaning or repair in the following areas:* Debris and spills were noted in drawers and cupboards;* Counter edges had chips, gouges and missing pieces of laminate;* Spills/splatters were on walls near the refrigerators;* A fan on the floor had thick dust and cobwebs hanging from the front;* Spills and debris were noted on shelves and in drawers of refrigerators; and* Microwave was noted with spills and splatters along the inside of the door, sides, and top.The need to ensure the kitchen and neighborhood kitchens were kept clean and in good repair was shown to and discussed with Staff 1 (Administrator) and Staff 6 (Dietary Manager) on 05/17/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 1 of 1 sampled resident (#1). Findings include, but are not limited to:Resident 1 was admitted to the facility on 03/02/22. The resident's move-in evaluation was dated 03/02/22. The following elements were not addressed in the move-in evaluation:* Customary routines: eating, bathing;* Interests, hobbies, social, leisure activities;* Spiritual, cultural preferences and traditions;* List of current diagnoses;* Vital signs if indicated by diagnosis, health problems, or medications;* Memory, orientation, confusion, and decision-making abilities;* Presence of depression, thought disorders, or behavioral or mood problems;* History of treatment and effective non-drug interventions;* Personality, including how the person copes with change or challenging situations;* Ability to understand and be understood;* ADLs including mobility, assistive devices, and dental status;* Ability to use call system;* Transportation;* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;* Nutrition habits, fluid preferences, and weight if indicated;* Complex medication regimen;* Recent losses;* Unsuccessful prior placements;* Elopement risk or history;* Smoking, ability to smoke safely;* Alcohol and drug use not prescribed by a physician; and* Environmental factors which impact the resident's behavior, including, but not limited to, noise, lighting, and room temperature.The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/18/22. 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 (#6) who recently moved in. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in early September 2022. The resident's move-in evaluation was dated 08/17/22. The following elements were missing or not addressed in the move-in evaluation:* Effective non-drug interventions for mental health issues;* Personality, including how the person copes with change or challenging situations;* Pain: pharmaceutical interventions, including how a person expresses pain or discomfort;* Skin condition;* Nutrition habits;* Emergency evacuation ability;* Elopement risk or history; and* Environmental factors which impact the resident's behavior, including, but not limited to, noise, lighting, and room temperature.The need to ensure move-in evaluations addressed all required areas and information was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 10/26/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced a significant change of condition were assessed by the RN for 1 of 2 sampled residents (#4) with a significant change of condition. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's Disease. Review of the resident's 02/14/22 through 05/17/22 weight records, progress notes, and RN assessments, observations of the resident, and interviews with staff revealed the following: Resident 4's weight on 02/25/22 was 183 lbs. His/her weight on 04/05/22 was 198.2 pounds. This represented a 15.2 weight gain or 8.3 percent of the resident's body weight in one month, which was severe. There was no documented evidence the RN had completed an assessment of the resident when s/he experienced a severe weight gain. The resident's weight on 05/17/22 was 191 lbs. This represented a 7.2 lb or 3.6% weight loss. The resident was observed to be fed by staff on multiple occasions during the survey. In an interview with Staff 2 (RN), she acknowledged an assessment had not been completed. The RN indicated the facility had attributed the resident's weight gain to increased oral intake as the resident had transitioned from feeding him/herself to allowing staff assist during that time frame. The need to ensure residents who experienced a significant change of condition were assessed by the RN was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RN consultant) and Staff 4 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure on-site health services were coordinated with outside health providers and that providers left written information in the facility which addressed the services being provided and any clinical information necessary for facility staff to provide supplemental care for 1 of 2 sampled residents (#4) who received services from outside providers. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's Disease. Review of the resident's facility record and interviews with staff revealed the following: During the acuity interview on 05/17/22, Resident 4 was identified to be receiving hospice services. A progress note dated 04/19/22 indicated hospice services had been initiated. During an interview with Staff 1 (Administrator), she stated the facility was unable to locate hospice provider written communications. The need to ensure on-site health services were coordinated with outside health providers and that providers left written information in the facility which addressed the services being provided and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN consultant) and Staff 4 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and/or provided clear instruction and parameters for administration of PRN medications for 2 of 4 sampled residents (#s 2 and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2 admitted to the facility in April 2019 with diagnoses to include diabetes. Resident 2's 05/01/22 through 05/17/22 MAR was reviewed and revealed the following:* Blood Glucose Monitoring (CBG) was ordered to be checked twice a day, before breakfast and dinner. On three occasions the MAR was blank where the CBG should have been documented. * Basaglar Insulin 15 units subcutaneous injection was ordered to be administered daily with dinner. On three occasions the MAR was blank where the insulin administration should have been initialed as given. * High protein snacks were ordered to be provided three times a day. There were 27 occasions the MAR was blank where the snacks should have been initialed as given. Staff 4 (RCC) reported staff had forgotten to go back and initial the MAR/DAR (Diabetic Administration Record) after checking Resident 2's CBG, administering insulin and after providing snacks. The need to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RN Consultant) on 05/18/22. They acknowledged the findings.
