Village at Valley View

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

1. On 10/22/25, from 9:55 am thru 12:40 pm, the facility main kitchen was observed.

a. The following areas needed cleaning:

* Janitor’s wall and floor had a build-up of black residue;
* Drain next to the ice machine had a build-up of black residue;
* Slicer was not covered when not in use;
* Exterior of the microwave had food debris;
* Commercial can opener had a build-up of food debris;
* In the dry food storage area, bulk food containers, including beans and rice, had spills on the shelf;
* Commercial mixer was not covered when not in use and had accumulated food debris;
* Bulk food containers, both outside and lids, had accumulated food debris;
* A residential mixer had food residue on the exterior;
* A rack used to store clean dishes and equipment had visible dust;
* All trash can exteriors and bases had accumulated debris;
* Wall around the dishwasher and below the handwashing sink had spills;
* Sprinkler heads had layers of dust;
* Light fixture covers on the sides had grease buildup and visible dust;
* Vents throughout the kitchen had accumulated dust;
* Ceiling around vents and above the prep station had layers of dust and grease build-up;
* Three tiers of the plastic food-holding cart had accumulated food debris;
* The vent in the walk-in cooler had accumulated dust;
*Rack in the walk-in cooler, used to store raw meat, had a build-up of dust and food residue;
* Handwashing sink pipe next to the prep station had layers of dust; and
* An electric wire hanging on the wall above the prep station had layers of dust.

b. The following areas needed repair:

* The edges of the white shelving in the dry food storage were worn.

2. On 10/22/25, at 12:04 pm, the Rose Cottage kitchenette was observed, and the following was noted:

* Cabinet contained multiple opened syrup bottles that were undated and had spills; and
* Cabinet under the two-compartment sink had water damage and brown residue.

3. On 10/22/25, at 12:10 pm, the Daisy Cottage kitchenette was observed, and the following was noted:

* The cabinet next to the oven had spills and food debris; and
* Cabinet under the two-compartment sink had water damage.

4. On 10/22/25, at 12:20 pm, the Lily Cottage kitchenette was observed and the following was noted:

* A cabinet drawer had significant paint chipping; and
* Cabinet under the sink had brown residue and water damage, with paper and tape being used to secure the area.

5. Improper food storage:

* A bag of cocoa powder, in the dry food storage, was undated;
* The walk-in cooler contained multiple undated cheese items and several sauce and dressing containers had spills and were undated;
* Multiple packages of raw meat were not in containers to prevent drips; and
* In the walk-in freezer, a box of cheesy garlic bread was undated and not completely covered or sealed.

6. Other areas of concern include:

* Colored cutting boards were heavily scored;
* All kitchen staff did not properly restrain their hair or beards;
* At 11:40 am, Staff 2 (Executive Chef) prepared a pureed diet using peeled potato, peas, and chopped turkey, placing all three items into a blender and blending them. After blending, potato skins were visible in the pureed diet. The surveyor directed Staff 2 to remove the potato skins when preparing the pureed diet; and
* Combining all three food times in one blender made the pureed diet unpalatable.

The areas of concern were observed and discussed with Staff 2 on 10/22/25 at 12:30 pm and Staff 1 (ED) at 12:40 pm. 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 limited to:

Refer to C240.

Based on observation, interview, and record review, it was determined the licensee failed to provide administrative oversight to ensure the quality of care and services rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 02/10/25 through 02/14/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 02/10/25 through 02/14/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

In an interview on 02/12/25 at 3:00 pm, Staff 1 (Administrator) and Staff 2 (Executive Nurse) confirmed that ongoing quality improvement programs were not being conducted.

The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1 and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

Refer to the deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to:

Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed.

On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister.

On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister.

On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN.

On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first.

At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound.

The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to:

Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed.

On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister.

On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister.

On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN.

On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first.

At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound.

The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to:

Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed.

On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister.

On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister.

On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN.

On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first.

At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound.

The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to:

Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed.

On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister.

On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister.

On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN.

On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first.

At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound.

The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' rights to be treated with dignity and respect and to be free from physical restraints for 1 of 1 sampled resident (#3) who had a full-length bed rail and received feeding assistance and for an unsampled resident who required feeding assistance. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, outside provider notes, dated 11/01/24 through 12/31/24, “Lenity Oregon Device Assessment,” dated 08/21/24, and signed physician orders were reviewed. Observations of the resident and interviews with the staff and resident’s family were completed.

a. During the acuity interview on 02/10/25 at approximately 2:30 pm, Resident 3 was identified to have side rails on his/her hospital bed.

The resident’s service plan indicated the resident required full assistance with transferring and ADL care including toileting and had a history of falls requiring fall interventions.

On 11/01/24, the hospice RN documented that a “signed MD order was faxed to the facility for a full rail on [his/her] hospital bed to help with [Resident 3’s] safety, protection and comfort.” This intervention was put into place because the half rail hospice installed previously was allowing for Resident 3 to “get the trunk of [his/her] body upright” and then s/he would fall out of bed.

On 11/01/24, an ISP identified the use of full bed rails which directed staff to ensure the rails were in the up position while the resident was in bed.

On 02/11/25 at 10:00 am, this surveyor entered Resident 3’s room with caregiving staff to make observations of ADL care. The resident’s bed was observed to have a full bed rail that extended the length of the left side of the hospital bed. The right side of the hospital bed was pushed against the wall. The rail was in the elevated position and Resident 3 was positioned diagonally with his/her left leg draped over the rail. The resident was yelling for help. The caregivers lowered the rail and assisted the resident out of bed and with his/her ADL needs.

On 02/12/25 at 10:48 am, Staff 18 (CG) was asked how the resident used the bed rail. Staff 18 confirmed the resident did not use the rail for mobility, and acknowledged Resident 3 was trying but could not get out of bed during the observation on 02/11/25.

