Bonaventure of Tigard Memory Care

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

Findings include, but are not limited to:

On 01/23/25 at 10:50 am, the facility kitchen was observed to need cleaning and repair in the following areas:

* Juice machine in service area – rusty stained ledge/drip pan full of “mucky” liquid/drips/spills;

* Top and sides of dishwashing machine – debris/drips/spills;

* Wall behind spray hose, under counter and behind dishwashing machine – significant build up of black matter;

* Lower shelf in dishwashing holding dish washing racks - build up of spills/food debris;

* Floor under steamtable, small refrigerator and under and behind cooking equipment – build up of food debris/black matter;

* Drains under steamtable and two sink prep counter – build of food debris/black matter/spills;

* Ceiling vents above clean dishes/pot and pans storage rack – build up of dust;

* Lower shelf of prep counter – food debris/spills/drips;

* Food bin lids – food debris: and

* Dishwashing machine was not running at appropriate rinse temperature; rinse gauge was non-functional; booster not operating; kitchen staff unaware of proper wash and rinse temperatures; temperature logs were blank since 1/15/25; Staff 4 (Maintenance Director) and Staff 3 (Regional Dining Manager) contacted EcoLabs for immediate assistance with rinse temperature and service for repairing the booster; EcoLabs had recently modified sanitation procedure with bleach although facility had no test strips for checking chlorine level; Staff 3 obtained test strips and determined chlorine level was too low.

The facility will use three sink method for cleaning and sanitizing dishes until dishwashing machine is repaired and operating at required temperatures for wash and rinse.

Improper food storage concerns:

* Ice cream tubs in high traffic area not covered;

* Walk in freezer – boxes and tub of ice cream on the floor, open bag of pretzels;

* Dry storage – bag of sugar on floor, open bag of dry pasta; and

* Pan of cake on prep counter - uncovered.

The areas of concern were discussed with Staff 2 (Executive Director) and Staff 3 on 01/23/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.

Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 10/25/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the kitchen inspection, conducted 01/26/24, 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: On 10/15/23 at 11:00 am, the kitchen was observed and the following areas were identified: * The walk in freezer floor had frozen drips of ice cream and food debris; * The exterior doors of the sandwich refrigerator had drips/spills, the interior shelf was rusty and the covering was peeling;* Uncovered/unlabeled/undated containers of hot dogs and hamburgers were on the bottom shelf of the sandwich refrigerator; * The rolling cart at the end of the steam table had a tray of uncovered individual servings of syrup, brown sugar and raisins; * Fresh eggs were stored in walk in refrigerator above a container of ready to eat food with lid that was loose, creating a potential for cross contamination if eggs were cracked and dripped on the container; * The shelf below steam table containing serving plates/bowls had crumbs/food debris; * Ceiling vents above storage of clean pots/pans and above the steam table had accumulation of dust;* Hood vents above the grill had a build up of grease and dust:* The dishwashing room wall below the dirty beverage racks and behind the spray hose had drips/spills/black matter;* The wash temperature for the dish machine was not meeting minimum temperature per the data plate; and * Kitchen staff were not wearing hair restraints and/or facial hair restraints. The areas of concern were discussed with Staff 1 (Dietary Services Manager), Staff 2 (Executive Director) and Staff 3 (Memory Care Director) on 10/25/23. The findings were acknowledged.

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

The findings of the re-licensure survey conducted 09/20/22 through 09/22/22 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 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 09/22/22, conducted 05/30/23 through 05/31/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and 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 survey conducted 07/27/23 through 07/28/23 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to maintain complete and accurate records for 1 of 2 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the memory care in July 2022 with diagnoses including Alzheimer's disease. Resident 1 was identified during the acuity interview on 09/20/22 to have weight loss.a. On 09/22/22, Resident 1's weight record for 07/2022 - 09/2022 were requested from the facility. The weight record originally provided by the facility were as follows:* 07/10/22 - 285.5 (taken from hospital discharge paperwork);* 08/10/22 - 264.0 (taken by the facility); and* 09/12/22 - 252.0 (taken by the facility).In an Interview on 09/22/22, Staff 3 (Regional RN) reported staff entered the date the facility received a faxed copy of the residents hospital discharge paperwork as the date of the residents most recent weight, instead of the actual date the weight was taken, which was 1/2022. Staff 3 provided additional weight values that were found in the resident's hospital records, but had not been entered into the QuickMAR system. The weights were as follows:* 07/07/22 - 279.00 (hospital discharge paperwork); and* 09/15/22 - 240 (hospital discharge paperwork). b. Review of 09/01/2022 through 09/20/22 MAR identified the following:On multiple occasions Staff 4 (RN) documented insulin administration under multiple unlicensed staff rather than documenting under his own login/initials. This represented an inaccurate record. The findings were shared with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) during the exit interview on 09/22/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.Resident 1 was admitted to the MCC in July 2022 with diagnosis of Alzheimer's disease and was dependent on staff for ADL care.On 09/22/22 observations of Resident 1's apartment showed bed pillows and soiled linens placed on the floor, soiled incontinent supply, soiled gloves and soiled incontinent wipes laying on the carpeted floor. There were no staff present in the room.The above observations were shown to Staff 2 (Site Manager) on 09/22/22. She acknowledged the lack of appropriate infection control practices.