2. Resident 4 was admitted the facility in 05/2021 with diagnoses including Alzheimer's Disease. Review of the resident's current physician orders and the 04/1/22 through 05/17/22 MAR revealed the following: a. Resident 4 had multiple PRN bowel and pain medications which lacked parameters which instructed staff related to the sequence of administration.b. There were multiple blanks on the MAR. The need to ensure the MAR was accurate and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to maintain legible signatures of staff who administered medications and treatments, either on the MAR or on a separate signature page, filed with the MAR for 4 of 4 sampled residents (#s 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: A review of Resident 2, 3, 4 and 5's 05/01/22 through 05/17/22 MARs revealed there were no documented signatures to identify which staff administered medications and treatments.The need to ensure the facility maintained legible signatures of staff who administer medications and treatments, either on the MAR or on a separate signature page filed with the MAR, was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of PRN psychotropic medications and specific reasons for the use of the psychotropic medication for the resident were communicated to staff for 1 of 3 sampled residents (#4) who received as needed psychotropic medications. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's Disease.Review of the resident's current physician orders, 04/04/01/22 through 05/17/22 MAR, and progress notes revealed the following: A 04/18/22 physician order instructed staff to administer one 0.5 mg tablet oflorazepam every six hours as needed for anxiety, agitation, or nausea. There was no documented evidence the facility provided information to staff as to how the resident expressed anxiety or agitation or what non-drug interventions to attempt prior to administration of the PRN psychotropic medication. The medication was administered three times on 04/22/22 and once on 04/23/22. There was no documentation related to why the medication was administered or that non-pharmacological interventions were attempted prior to administration.The need to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medications and the specific reasons for the use of the psychotropic medication for the resident were communicated to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of PRN psychotropic medications for 2 of 2 sampled residents (#s 6 and 7) who received psychotropic medications. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in September 2022 with diagnoses including Alzheimer's Disease.Review of the resident's current physician orders, 10/01/22 through 10/26/22 MAR, and progress notes revealed the following: a. Resident 6 had a physician's order for Quetiapine 50 mg every four hours as needed for agitation. The resident received the PRN medication eleven times between 10/01/22 and 10/26/22. Ten of the eleven administrations lacked documentation that non-pharmacological interventions were tried and were ineffective before administering the medication.b. Resident 6 had a physician's order for Lorazepam 0.5 mg twice a day as needed for anxiety. The resident received the PRN medication nineteen times between 10/10/22 and 10/26/22. Thirteen of the nineteen administrations lacked documentation that non-pharmacological interventions were tried and were ineffective before administering the medication.2. Resident 7 was admitted to the facility in September 2020 with diagnoses including dementia.Resident 7 had a physician's order for Lorazepam 0.5 mg every day as needed for agitation. The resident received the PRN medication three times between 10/01/22 and 10/26/22. Three of the three administrations lacked documentation that non-pharmacological interventions were tried and were ineffective before administering the medication.During interviews on 10/26/22 with Staff 15 (MT) and on 10/27/22 with Staff 19 (MT), the electronic MAR was reviewed. Staff were unable to locate documented non-pharmacological interventions in the electronic system. Staff 15 stated that MT's had been instructed to enter a progress note following the administration of PRN psychotropic medications to document the interventions attempted before giving the medications. The need to ensure documentation that non-pharmacological interventions were attempted and found ineffective prior to the administration of psychotropic medications was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 10/27/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident service plan and evaluated on a quarterly basis for 1 of 1 sampled resident (#4) who had a side rail. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's disease. Review of the resident's facility record revealed a lack of documented evidence the use of the side rail had been included in the service plan and evaluated on a quarterly basis. The need to ensure documentation of the use of supportive devices with restraining qualities was included in the resident service plan and evaluated on a quarterly basis was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 8, 12, 17 and 18) completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to:A review of staff training records on 05/18/22 revealed the following:There was no documented evidence Staff 8 (CG), Staff 12 (CG), Staff 17 (CG), or Staff 18 (MT), hired 01/21/22, 04/15/22, 01/31/22, and 09/13/21, respectively, had completed the required training in First Aid and abdominal thrust.The need for staff to complete all required training within the appropriate time frame was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:Fire drill records were reviewed from 12/01/21 through 05/16/22. The following deficiencies were identified:* There was no documented evidence the facility was conducting fire and life safety instruction on alternating months from fire drills; and* The evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, evidence alternate routes were used, and the number of occupants evacuated. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) and Staff 5 (Maintenance Director) on 05/18/22. She 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 C252, C330, Z164 and Z165.