The full-length bed rail was seen as a restraint because it was limiting Resident 3’s independent mobility by restricting him/her to the bed unless assisted out by caregivers.

The facility failed to ensure Resident 3’s right to be free of physical restraint was maintained.

b. During the acuity interview on 02/10/25 at approximately 2:30 pm, Resident 3 and multiple unsampled residents were identified to need feeding assistance.

Meal observations were conducted on 02/10/25 through 02/14/25. Two caregivers were observed providing feeding assistance for Resident 3 and an unsampled resident over the course of two meals. Staff were standing over the residents instead of sitting next to them while providing assistance.

On 02/13/25 at 12:16 pm, Staff 16 (MT) was asked why she stood while assisting residents with eating. Staff 16 reported standing made her appear like she was doing something. If she sat, it looked like she wasn’t doing anything.

The need to ensure residents’ rights to be treated with dignity and respect and to be free from physical restraint was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred and failed to report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to ensure investigations included all required components including Administrator review, for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to:

1. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

The resident’s Observation notes, dated 11/12/24 through 02/10/25, Interim Service Plans (ISPs), dated 09/18/24 through 02/08/25, incidents report, dated 11/09/24 through 02/09/25, Care History (alert charting documentation), dated 11/10/24 through 02/13/25, and Outside Services Documentation, dated 11/03/24 through 02/07/25, were reviewed and the following incidents were identified:

* 11/09/24: Unwitnessed fall in the resident’s private bathroom;
* 11/15/24: Staff documented on an ISP relating to a rash on Resident 1’s private areas, bottom, and thigh reporting the rash occurred due to “[Bowel movement and] sitting in a wet brief”;
* 11/26/24: Unwitnessed fall with injury;
* 12/18/24: Skin tear on left arm;
* 01/09/25: Left second finger bruising and blister; and
* 01/31/25: Resident to resident altercation.

There was no documented evidence the incidents of abuse, or suspected abuse, were immediately reported to the local SPD office or that the physical injuries of unknown cause were immediately investigated to conclude the injury was not the result of abuse.

Additionally, there was no documented evidence that the incidents that were investigated by the facility included documentation of the Administrator’s review.

Documentation was received on 02/12/25 at 3:10 pm and on 02/14/25 at 11:08 am that the above incidents were reported to the local SPD office.

The need to ensure all incidents of abuse, or suspected abuse, were reported to the local SPD office, injuries of unknow cause were immediately investigated and reported to the local SPD office when abuse, or suspected abuse, could not be ruled out, and included documentation of the Administrator’s review was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

2. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident’s Observation notes, dated from 12/21/24 through 02/10/25, Interim Service Plans, dated from 12/21/24 through 01/31/25, and incident reports, dated from 12/24/24 through 01/31/25, were reviewed and the following was identified:

* 01/31/25: Resident to resident altercation.

There was no documented evidence the facility reported the incident to the local SPD office or that the Administrator reviewed the investigation.

Documentation was received on 02/12/25 at 3:10 pm that resident to resident altercation was reported to the local SPD office.

The need to ensure all incidents of abuse were immediately reported to the local SPD office and investigations had documented evidence of the Administrator’s review was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

3. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia.

The resident's 11/10/24 to 02/10/25 Observation notes, Interim Service Plans, incident reports, and Incident Investigations were reviewed, and interviews with staff were conducted.

a. On 11/19/24, the resident’s Observation notes stated, “Care staff found big bruise size of a soft ball ish on [Resident 4’s] ride [sic] side of [his/her] ribs” and “[I]nformed the Nurse.” There was no documented evidence an immediate investigation was completed to rule out abuse or that the injury was immediately reported to the local Seniors and People with Disabilities (SPD) office.

During an interview on 02/11/25 at 12:20 pm, Staff 3 (Wellness Director/LPN) stated she had not been informed of this injury, and no investigation or reporting had occurred at the time of injury. The survey team requested the injury be reported to the local SPD office, and confirmation was provided on 02/11/25 at 1:57 pm.

b. On 01/22/25, the resident experienced an unwitnessed fall which resulted in an injury to his/her head. The incident was immediately investigated by Staff 3, and the investigation concluded that abuse or suspected abuse could be ruled out and did not need to be reported to the local SPD office. The investigation did not include all required components, including administrator review.

The need to ensure all injuries of unknown cause were immediately reported to the local SPD unless an immediate investigation reasonably concluded that the injury was not the result of abuse, and that all investigations included all required components, was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

4. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident's 11/10/24 to 02/12/25 Observation notes, Interim Service Plans, incident reports, and Incident Investigations were reviewed. Observations of the resident and interviews with staff were completed.

a. The resident's Observation notes indicated the resident experienced the following injuries of unknown cause:

* 12/02/24 - "[C]are staff found bruise on [his/her] left arm bigger than a quarter";
* 12/08/24 - "[R]esident [had] a small/medium bruise on [his/her] left calf”; and
* 02/12/25 – “[R]esident had a non-injury fall…I did not find any visible [injuries], just a new small skin tear.”

During an ADL observation on 02/11/25, a blood blister was visualized by this surveyor on the resident’s left calf. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director / LPN) reported the blood blister was identified by a caregiver on 02/01/25 and reported to the MT on duty. No additional documentation regarding the incident was available.

There was no documented evidence an immediate investigation was completed for any of the injuries of unknown cause. Survey requested the above injuries of unknown cause be reported to the local SPD office. Confirmation of reporting for all injuries of unknown cause was received by 3:08 pm on 02/14/25.

b. Resident 3 had a skin tear to his/her left elbow documented in an Observation note on 11/11/24. The Incident Investigation report from the event, dated 10/28/24, was reviewed and failed to have evidence the administrator reviewed the investigation.