Based on interview and record review, it was determined the facility failed to ensure an unwitnessed fall and an injury of unknown origin were promptly investigated to include administrator review for 1 of 1 sampled resident (# 1) with incidents. Findings include, but are not limited to:Resident 1 was admitted to the facility in 07/2022 with diagnoses including Alzheimer's disease.Review of the resident's clinical records, including progress notes, incident reports, investigations, and temporary service plans, dated 07/18/22 through 09/20/22, revealed the following:* On 07/18/22 the resident had a skin tear; * On 07/28/22 an unwitnessed fall and sustained skin tears on the left lower leg and right lower leg; and* On 07/31/22 the resident sustained a cut and bruise on the right hand. There was no documented evidence the incidents had been reviewed by the administrator until 08/11/22 and 09/15/22, respectively. The need to ensure resident incidents were promptly investigated to include administrator review of the incidents was discussed with Staff 1 (ED), Staff 2 (Site Manager), and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to immediately investigate an injury of unknown cause and document that it reasonably concluded the injury was not the result of abuse, or report the injury to the local SPD office, for 1 of 3 sampled residents (#8) with an injury of unknown cause. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the facility in 07/2021 with diagnoses including vascular neurocognitive disorder.Review of Resident 8's clinical records during the survey noted the following:* 04/27/23 - "Resident has three spots on top of [his/her] head (scalp) 0.4 centimeter diameter now it's scabbed over." The facility lacked an investigation into the injury of unknown cause which reasonably concluded and documented the injury was not the result of abuse. The injury was not reported to the local SPD office.The need to immediately investigate injuries of unknown cause to reasonably rule out abuse and neglect or report the injury to the local SPD office was discussed with Staff 2 (Area Manager) and Staff 3 (Regional RN) on 05/31/23. They acknowledged the findings. The survey team requested the facility submit the report. Documentation was provided on 05/31/23.