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces did not contain drop-offs and were maintained in good repair. Findings include, but are not limited to:Observations of the three secured courtyards on 05/17/22 showed the following:* Concrete that had cracked, chipped, and separated created uneven surfaces; and* Multiple drop-offs of two to four inches were noted along pathway edges.The need to ensure pathways in the resident courtyard did not have potential tripping hazards was discussed with Staff 1 (Administrator) on 05/17/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility on 05/17/22 showed the following areas in need of cleaning or repair:* Walls throughout the facility had large, long black streaks and scrapes. The walls had spills, dings, and chipped paint; * On entrance into the facility two doll babies, being held by a resident, had large amounts of brown substance on the lower legs and clothing; * Window sills throughout the facility had food debris, dust, dead insects, and pieces of tissues. The sills in the front sitting area had large chips with missing paint; and* The common area bathroom near room 25 did not have a call light cord in place for residents to gain assistance when using the restroom. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 05/17/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 231, C 240, C 252, C 372, C 420, C 510 and C 513.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 8 and 17) completed all required pre-service orientation prior to performing any job duties; 3 of 3 newly hired staff (#s 8, 12 and 17) completed all required pre-service dementia training before providing care and services independently; 4 of 4 staff (#s 8, 12, 17 and 18) demonstrated competency in all assigned job duties within 30 days of hire; and 2 of 2 long-term staff (#s 4 and 13) completed 16 hours of annual training. Findings include, but are not limited to:Staff training records were reviewed on 05/18/22.1. There was no documented evidence Staff 8 (CG), hired 01/21/22, and Staff 17 (CG), hired 01/31/22, completed one or more of the required pre-service orientation topics:* Resident rights and values of community-based care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures; and* Written job description.2. There was no documented evidence Staff 8, Staff 12 (CG), hired 04/15/22, and Staff 17 completed one or more of the required pre-service dementia topics:* Dementia disease process including progression of the disease, memory loss, and psychiatric and behavioral symptoms;* Techniques for understanding, communicating, and responding to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being;* Family support and the role family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.3. There was no documented evidence Staff 8, Staff 12, Staff 17, and Staff 18 (MT), hired 09/13/21, demonstrated competency in all assigned job duties within 30 days of hire. The facility was instructed Staff 18 could not be scheduled to perform medication administration until there was documented evidence she had demonstrated competency in those job duties.4. There was no documented evidence Staff 4 (RCC), hired 04/26/16, and Staff 13 (MT), hired 08/03/18, completed the required 10 hours of annual training related to provision of care in community-based care or the required six hours related to dementia care.The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 280, C 290, C 310, C 320, C 330 and C 340.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C252 and C330.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 3 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 3 and 4's current service plans were reviewed during survey. Both of the service plans lacked information and staff instructions related to individualized nutrition and hydration preferences and needs.The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate residents for activities and to develop individualized activity plans from the evaluation for 4 of 4 sampled residents (#s 2, 3, 4 and 5) whose service plans were reviewed, and failed to offer a selection of daily structured and non-structured meaningful activities which promoted or helped sustain the physical and emotional well-being of residents. Findings include, but are not limited to:A review of the service plan for Residents 2, 3, 4 and 5, and an interview with Staff 1 (Administrator) on 05/18/22 revealed the following:1. The facility had not completed activity evaluations which addressed the following:* Past and 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.2. There was no documented evidence individualized activity plans, which addressed what, when, how, and how often staff should offer and assist the resident with activities, were developed and documented.3. Observations made on 05/17/22 and 05/18/22 revealed the facility was not providing a selection of daily scheduled or unscheduled activities to promote or help sustain the physical and emotional well-being of residents.The need to ensure the facility completed an activity evaluation addressing the required elements, developed an individualized activity plan based on the evaluation for each resident, and provided meaningful activities for residents every day was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22. 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 3 of 3 sampled residents (#s 6, 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Residents 6, 7 and 8's service plans offered information relating to the resident's past interests and some current 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. 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 (Administrator) on 10/27/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others, and had not coordinated outside consultation for these behaviors for 2 of 2 sampled residents (#s 6 and 8) who had documented behaviors. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 06/2020 with diagnoses including cerebrovascular accident and dementia with behavioral disturbance.In an interview on 10/26/22 with Staff 2 (RN) and Staff 4 (RCC), Resident 8 was identified as having frequently refused care, and "occasionally yelled and hit at staff". Reportedly, it was often necessary to wait and re-approach the resident when rendering assistance.Resident 8's service plan, dated 10/10/22 provided the following information to staff: "Sometimes it requires 3 people for peri care. [He/she] will become stiff and combative. This is a difficult task."Resident 8's records lacked an individualized behavioral plan, which implemented effective interventions and assisted staff in minimizing the negative impact of the behaviors. The facility had not coordinated outside consultation, to obtain behavioral support services for the resident.On 10/27/22 the need to develop and implement an individualized service plan for behaviors that negatively impacted the resident or others, was discussed with Staff 1 (Administrator) and staff 2 (RN). They acknowledged the findings.