The need to ensure immediate investigations were completed for injuries of unknown cause and/or reported to the local SPD if abuse could not be ruled out and investigations of abuse or suspected abuse included documentation of the administrator’s review was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements, and were updated and changed as appropriate within the first 30 days for 1 of 1 newly admitted resident (#2), and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 2 of 3 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer's disease, anxiety, and depression.

The resident's initial evaluation was reviewed, and it failed to address the following required elements:

* Customary routines including sleeping, eating, and bathing;
* List of medications and PRN use;
* Presence of depression, thought disorders, and/or behavioral or mood problems;
* History of treatment and effective non-drug interventions relating to mental health issues;
* Memory, orientation, and confusion;
* Vision and speech;
* Pain including pharmaceutical and non-pharmaceutical interventions, and how a person expresses pain or discomfort;
* Nutrition habits, fluid preferences, and weight if indicated;
* List of treatments;
* Complex medication regimen;
* History of dehydration or unexplained weight loss or gain;
* Elopement risk or history;
* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature;
* Pronouns; and
* Gender identity.

On 02/14/25 at 11:59 am, it was confirmed that there was no documented evidence the resident was re-evaluated with updates and changes as appropriate within 30 days of move in.

The need to ensure the initial evaluation included all required elements and was updated and changes were made as appropriate was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

Observations of the resident, staff interviews, and review of the record were conducted. Between 09/17/24 and 10/23/24, the resident experienced a resident to resident altercation, a fall that resulted in a hip fracture and hospitalization, and was admitted onto hospice.

Resident 1's most recent evaluation, dated 10/31/24, was not reflective of, or had conflicting information related to the resident's health status and current needs in the following areas:

* The admission onto hospice and what services they were going to provide;
* Ability to ambulate (the “Fall” section noted independence with walking);
* Behavior interventions for physical aggression towards other residents; and
* Weight bearing status.

There was no documented evidence Resident 1 was evaluated at least quarterly after 10/31/24.

The need to ensure Resident 1's evaluation was reflective of his/her health status and current needs, and was updated at least quarterly was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's disease.

The resident’s clinical record was reviewed. The most recent quarterly evaluation for Resident 3 was completed on 10/15/24. On 02/12/25 at 2:40 pm, Staff 3 (Wellness Director / LPN) confirmed the subsequent quarterly evaluation, due on 01/13/25, was not completed.

The need to ensure evaluations were completed quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes and entries made to the service plan must be dated and initialed, service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and service plans were implemented for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia.

The resident's current service plan available to staff, dated 01/19/25, and 11/10/24 through 02/10/25 Observation notes were reviewed, interviews with staff were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas:

* Ted hose;
* Bathing;
* Involvement of hospice, including tasks they assisted with and frequency of visits;
* Repositioning;
* Hospital bed with half side rails;
* Assistance required with eating;
* Frequency of safety checks;
* Evacuation assistance; and
* Number of staff required to assist with transfers, incontinence care, dressing.

The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan available to staff, dated 10/31/24, revealed the service plan was not reflective of the resident’s current care needs and did not provide clear direction to staff in the following areas:

* What services hospice provided and when they provided them;
* Mobility and ability to walk short distances on his/her own;
* All fall interventions staff should be utilizing;
* Customary routines relating to Resident 1's sleeping patterns;
* How the resident participated in dressing, toileting, and bathing;
* The frequency of toenail care provided when facility staff assisted with showers and where his/her personal nail kit was located;
* Who staff would contact if the shower chair was not in "safe working condition";
* Monitoring and/or cueing while eating;
* Meal reminders;
* What a "bad day" looked like and which behaviors the resident exhibited when s/he was having a "bad day";
* Missing toes on the resident's right foot;
* Resident 1's daily routine; and
* The resident's independence with the key to his/her apartment.

Additionally, there were handwritten updates that lacked staff initials and dates.

There was no documented evidence the facility had completed a quarterly service plan review for the resident, which would have been due on or around 01/29/25.

The need to ensure resident service plans were completed quarterly, were reflective of current care needs and preferences, provided clear direction to staff, and handwritten updates were initialed and dated was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

3. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with staff, and review of the service plan available to staff, dated 12/20/24, revealed the service plan was not reflective of the resident’s current care needs and did not provide clear direction to staff in the following areas:

* Fall risk;
* Mobility device used;
* What to monitor for relating to receiving a scheduled blood thinner;
* How Resident 2 assisted with dressing, grooming, oral care, and bathing;
* Dressing in layers at times;
* Brief versus regular underwear use;
* Who staff would contact if the shower chair was not in "safe working condition";
* Hearing aids and assistance needed; and
* Interventions for when Resident 2 was "helping" other residents.

Additionally, there were handwritten updates that lacked staff initials and dates.

The need to ensure resident service plans were reviewed within 30 days of move in, were reflective of current care needs and preferences, provided clear direction to staff, and handwritten updates were initialed and dated was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with the resident’s family and staff, and review of the service plan available to staff, dated 04/30/24, revealed the service plan was not reflective of the resident’s current care needs, did not provide clear direction to staff, and/or was not implemented in the following areas:

* Ambulation status;
* Wheelchair versus walker use;
* Transfer assistance required;
* Frequency of safety checks;
* Emergency evacuation needs;
* Fall mat;
* Wheelchair seat cushion;
* Clothing preferences while sleeping;
* Mechanical soft and thickened liquids;
* Use of a straw; and
* Divided plate.

There was no documented evidence the facility had completed a quarterly service plan review for the resident, which would have been due on or around 01/13/25.

The need to ensure resident service plans were completed quarterly, were reflective of current care needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 3 and 4’s most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

During an interview on 02/14/25 at 10:10 am, Staff 5 (RCC) confirmed the facility lacked documented evidence of a Service Planning Team for all residents.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed for 2 of 2 sampled residents (#s 1 and 3); and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident's current service plan available to staff, dated 04/30/24, Observation notes, dated 11/10/24 through 02/14/25, Interim Service Plans (ISPs), and weight records, dated 09/10/24 through 02/10/25, were reviewed, and observations of the resident during ADL care were made.

a. Resident 3’s weight records were reviewed and revealed the following:

* 11/01/24 - 89.8 pounds;
* 12/03/24 - 85.3 pounds;
* 01/06/25 - 93.2 pounds; and
* 02/06/25 - 88.6 pounds.