Based on interview and record review the facility failed to ensure initial evaluations were completed prior to move-in, were reflective of resident's care needs and status and evaluations were updated with significant changes of condition for 1 of 1 Residents (#1). Findings include, but are not limited to:Resident 1 was admitted to the MCC facility in July 2022 with diagnosis of Alzheimer's disease. A review of the clinical record during the survey revealed the following:a. The "Initial and Annual Nursing Assessment", which was used by the facility for the initial resident evaluation was not completed until 09/16/22. b. The 09/16/22 evaluation was not reflective of the resident's current care needs and status in the following areas:* CPAP use;* Pain management and non-pharmacological interventions for pain; and* Nutrition and special diet.c. Resident 1 experienced multiple significant changes of condition from 07/07/22 through 09/20/22 related to weight loss and increased ADL care needs. There was no documented evidence the facility had evaluated the changes of condition.The need to ensure the facility had a system in place to ensure resident evaluations were completed timely and were reflective of the resident's care needs and status was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.
2. Resident 8 was admitted to the facility in 07/2021 with diagnoses including vascular neurocognitive disorder.Review of the resident's quarterly evaluation dated 03/23/23 and progress notes dated 01/22/23 through 05/29/23 identified the following:a. The resident experienced a significant change in condition in 02/2023 due to a significant weight loss of over 6.63% in one month. The facility lacked documented evidence Resident 8's evaluation was reviewed with updates documented when the significant change in condition was identified. b. Review of the resident's 03/23/23 quarterly evaluation and interviews with staff identified the evaluation was not reflective in the following areas:* Physical aggressions and other behavior patterns; * Elopement risk or history; and* Customary sleeping patterns.The need to ensure Resident 8's evaluation was reviewed with updates documented when the resident experienced a significant change in condition and addressed all required elements was discussed with Staff 2 (Area Manager) and Staff 3 (Regional RN) on 05/31/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations contained all required elements and quarterly evaluations were updated and documented each time a resident had a significant change in condition, were the basis of the resident's service plan and were reflective of resident's care needs for 2 of 3 sampled residents (#s 8 and 10) whose move-in and quarterly evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 10 was admitted to the facility on 04/01/23 with diagnoses including Alzheimer's disease.Review of the initial evaluation dated 04/01/23 revealed the following elements were missing:* Customary routines, including eating;* Mental health issues, including history of treatment;* Cognition, including orientation and decision making abilities; and* Nutrition habits and fluid preferences.The need to ensure the initial evaluation included all of the required elements was discussed with Staff 2 (Area Manager) and Staff 3 (Regional RN) on 05/31/23. They 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 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. A review of Resident 3's 07/06/22 service plan revealed the service plan was not reflective, did not provide clear instruction to staff and/or was not being followed in the following areas:* Pain;* Activities;* Wheelchair use; and* Nutrition and hydration.Observations of Resident 3 on 09/20/22 at 11:55 am, the resident was self-propelling in a wheelchair down the hallway.In an interview with Staff 1 (ED) on 09/22/22 at 10:10 am, she verified Resident 1 did use a wheelchair which was an intervention to a non-injury fall the resident had on 09/17/22.The need to ensure the service plan was reflective of the resident's status and care needs was discussed with Staff 1, Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.
2. Resident 1 was admitted to the MCC facility in July 2022 with diagnosis of Alzheimer's disease.A review of Resident 1's 09/03/22 service plan and temporary care plans revealed the service plan was not reflective and did not provide clear instruction to staff in the following areas:* Evacuation status;* Weight loss;* Current fall interventions;* Mobility, use of a wheelchair with staff assistance;* Two- person incontinent care while in bed;* Toileting schedule lacked clear instructions;* Outside services for wound care;* Skin integrity and interventions to prevent skin breakdown;* Pain including non-pharmacological interventions for pain;* Activities; and* Nutrition and hydration.The need to ensure the service plan was reflective of the resident's status and care needs was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction to staff and were completed timely for 2 of 2 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 09/2022 with diagnoses including diabetes and dementia. Interviews with staff and review of both the service plan, dated 02/15/23 and evaluation dated 04/04/23 revealed Resident 7's service plan was not reflective of the resident's use of routine insulin, not sliding scale, and was not completed at the time of the evaluation.The need to ensure the service plans were updated at least quarterly and reflected residents' current needs was reviewed with Staff 2 (Area manager) on 05/30/23. She acknowledged the findings. A new service plan dated 05/30/23 was provided.
2. Resident 8 was admitted to the facility in 07/2021 with diagnoses including vascular neurocognitive disorder. The resident was noted to be at risk for weight loss.A review of Resident 8's most recent service plan, dated 05/23/23 revealed it was not reflective and lacked clear instruction to staff in the following areas:* History of physical and verbal aggression; and * History and risk of significant weight loss.The need to ensure service plans were reflective and gave clear instruction to staff was discussed with Staff 2 (Area Manager) and Staff 3 (Regional RN) on 05/31/23. They acknowledged the findings.

1. Resident 7 updated service plan regarding insulin order. Primary Care Physician discontinued sliding scale order and new insulin orders reflect current routine dose. Service plan and MAR updated and all staff notified.Resident 8 service plan updated and reflects history of aggression and weight loss.2. Monthly audits of service plans to ensure accuarcy of information with clear instructions for staff on care.Montly weight logs to be entered before the 8th of every month.3. Monthly audits of care plans, physician orders, and MAR4. Memory Care Director, Licensed Nurse and Med Techs