2. Resident 6 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease.Resident 6's progress notes documented multiple incidents of problematic behaviors including resident to resident altercations, elopement attempts, resistance to care, striking staff, disrobing in public, pacing, difficulty sleeping and eating in the dining room.The resident's current service plan, last updated 10/06/22, included a description of the behaviors displayed by the resident. The interventions included the following:* Cues, reminders, or redirection for elopement risk, a sign posted to remind visitors to be sure no one follows them out of the building;* Day and night time two-hour safety checks, attempt to distract when going into other resident's rooms, if resistant or combative please give PRN medications; and* Provide distraction. Resident "loves to fold laundry, ...courtyard areas and walks in the halls."During interviews on 10/26/22 and 10/27/22, direct care staff confirmed Resident 6 displayed the behaviors listed above and staff would attempt to re-direct the resident when s/he was displaying unsafe behaviors. Staff had attempted providing alternate seating arrangements for the resident at meal time in an effort to reduce stimulation and noise during meals. Staff stated attempts to re-direct the resident and use of PRN medications were mostly ineffective.In an interview on 10/26/22, Resident 6's behaviors were discussed with Staff 1 (Administrator) and Staff 2 (RN). Facility staff had discussed some other interventions that were attempted but these interventions had not been documented on the service plan or Interim Service Plans (ISP's). The facility had not attempted to get outside consultation to provide behavior support services and help determine interventions for the behaviors.The need to include an individualized behavior plan for residents with behavioral symptoms, ensure staff were provided clear direction on interventions to provide and initiate and coordinate outside consultation for problematic behaviors was discussed with Staff 1 and Staff 2 on 10/27/22. They acknowledged the findings.

The findings of the Health and Safety Monitoring survey, conducted 8/24/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 57 for Memory Care Communities.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the Health and Safety Monitoring survey of 8/24/21, conducted on 11/5/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observations and interviews, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Failure to implement recommendations placed residents at risk for exposure to the COVID-19 virus. Findings include, but are not limited to:On 8/24/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:a. The facility had not established adequate storage and disinfection practices for eye protection.b. Staff were disinfecting high touch areas twice a shift, but not documenting it. Facility was not utilizing a cleaning checklist or log to ensure disinfection was completed. Staff were unaware of contact time for disinfectants used.c. The staff break room lacked instruction and supplies for staff to manage PPE, instruction to social distance, and cleaning/disinfection of area after use, including shared items and table. Two loose face masks were observed on a table. d. Staff were performing self-screening, including temperature checks and symptom screening.e. Facility had not been consistently performing and documenting staff competency audits for performance/adherence to infection control practices and proper PPE use.f. The following was observed in the east laundry room:*No clear separation or sign noting clean and dirty areas;*Loose dirty laundry was observed on the floor. Additionally, incontinent and soiled laundry was stacked in the hopper basin, on tables, in square cube shelving, and in laundry baskets. Soiled laundry had overflowed from the baskets and tables onto the floor;*The handwashing sink was full of miscellaneous items which included boxes of gloves, fabric incontinence pads, blankets, and a food tray, rendering the sink unusable for hand hygiene;*Trash and debris were observed on the floor in both the clean and dirty sides;*The hopper was in the clean side of the laundry room. There was no barrier between the hopper and clean laundry area to prevent cross contamination. In addition, clean clothing was stored near the hopper; and *The laundry room had a strong urine odor. The following was observed in the west laundry room:*No clear separation or sign noting clean and dirty areas;*Loose incontinent and soiled laundry was stacked on tables, in square cube shelving, and in laundry baskets. Laundry had overflown from hampers/baskets onto the floor;*Clean fabric incontinence pads were observed on the floor; and *Miscellaneous broken items were stored in the room.The need to implement effective infection control practices was reviewed with Staff 1 (Administrator) on 8/24/21. She acknowledged the need for increased oversight of infection control practices in the building.

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