Between 11/01/24 and 12/03/24, Resident 3 had a weight loss of 4.5 pounds or 5.01% of his/her total body weight in one month. Between 12/03/24 and 01/06/25, Resident 3 had a weight gain of 7.9 pounds or 9.26% of his/her body weight in one month. These weight fluctuations represented significant changes of condition, and the facility was required to evaluate, to refer to the facility RN, to document the change, and to update the service plan as needed.

On 02/13/25 at 1:26 pm, Staff 3 (Wellness Director/LPN) stated the weight changes were “probably not” referred to the RN, and no additional documentation regarding the weight changes was provided.

b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:

* 11/11/24 - Skin tear to left elbow;
* 11/29/24 - New medications;
* 12/02/24 - Bruise on left arm;
* 12/07/24 - Out of liquid thickening powder;
* 12/08/24 - Bruise to left calf;
* 12/12/24 - Discontinuation of routine Tylenol (for pain); and
* Refused medications in 01/2025 and 02/2025.

During an ADL observation on 02/11/25, a blood blister was visualized by this surveyor on the resident’s left calf. On 02/11/25 at 11:15 am, Staff 3 reported the blood blister was identified by a caregiver on 02/01/25 and reported to the MT on duty. However, the facility had no documentation of the blood blister in the resident’s chart, including resident-specific actions or interventions needed for the blister, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly.

The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed; and determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

The resident's current service plan available to staff dated 10/31/24, Observation notes, dated from 11/12/24 through 02/10/25, Interim Service Plans, dated from 09/18/24 through 02/08/25, and weight records, dated from 11/01/24 through 02/05/25 were reviewed. Observations of the resident were made, and staff were interviewed. The following changes of condition were noted:

* 10/23/24: Return from hospital due to a fall with a hip fracture, surgical incision, and weight bearing as tolerated. There was no documented evidence the surgical incision or his/her weight bearing status was monitored through resolution.

* 10/23/24: Hospice admission (which constituted a significant change of condition). There was no documented evidence the facility referred to the RN.

* 11/26/24: Fall with a skin tear on left arm. Although the fall was monitored, there was no documented evidence of the facility monitoring the skin tear that resulted from the fall through resolution.

* 12/01/24: Significant weight loss. There was no documented evidence the weight loss was referred to the RN.

Refer to C 280, example 1b.

* 01/06/25: Significant weight gain. There was no documented evidence the weight gain was referred to the RN.

Refer to C 280, example 1b.

* 01/29/25: Increase in the morning dosage of Seroquel (for agitation). There was no documented evidence of monitoring through resolution.

* 01/31/25: Resident to resident altercation. There was no documented evidence of monitoring through resolution.

* 02/08/25: The resident fell out of his/her wheelchair as another resident was pushing him/her and caused the wheelchair to "tip over." There was no documented evidence that actions or interventions were determined and communicated to staff on each shift.

The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed, and determined and documented what action or interventions were needed for short-term changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

3. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident's current service plan available to staff dated 12/20/24, Observation notes, dated from 12/21/24 through 02/10/25, and Interim Service Plans, dated from 12/21/24 through 01/31/25. Observations of the resident were made, and staff were interviewed. The following changes of condition were noted:

* 12/24/24: Fall;
* 12/28/24: Staff documented the resident was experiencing "chest burn/pain in chest area";
* 01/15/25: Staff documented "resident felt not good"; and
* 01/31/25: Resident to resident altercation.

There was no documented evidence the facility determined and documented actions or interventions, communicated those actions or interventions to staff on all shifts, and/or monitored the changes of condition through resolution.

The need to ensure the facility determined and documented actions or interventions needed, communicated those actions or interventions to staff on all shifts, and monitored the changes of condition at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

4. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia.

The resident's current service plan available to staff, dated 01/19/25, and 11/10/24 through 02/10/25 Observation notes were reviewed, interviews with staff were conducted, and observations of the resident were completed.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution:

* 11/19/24 – Bruise on ribs;
* 12/12/24 – Change in diet texture to mechanical soft;
* 01/13/25 – Change in diet texture to puree;
* 01/15/25 – New medication;
* 01/22/25 – Unwitnessed fall with injury;
* 02/04/25 – Changes to medications; and
* Missed medications throughout 01/2025 and 02/2025.

The need to ensure the facility determined and documented actions or interventions needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#s 1 and 3) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia and atrial fibrillation.

The resident’s weight records, dated 11/01/24 through 02/05/25, Outside Services Documentation, dated 11/03/24 through 02/07/25, and Observation notes, dated 11/12/24 through 02/10/25, were reviewed and staff were interviewed.

a. The resident sustained a fall on 09/24/24 which resulted in a hip fracture with surgical repair and a hospital admission. The resident returned to the facility on 10/23/24 when s/he had been admitted onto hospice services and was identified as “weight bearing as tolerated”, which constituted a significant change of condition.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

b. The following weights were recorded by the facility:

* 11/01/23: 139.4 pounds;
* 12/01/24: 130.8 pounds;
* 01/06/25: 143.8 pounds; and
* 02/05/25: 143 pounds.

Weights for 09/2024 and 10/2024 were requested on 02/11/25 at 11:37 am. On 02/11/25 at 12:19 pm, Staff 16 (MT) verified the facility had not obtained Resident 1’s weights during that specific time period.