2. During the acuity interview Resident 6 was identified for weight loss. The last six month's of Resident 6's weights were reviewed on 09/22/22. Resident 6 had the following significant change of condition: * Weight records dated 04/10/22 through 09/07/22 were reviewed and indicated the resident experienced a 13 pound unplanned weight loss between 04/10/22 and 09/07/22. The following weights were documented in the resident's chart:* 04/10/22: 114 lbs.; * 05/10/22: 110 lbs.;* 06/10/22: 108 lbs.;* 07/10/22: 107 lbs.;* 08/10/22: 107 lbs.; and* 09/10/22: 101 lbs.Between 04/10/22 and 09/10/22 the resident lost 13 pounds or 11.4% total body weight. This constituted a significant change of condition for severe weight loss.Survey requested a new weight for Resident 6 on 09/22/22. Resident 6's current weight was recorded as 106 lbs. which was a five pound weight gain from the previous weight taken on 09/10/22. This constituted a 7.01% total body weight loss between 04/10/22 and 09/22/22. There was no documented evidence interventions were determined, documented and communicated to staff regarding the weight loss or the RN was notified for a significant change of condition. The need to ensure changes of condition were evaluated, actions and interventions determined and monitored for effectiveness and referred to RN was discussed with Staff 1 (Executive Director) and Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.Refer to C 280, example 2.
Based on observation, interview and record review, it was determined the facility failed to evaluate and determine actions or interventions, monitor with weekly progress documented for short-term changes of condition until the condition resolved, and refer to the RN when appropriate for 2 of 2 sampled residents (#s 1 and 3) reviewed for changes in ADL care and weight loss. Resident 1 had continued weight loss. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC facility in July 2022 with diagnoses including Alzheimer's disease.A review of Resident 1's clinical record, chart notes and incident reports indicated the following: a. Between July 2022 and September 2022 Resident 1 experienced a significant weight loss of 5.08% of his/her total body weight, or 14.2 lbs. over a one month period. The following monthly weights were recorded in the resident's chart: * 07/07/22 - 279.00 lbs;* 08/10/22 - 264.8 lbs; and* 09/12/22 - 252 lbs. This represented a significant weight loss within a one month period which required referral to the facility RN.There was no documented evidence the facility had evaluated the residents weight loss, monitored for further weight loss, developed and implemented interventions for weight loss, or referred to the RN for a significant change of condition. The failure to evaluate and monitor the resident's weight loss and refer to the RN as required resulted in the residents' continued significant weight loss. On 09/22/22, the surveyor requested the facility staff weigh the resident. The surveyor observed the resident weigh 246 pounds, which was an additional six pound weight loss from the previous weight taken on 09/12/22. The need to ensure changes of condition were evaluated, actions or interventions developed and referred to the RN when a resident experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings. Refer to C 280, example 1b. A review of the charting notes and incident reports identified the following changes of condition lacked monitoring of fall interventions for effectiveness, monitoring with weekly progress noted until resolved and/or were referred to the RN, when appropriate: * On 07/20/22 - A fall in the bathroom;* On 07/22/22 - A fall out of bed;* On 07/28/22 - An injury fall with skin tear in bathroom;* On 07/29/22 - Change in behavior;* On 07/31/22 - A skin tear to the right hand/wrist; * On 08/10/22 - A skin tear and bruise on right hand;* On 08/18/22 - A skin issue on buttocks; * On 08/24/22 - Diarrhea;* On 08/26/22 - A skin issue on the back; and* On 09/13/22 - Diarrhea, vomiting with an ER visit.During an interview with Staff 14 (MT) on 09/22/22, it was reported that the facility doesn't do bowel monitoring.The need to ensure short term changes of condition were monitored, or monitored to resolution, actions or interventions developed and reviewed for effectiveness when a resident experienced a change of condition, and all significant changes of condition were referred to the RN for assessment was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.
2. Resident 7 was admitted to the facility in 09/2022 with diagnoses including diabetes and dementia. The resident's 01/26/23 through 05/25/23 progress notes, and temporary care plans were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:* Non-injury fall;* Miralax (bowel medication) changed to PRN; and * Return from hospital.Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition until resolution.The need to ensure short-term changes of condition had documented resolution was discussed with Staff 2 (Area Manager) and Staff 3 (Regional RN) on 05/31/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to monitor short-term changes of condition with weekly progress noted until resolution for 2 of 3 sampled residents (#s 7 and 8) who experienced short-term changes in condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 07/2021 with diagnoses including vascular neurocognitive disorder.The resident's 01/22/23 through 05/29/23 progress notes were reviewed and revealed the following:* 02/28/23 - "Resident hit one of our activity directors on the mouth when she only said good morning...";* 02/28/23 - " Missed scheduled medications: MT reported there is no risperidone, trazadone, gabapentin..."; and* 04/27/23 - "Resident has three spots on top of [his/her] head (scalp) 0.4 centimeters diameter, now it's scabbed over."The facility lacked documented evidence the conditions were monitored with progress noted at least weekly through resolution.The lack of monitoring for Resident 8's short-term changes in condition was discussed with Staff 2 (Area Manager) and Staff 3 (Regional RN) on 05/31/23. They acknowledged the findings.