Resident 1 experienced an 8.6 pound weight loss, or 6.16% of his/her total body weight, in one month (from 11/01/24 through 12/01/24), and a 12.2 pound weight gain, or 8.53% of his/her total body weight, in one month (from 12/01/24 through 01/06/25). Both the weight loss and weight gain represented a significant change of condition.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer’s disease.

Resident 3's weight records were reviewed and revealed the following:

* 11/01/24 - 89.8 pounds;
* 12/03/24 - 85.3 pounds;
* 01/06/25 - 93.2 pounds;
* 02/06/25 - 88.6 pounds; and
* 02/12/25 - Resident refused re-weigh during survey.

From 11/01/24 to 12/03/24, Resident 3 had a weight loss of 4.5 pounds or 5.01% of his/her body weight in one month. Additionally, from 12/03/24 to 01/06/25 the resident had a weight gain of 7.9 pounds or 9.26% of his/her body weight in one month. Both weight fluctuations indicated a significant change of condition and required an RN assessment.

RN assessments for both significant changes of condition were requested on 02/11/25. On 02/14/25 at 9:41 am, Staff 2 (Executive Nurse) confirmed there was no documented evidence the facility RN completed an assessment of Resident 3’s significant weight loss or weight gain.

The need to ensure all significant changes of condition were assessed by an RN was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 02/10/25, Resident 5 was identified to be administered insulin injections by non-licensed staff.

Resident 5’s MAR, reviewed from 01/01/25 through 02/12/25, revealed the resident received Admelog (insulin to treat diabetes) once daily and Lantus (insulin to treat diabetes) once daily. The insulin had been given by Staff 13 (Lead MT) and Staff 16 (MT) on multiple occasions.

Review of delegation records and the MAR, showed the following:

a. There was no documented evidence that the reauthorization for Staff 13, dated 02/06/25, and Staff 16, dated 01/09/25, occurred prior to the end of the prior reauthorization period.

b. There was no documentation by the RN verifying that all requirements from the initial delegation were met.

c. There was no documented evidence of a nursing assessment and condition of the resident in their environment of care to determine that the condition remained stable and predictable, and delegation remained a safe care delivery option.

d. There was no documented evidence that the RN had verified Staff 13 and Staff 16’s documentation and observed Staff 13 and Staff 16 perform the nursing procedure.

e. There was no documentation of the length of authorization period.

The requirements for delegation were reviewed with Staff 2 (Executive Nurse) on 02/13/25 and 02/14/25. She acknowledged the findings.

The need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, and the service plan was adjusted, if necessary, and reporting protocols were in place for 2 of 3 sampled residents (#s 1 and 3) who received outside services. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer's disease.

The resident's service plan available to staff, dated 04/30/24, the 01/2025 MAR, current physician orders, outside provider notes, and Interim Service Plans were reviewed. The following recommendation from outside providers was identified:

* 12/22/24 - “There was an issue and discrepancy with [his/her] Xanax order [for anxiety/agitation]. Hospice showed 2 tabs PRN [every four hours] but [the] facility order showed 1 tab [every four hours]. The meds were sent from the pharmacy with 2 tabs per bubble pack, which means only 1 was being used and the other wasted. This is a risk for miscount and diversion. Xanax with 1 tab per bubble pack is being delivered and the others with 2 tabs per pack will be wasted per protocol.”

On 02/12/25 at 11:39 am, Staff 11 (Lead MT) and this surveyor reviewed Resident 3’s narcotics which included a bubble pack for Xanax with two tablets per bubble dated as delivered to the facility on 12/09/24.

On 02/13/25 at 1:26 pm, Staff 3 (Wellness Director/LPN) verified she was unaware of this recommendation by the hospice RN.

The need to ensure the facility management or the licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, the service plan was adjusted, if necessary, and reporting protocols were in place was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

The resident's service plan available to staff, dated 10/31/24, Outside Services Documentation, dated from 11/03/24 through 02/07/25, and Interim Service Plans, dated from 09/18/24 through 02/08/25, were reviewed. The following recommendations from outside providers was identified:

* 11/03/24: "day [three] or [four] of [no bowel movement], advised give suppository," call if "impaction", and call if the resident starts exhibiting "pain or [decrease] in mobility"; and
* 01/09/25: "monitor [left second] finger wound."

There was no documented evidence the recommendations were communicated to staff or that the facility followed the recommendations.

The need to ensure the facility management or the licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted, if necessary, and reporting protocols were in place was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 3 sampled residents (#s 3 and 4) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to:

1a. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident was dependent on staff for all ADL care including incontinence care, grooming, and hygiene.

At 10:15 am on 02/11/25, Staff 19 (CG) and Staff 27 (CG) were observed providing incontinence care for Resident 4 in his/her bed. Staff 19 and Staff 27 were observed donning gloves and then assisting the resident in rolling in order to remove his/her soiled incontinence pad and soiled brief. Staff 27 placed the soiled incontinence pad onto the floor without first placing it in a bag. Staff 19 and 27 proceeded to assist the resident in donning a clean brief and placing a clean incontinence pad on the bed without removing their soiled gloves or performing hand hygiene. After providing incontinence care, staff were observed discussing oral hygiene for the resident, and Staff 27 began to reach for an oral mouth swab while still wearing soiled gloves. This surveyor stopped the process and requested staff perform hand hygiene and don clean gloves prior to continuing to provide ADL assistance.

b. Observations of meal service were conducted from 02/10/25 through 02/13/25 and the following was identified:

* Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing; and
* No hand hygiene for residents occurred, despite multiple unsampled residents observed to be eating with their hands.

The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

2. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

At 10:00 am on 02/11/25, Staff 16 (MT) and Staff 18 (CG) were observed providing ADL assistance for Resident 3. During the observation, both staff donned gloves and assisted the resident in transferring to the toilet. Staff 16 removed the resident’s soiled brief and incontinence pad. Staff 16 proceeded to put lotion on the resident’s arms and legs. No glove change or hand hygiene was performed between tasks. Staff 18 provided perineal care and assisted the resident in donning a clean brief and pants. Staff 18 then assisted the resident to the sink and started to set-up the resident’s toothbrush. No glove change or hand hygiene was performed between tasks. This surveyor stopped the process and requested the staff perform hand hygiene and don clean gloves prior to continuing ADL assistance.