1. Resident 8 short term change of condition was updated to temporary care plans, alert charting, and progress notes. Licensed Nurse assessment determined condition was temporary. Monitored daily until resolved.2. Staff training and education to monitor for change of condition, how to notify, document, and follow up. Training on alert charting, progress notes and notifying appropriate parties.3. Daily audits of alert charting, temporary care plans, progress notes will be done to monitor change of condition and then added to service plans and care implimented by staff. 4. Memory Care Director, Med Techs and Licensed Nurse.

2. The last six month's of Resident 6's weights were reviewed on 09/22/22. Resident 6 had the following significant change of condition: * Weight records dated 04/10/22 through 09/07/22 were reviewed and indicated the resident experienced a 13 pound unplanned weight loss between 04/10/22 and 09/07/22. The following weights were documented in the resident's chart:* 04/10/22: 114 lbs.; * 05/10/22: 110 lbs.;* 06/10/22: 108 lbs.;* 07/10/22: 107 lbs.;* 08/10/22: 107 lbs.; and* 09/10/22: 101 lbs.Between 04/10/22 and 09/10/22 the resident lost 13 pounds or 11.4% total body weight. This constituted a significant change of condition for severe weight loss.There was no documented evidence an RN assessment had been completed for a significant change of condition. The need to ensure an RN assessment was completed for significant weight loss was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN). They acknowledged the findings.
Based on observation, interview and record review the facility failed to ensure the facility RN completed an RN assessment for 3 of 4 resident's (#s 1, 3 and 6) who experienced significant changes of condition related to decline in health status and weight loss. Resident 1 experienced continued weight loss. Findings include but are not limited to:1. Resident 1 was admitted to the MCC facility in July 2022 with diagnoses including Alzheimer's disease.A review of Resident 1's clinical record, chart notes, interviews with staff and observations of the resident using a wheelchair and requiring staff escorts to and from meals and activities was completed during the survey. The following significant changes of condition were identified:a. On 09/13/22, Resident 1 experienced emesis, diarrhea, general weakness, decline in appetite and level of participation in self care and activities. S/he was sent to the ER and returned on 09/15/22 with a recommendation for hospice. In an interview with Staff 8 (MT) on 09/22/22, the resident now needed full assistance for mobility while using the wheelchair, s/he was no longer able to ambulate with a walker, appetite had declined and needed encouragement to eat, was weaker and needed two person incontinent care while in bed due to no longer being able to transfer to the toilet. The decline in health status and increase in ADL care needs represented a significant change of condition that required an RN assessment. There was no documented evidence the facility RN documented an assessment of Resident 1's decline in health status which documented findings of the assessment, residents' current status and condition or had updated the service plan as appropriate.b. Between July 2022 and August 2022 Resident 1 experienced a significant weight loss of 5.08% of his/her total body weight, or 14.2 lbs. over a one month period. The following monthly weights were recorded in the resident's chart: * 07/07/22 - 279.00 lbs;* 08/10/22 - 264.8 lbs; and* 09/12/22 - 252 lbs (additional 12.8 lbs. or 4.83% total body weight).The weight loss identified on 08/10/22 represented a significant weight loss within a one-month period which required an RN assessment. There was no documented evidence the facility RN documented an assessment of Resident 1's weight loss which documented findings of the assessment, residents' current status and condition, interventions needed as a result of the assessment or update the service plan as appropriate. c. Between July 2022 and September 2022, Resident 1 experienced continued significant weight loss of 27 pounds or 9.6% total body weight within three months. There was no documented evidence the facility RN documented an assessment of Resident 1's weight loss which documented findings of the assessment, residents' current status and condition, interventions needed as a result of the assessment or update the service plan as appropriate.Observations of lunch service on 09/21/22 and 09/22/22 Resident 1 was independently eating however, needed some cueing to initiate eating. S/he was observed to consume 50-75% of the meal and 25% of the meal, respectively. On 09/22/22, the surveyor requested the facility staff weigh the resident. The surveyor observed the residents weight was 246 pounds, which was an additional six pound weight loss from the previous weight taken on 09/12/22. The failure to conduct an RN assessment which included resident specific interventions for weight loss resulted in continued significant weight loss for Resident 1. The need to ensure an RN assessment was completed for significant weight loss and change in health status was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 1) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview on 09/21/22, staff reported Resident 1 was administered insulin injections by non-licensed staff. Interviews with staff, review of delegation records and the 09/01/22 - 09/20/22 MAR revealed the following:1. On two occasions, Staff 5 (Activity Director) administered insulin to Resident 1. The records lacked documented evidence of Staff 5 being delegated to administer insulin to Resident 1.2. On