The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to:

During the re-licensure survey, conducted 02/10/25 through 02/14/25, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 160 – Reasonable Precautions;
* C 282 – RN Delegation and Teaching;
* C 302 – Tracking Control Substances;
* C 303 - Medication and Treatment Orders;
* C 305 - Resident Right to Refuse;
* C 310 - Medication Administration; and
* C 330 – Psychotropic Medications.

The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. 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 3 of 3 sampled residents (#s 2, 3, and 4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia.

The resident had a signed physician orders for scheduled morphine (for pain), 20mg/ml, to be administered four times daily, PRN morphine, 20 mg/ml, to be administered hourly as needed, and PRN oxycodone (for pain), 5 mg tablet, to be administered every six hours as needed. Morphine and oxycodone are narcotic pain medications and are controlled substances.

Review of the resident's 01/01/25 through 02/10/25 MARs and Controlled Substance Disposition logs revealed the following:

a. On the following dates, scheduled morphine was shown as administered on the MAR, but was not documented in the Controlled Substance Disposition log:

* 01/21/25 at 8:00 am;
* 01/22/25 at 8:00 am;
* 01/29/25 at 8:00 am;
* 02/05/25 at 12:00 am;
* 02/05/25 at 6:00 am;
* 02/06/25 at 12:00 am; and
* 02/06/25 at 6:00 am.

b. On 02/04/25 at 6:00 pm, morphine was documented as administered in the Controlled Substance Disposition log, but was not documented as administered on the MAR.

c. On 02/09/25 at 6:00 am, the MAR was blank with no indication of whether morphine had been administered to the resident.

d. On 02/11/25 at 12:30 pm, Staff 14 (MT) was unable to locate Resident 4’s PRN oxycodone medication. Upon further investigation, Staff 3 (Wellness Director/LPN) stated it appeared the resident had not used PRN oxycodone since 07/2023, and the medication was disposed of in 08/2024. She stated it appeared the medication had not been reordered from the pharmacy and was not made available for the resident to use if needed since 08/2024. She stated she had not been aware the medication was not in the medication cart.

As of 02/11/25 at 12:30 pm, the resident’s bottle of liquid morphine appeared to have 19 ml remaining, confirmed by Staff 14 who was present. The Controlled Substance Disposition log showed that as of 02/11/25 at 12:00 pm, the bottle had 15.50 ml remaining.

During an interview on 02/11/25 at 4:00 pm, the above information was reviewed with Staff 3, who acknowledged the facility was not aware of the above discrepancies prior to them being identified by the survey team. She stated there was no current process for reviewing or reconciling narcotic medications.

The need to ensure a system was in place for accurately tracking controlled substance distribution was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

2. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident's Controlled Substance Disposition logs, MARs, dated 01/01/25 through 02/10/25, and physician’s orders were reviewed.

Resident 2 was prescribed PRN hydrocodone/APAP 5-325 mgs for pain. The following inaccuracies were identified between the resident's MARs and the Controlled Substance Disposition log:

The Controlled Substance Disposition log reflected the medication was administered on 01/07/25 and 01/09/25, but the 01/2025 MAR only had documentation that the PRN was administered on 01/09/25.

The narcotic count reflected the information documented in the Controlled Substance Disposition log.

The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

3. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 01/01/25 through 02/09/25 were reviewed.

Resident 3 had a physician order dated 08/02/24 for alprazolam 0.25 mg – one tablet by mouth every four hours as needed for anxiety, agitation, or sleep.

The following inaccuracy was identified between the resident's MAR, physician orders, and the Controlled Substance Disposition log:

Resident 3’s MAR indicated s/he received a PRN dose of alprazolam on 01/03/25 at 10:36 pm by Staff 31 (MT). The Controlled Substance Disposition log documented the dose was administered by Staff 32 (MT) on 01/02/25 at 6:30 with am and pm not specified. No other doses were documented as administered in the MAR or the Controlled Substance Disposition log for 01/2025.

The inaccuracy was reviewed with Staff 3 (Wellness Director / LPN) on 02/13/25 at 1:26 pm. She acknowledged the discrepancies.

The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed; and failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

Resident 3's current physician's orders, the MAR, dated 01/01/25 through 02/09/25, and bowel monitoring records, dated 01/01/25 through 02/09/25 were reviewed.

a. The MAR was blank for the following medications:

* Alprazolam (for anxiety) – blank on one occasion;
* Carbamide (for ear wax build up) – blank on one occasion;
* Nystatin (for rash) – blank on one occasion; and
* Refresh artificial tears (for dry eyes) – blank on one occasion.

On 02/12/25 at 11:39 am, the surveyor and Staff 11 (Lead MT) reviewed the MAR and medication supply. Staff 11 was unable to verify if the above orders had been followed.

b. The resident’s triple antibiotic cream (for infection prevention) was not administered as prescribed on 01/24/25, 01/28/25, and 02/08/25. The MT documented the resident’s skin was clear.

c. The resident’s scheduled Senna (for constipation) was not administered as prescribed on 02/07/25 and 02/08/25 because the medication was documented as not in the cart.

d. The resident had physician ordered parameters for PRN Senna and PRN polyethylene glycol powder (both for constipation). The resident’s Senna was not administered as prescribed on ten occasions, and his/her PRN polyethylene glycol powder for constipation was not administered as prescribed on five occasions.

e. Observations of the resident during meals occurred on 02/10/25 and 02/11/25. On 02/10/25, the resident received a dinner meal of regular textured garlic bread, pasta salad, mixed vegetables and thin liquid water. On 02/11/25, the resident received a regular textured breakfast meal of cut waffle and cut sausage. The facility failed to provide the resident’s prescribed diet orders of mechanical soft textures and thickened liquids.

f. On 01/02/25, according to the Controlled Disposition log the resident received two tablets of alprazolam; however, the resident’s physician orders instructed staff to administer one tablet.

g. The facility failed to have signed physician orders in the resident’s record for the following two treatments the facility was responsible to administer:

* Triple antibiotic ointment – topically apply to sore on right side of face two times daily; and
* Carbamide 6.5% ear solution – use five drops in both ears at bedtime.

The need to ensure all medications were carried out as prescribed and written signed physician orders were documented in the resident’s facility record was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

The resident's current physician's orders, and MARs, dated 01/01/25 through 02/10/25, were reviewed. The following scheduled medications were not administered per physician's orders as staff documented that the medication was not available in the facility:

* Pepcid (for acid reflux): Three occasions;
* Senna (for bowel care): Once;
* Miralax (for bowel care): Once;
* Celexa (for depression): Once; and
* Flomax (for enlarged prostate): Eight occasions.

The need to ensure all physician’s orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

3. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident’s physician’s orders, MARs, dated 01/01/25 through 02/10/25, and Patient Discharge Instructions, dated 12/22/24, were reviewed. The following was identified:

a. There was an order that was signed on 12/19/24 for the facility to report if the systolic blood pressure was greater than 180 or less than 100 or the diastolic blood pressure was greater than 90 or less than 40 unless otherwise specified. The facility had documented evidence that Resident 2’s blood pressure was only taken on 12/24/24. Multiple staff reported they were unaware of the signed physician’s order to obtain the resident’s blood pressure or the parameters of when to contact the physician.

b. The following medications were not administered as staff documented that they weren't available at the facility:

* Seroquel (for agitation/aggressive behaviors): Ten occasions;
* Senna (for bowel care): Ten occasions; and
* Valacyclovir (for shingles): 11 occasions.

c. There was no documented evidence the facility had signed orders for eight out of nine medications that they were responsible to administer to the resident.

The need to ensure written signed physician orders were documented in the resident’s facility record and that all medications and treatments were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

4. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia.

The resident’s MAR dated 01/01/25 through 02/10/25 and all signed physician orders were reviewed, and interviews were conducted. The following was identified:

a. The resident’s facility record did not have documentation of a signed order for Desitin cream (for skin redness).

b. The resident had a signed order from hospice, dated 12/12/24, stating “Okay to do mechanical soft diet”, which was implemented by the facility. On 01/13/25, an Interim Service Plan instructed staff to provide the resident with a puree diet texture. The facility was not able to provide documentation of a signed order for this diet texture change.

c. The resident had a signed order, dated 11/21/24, for Secura Protective Cream (for skin protection) to be applied as needed. The treatment was not located on the MAR/TAR.

d. The resident had a signed order for docusate 50 mg / 5 ml solution to be given by mouth every 12 hours (for constipation). The medication was not administered as ordered on 31 out of 69 occasions with notations including the medication was “out of stock in cart”, “unable to find medication”, or the “resident was sleeping”.

e. The following medications were not administered as ordered, with notations stating the resident was sleeping:

* Citalopram 10 mg (for depression): 12 occasions;
* Olanzapine 5 mg (for agitation/paranoia): six occasions; and
* Acetaminophen 325 mg (for pain); 11 occasions.

The need to ensure written, signed physician’s orders were present in the resident’s facility record for all medications and treatments the facility was responsible for administering, and all medication and treatment orders were carried out as prescribed, was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

5. Resident 5 moved into the facility in 01/2024 with diagnoses include dementia and type II diabetes.

The resident’s MAR, dated 01/01/25 through 02/12/25, and all signed physician orders were reviewed, and interviews were conducted. The following was identified:

a. The resident’s facility record did not have documentation of a signed order for the following medications and/or treatments:

* Icthammol ointment (for nail inflammation);
* Hydrocortisone 2.5% cream (for rash);
* Nystatin powder (for rash);
* Acetaminophen 500 mg (for pain) PRN every six hours; and
* Admelog insulin pen (for type II diabetes).

b. The order for nystatin powder stated it was to be applied “every 8 hours [for] 14 days.” The order was dated 01/09/25, and the facility began administering the treatment on 01/11/25. The facility was still administering the treatment every eight hours as of 02/12/25.

c. The resident had a signed order dated 12/19/24 which instructed staff to “Check blood sugar before each meal and at bedtime.” Staff 2 (Executive Nurse) confirmed on 02/13/24 that this order was not being followed.

d. The resident had a signed order dated 12/19/24 for Admelog insulin pen which was not being followed:

* The order instructed staff to administer the medication with the largest meal of the day. There was no documentation of which meal of the day was the largest. The medication was scheduled to be administered at 7:30 am.

* On 01/05/25, the medication was not administered. Notations stated the resident’s CBG was 73 mg/dl. The signed orders stated that “if blood sugar is less than 80 mg/dl, then eat 15 gm of fast-acting carbohydrate” and “recheck blood sugar in 15 minutes and repeat if blood sugar is not above 90.” There was no documented evidence the resident received 15 gm of fast-acting carbohydrate or that his/her blood sugar was rechecked.

*On 02/11/25 at 7:19 am, Admelog Insulin was not administered as ordered, with notations stating “no pass reason: other” and no additional information documented.

The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 3 of 3 sampled residents (#s 1, 2, and 3) with documented refusals. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident's MARs, dated from 01/01/25 through 02/10/25, physician’s orders, and Observation notes, dated from 12/21/24 through 02/10/25, were reviewed. The following refusals were noted:

* Metamucil (for bowel care): Three occasions;
* Eliquis (blood thinner): Four occasions;
* Seroquel (for agitation/aggressive behaviors): Five occasions;
* Valacyclovir (for shingles): Four occasions;
* Latanoprost (for glaucoma): Three occasions; and
* Senna (for bowel care): Four occasions.