three occasions, Staff 13 (MT) recorded CBG's and administered insulin to Resident 1. The records lacked documented evidence Staff 13 had been delegated to administer insulin to Resident 1.3. On 13 occasions, Staff 9 (MT) recorded CBG's and administered insulin to Resident 1. The records lacked documented evidence Staff 9 was delegated to administer insulin to Resident 1.The requirements for delegation and the need to ensure accurate documentation was reviewed with Staff 1 (ED), Staff 2 (Site Manager)and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:C 282: RN Delegation and Teaching; and C 310: Systems: Medication Administration.The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled residents (# 3) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 3's 09/01/22 through 09/20/22 MAR was reviewed.Resident 3's MAR revealed multiple blanks for a PRN oxycodone that was given for pain.Resident 3's Controlled Substance Disposition Logs and MARs, reviewed from 09/01/22- 09/2/22, revealed three occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR lacked documentation that the resident received the medication. In an interview with Staff 2 (Site Manager) at 3:05 pm on 09/22/22, she acknowledged the blanks on the MAR and Controlled Substance Disposition Log inconsistencies.Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 on 09/22/22. They reviewed the documentation and acknowledged the discrepancies.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and documented all medications given for 1 of 2 sampled residents (# 1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in July 2022 with diagnoses including insulin-dependent diabetes. S/he had orders for Novalog sliding scale insulin TID with meals in varying amounts based on the results of the CBGs (blood sugars). The MARs, reviewed from 09/01/22 through 09/20/22 revealed the following:* There were three occasions where staff failed to document the CBG value and initial insulin administration was done or indicated a reason for not administering the insulin. MAR was not pulled The need to ensure an accurate MAR was kept for all prescribed mediations and treatments was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update the ABST (Acuity Based Staffing Tool) for 1 of 2 residents (#1) who experienced a significant change of condition as defined in OAR 411-054-0005. Findings include, but are not limited to: Resident 1 was admitted to the MCC facility in July 2022 with diagnoses including Alzheimer's disease.A review of Resident 1's clinical record, chart notes and incident reports indicated the following: a. Between July 2022 and September 2022 Resident 1 experienced a significant weight loss of 5.08% of his/her total body weight, or 14.2 lbs. over a one month period and a 9.677% over a three month period; andb. On 09/13/22 Resident 1 experienced a significant change of condition related to a decline in health status and an increase in ADL care needs which included two-person ADL care.The ABST report for Resident 1 failed to reflect his/her current care needs and level of assistance following a significant change of condition, in the following areas:* Assisting with bowel and bladder management;* Transferring in and out of bed or a chair;* Medication administration;* Monitoring physical conditions or symptoms;* Safety checks and fall prevention;* Cueing and support while eating; and* Cueing or redirecting due to cognitive impairment or dementia. The need to ensure the ABST tool was reviewed following a resident's significant change of condition was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) during the exit interview on 09/22/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired direct care staff (# 9) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 09/21/22 and 09/22/22 and identified the following:Staff 9 (MT) hired on 03/14/22, lacked documentation of demonstrated competency in First Aid and abdominal thrust.The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional (RN) on 09/22/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were being conducted every other month and fire drill documentation reflected all required elements. Findings include, but are not limited to:On 09/20/22, fire drill and fire and life safety records from 03/2022 through 08/2022 were reviewed with Staff 6 (Maintenance Director). The following deficiencies were identified:* There was no documented evidence the facility was conducting unannounced fire drills every other month; and* The facility was not relocating residents to the point of safety therefore, the facility failed to document residents who were unwilling to participate in the drill and document what changes were made to ensure the evacuation standard was met. The need to ensure fire drills were being conducted every other month and all required elements were documented was reviewed with Staff 1 (ED), Staff 2 (Site Manager), Staff 3 (Regional RN) and Staff 6 during the survey. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire drill records from 03/2022 through 08/2022 were reviewed on 09/20/22 with Staff # 6 (Maintenance Director). The following deficiencies were identified:The facility lacked documented evidence residents' were being instructed on general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside of the building in the event of an actual fire, at least annually. The need to provide and document annual fire safety instruction for residents, in accordance with the OFC was reviewed with Staff 1 (ED), Staff 2 (Site Manager), Staff 3 (Regional RN) and Staff 6 during the survey. 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 231, C 252, C 260, and C 270.

Based on observation and interview, it was determined the facility failed to ensure cleaning chemicals and disinfectants were labeled and safely stored in a locked storage. Findings include, but are not limited to:The memory care unit was toured on 09/20/22. The following deficiencies were identified:* An unlabeled chemical spray bottle and wound cleanser were found in the unlocked dining room cabinet; and* The staff lounge door was unlocked which contained multiple cleaning chemicals, disinfectants and rubbing alcohol that was accessible to residents.In an interview with Staff 2 (Site Manager) on 09/21/22, it was reported the staff lounge door should be locked and staff should have a key. On 09/21/22 the need to ensure chemicals were properly labeled and stored in a locked storage area was reviewed with Staff 1 (ED), Staff 2, Staff 3 (Regional RN) and Staff 6 (Maintenance Director) during the survey. They acknowledged the findings.

Based on observation and interview the facility failed to ensure the interior environment was kept clean and in good repair. The environment was toured on 09/21/22 with Staff 1 (ED), Staff 2 (Site Manager) and Staff 6 (Maintenance Director). The following areas required cleaning or repair:* Room 19, courtyard doors, kitchenette door, closet doors in the dining room were gouged or had black marks;* Cabinet underneath the sink in the dinning room had brown spills/splatter below the pipes;* Multiple wall corners, wall near the staff lounge and dinning room sink were gouged with exposed sheet rock;* Common area bathroom off the dining room was in need of cleaning; * Common area bathroom toilet, off the dining room required caulking around the toilet base;* Two striped colored chairs in the living room had multiple dark stains on the fabric; and* A brown leather chair in the living room had fabric that was peeling off. The need to ensure the interior environment was kept clean and in good repair was acknowledged by Staff 1, Staff 2 and Staff 6 on 09/21/22.

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 155, C 160, C 231, C 361, C 372, C 420, C 422, C 510 and C 513.
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:Please refer to C 231.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly-hired direct care staff (#s 5 and 9) completed pre-service orientation topics, 1 of 4 newly-hired direct care staff (# 5) completed pre-service dementia care training, and 2 of 3 newly-hired direct care staff (#s 9 and 10) failed to complete all required training and demonstration of competency. Findings include, but are not limited to: Training records were reviewed on 09/21/22 and 09/22/22. The following were identified:a. There was no documented evidence Infectious Disease Prevention training was provided to Staff 5 (Activities Director) hired on 06/14/22 and Staff 9 (MT) hired on 03/24/22. b. There was no documented evidence Staff 9 had completed any pre-service dementia care training.c. There was no documented evidence that Staff 9 and Staff 10 (CG) hired on 02/02/22 completed the required training's within 30-days of hire.The need to ensure newly-hired, direct care staff completed all orientation training prior to beginning any job duties, pre-service training was completed prior to working independently and newly hired staff demonstrated and documented required 30 day competencies was reviewed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. 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 C 252, C 260, C 270, C 280, C 282, C 300 and C 310.
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:Please refer to: C 252, C 260 and C 270.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident's 1 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN) on 09/22/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident 1 and 3's service plans offered some information about the residents' interests, however, the facility had not fully evaluated the residents': * Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities.Observations and interviews indicated the residents were dependent on staff to initiate activities.On 09/22/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED), Staff 2 (Site Manager) and Staff 3 (Regional RN), who acknowledged the findings.