There was no documented evidence the facility notified the provider when the resident refused to consent to physician’s orders.

The need to notify the provider when residents refused to consent to an order was reviewed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

2. Resident 1 moved into the facility in 09/2023 with diagnoses including dementia.

The resident's MARs, dated from 01/01/25 through 02/10/25, physician’s orders, and Observation notes, dated from 11/12/24 through 02/10/25, were reviewed. The following refusal was noted:

* 01/11/25: Miralax (for bowel care).

There was no documented evidence the facility notified the provider when the resident refused to consent to physician’s orders.

The need to notify the provider when residents refused to consent to an order was reviewed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's disease.

The resident's MAR, dated 01/01/25 through 02/09/25, was reviewed and revealed facility staff documented Resident 3 refused the following orders:

* Alprazolam 0.25 mg (for anxiety) on one occasion;
* Carbamide 6.5% (for ear wax) on 11 occasions;
* Nystatin powder (for rash) on seven occasions;
* Refresh eye drops (for dry eye) on 20 occasions;
* Secura Protective 10% cream (for skin protection) on 11 occasions;
* Senna (for constipation) on 11 occasions; and
* Triple antibiotic ointment (for infection prevention) on nine occasions.

On 02/12/25 at 10:43 am, Staff 3 (Wellness Director/LPN) confirmed there was no documented evidence the facility notified Resident 3's physician of the refusals.

On 02/14/25, the need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept and/or resident-specific parameters and instructions were included for PRN medications for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia.

The resident’s MAR dated 01/01/25 through 02/10/25, and physician’s orders were reviewed. The following was identified:

a. The resident had three PRN medications for pain which did not have parameters for order of administration:

*Morphine Sulfate 20mg/ml (.25ml / 5 mg per dose) every hour;
*Oxycodone 5 mg every six hours; and
*Acetaminophen 325 mg every four hours.

b. The resident had three PRN medications for shortness of breath which did not have parameters for order of administration:

*Morphine Sulfate 20mg/ml (.25ml / 5 mg per dose) every hour;
*Oxycodone 5 mg every six hours; and
*Promethazine 25 mg every four hours.

c. The resident had two PRN medications for nausea which did not have parameters for order of administration:

*Lorazepam 0.5 mg every four hours; and
*Promethazine 25 mg every four hours.

d. The resident had three PRN medications for constipation which did not have clear parameters for order of administration:

*Bisacodyl 10 mg suppository;
*Milk of magnesia 400 mg/5ml; and
*Lactulose 10 gm/15 ml solution.

e. Staff documented two separate reasons for why a medication was not administered at the same time and date (refused by the resident and the medication was not available or the resident was sleeping) for the following medications:

* Citalopram 10 mg (for depression): 10 occasions;
* Docusate 100 mg (constipation): 13 occasions;
* Acetaminophen 325 mg (for pain): eight occasions; and
* Olanzapine 5 mg (for agitation/paranoia): three occasions.

The need to ensure the MAR was accurate and that PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

2. Resident 5 moved into the facility in 01/2024 with diagnoses include dementia and type II diabetes.

The resident’s MAR dated 01/01/25 through 02/11/25 and physician’s orders were reviewed. The following was identified:

a. On 02/09/25 and 02/11/25, Lantus subcutaneous injection (for type II diabetes) was signed as administered by Staff 12 (Lead MT). At 11:56 am on 02/13/25, Staff 2 (Executive Nurse) stated she spoke with Staff 12 via phone and that Staff 12 reported she did not administer the medication on the dates above. Staff 12 told Staff 2 that another MT had administered the medication because Staff 12 was not yet delegated, but Staff 12 had still signed the MAR as the one administering the medication.

b. The resident received Admelog insulin pen injections (for type II diabetes) once daily. There was no documentation of the location of injection.

The need to ensure the MAR was accurate and complete was reviewed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

3. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

The resident’s MARs, dated from 01/01/25 through 02/10/25, and physician’s orders were reviewed. The following inaccuracies were identified:

a. There were two separate reasons staff documented why a medication was not administered at the same time and on the same date (refused by the resident and the medication was not available to administer):

* Pepcid (for acid reflux): Five occasions;
* Senna (for bowel care): Once;
* Flomax (for enlarged prostate): Three occasions; and
* Seroquel (for agitation/restlessness): Once.

b. There was no documentation if the following medications were administered as the MAR entries were blank on 01/22/25 at 8:00 am:

* Flomax;
* Celexa (for depression);
* Seroquel;
* Senna; and
* Dilaudid (for pain).

On 02/12/25 at approximately 11:15 am, Staff 14 (MT) verified the medications were administered per looking at the medication cards.

The need to ensure MARs were accurate and included the date and time of administration was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

4. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident’s MARs, dated from 01/01/25 through 02/10/25, and physician’s orders were reviewed. The following inaccuracies were identified:

There were two separate reasons staff documented why a medication was not administered at the same time and on the same date (refused by the resident and the medication was not available to administer):

* Seroquel (for agitation/aggressive behaviors): Four occasions;
* Senna (for bowel care): Nine occasions; and
* Valacyclovir (for shingles): 11 occasions.

The need to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings.

5. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident’s MAR, dated 01/01/25 through 02/09/25, and physician orders were reviewed during the survey and revealed the following:

a. Resident 3 had an order to receive ketoconazole shampoo as directed to wash hair on shower days (for fungal infection) dated 08/02/24. The order was transcribed onto the MAR to be administered as needed. On 02/12/25 at 11:55 am, Staff 11 (Lead MT) confirmed there was no documentation the treatment was ever administered, and she was unable to verify if the treatment had been administered as prescribed.

b. The facility failed to maintain an accurate MAR because staff documented Resident 3 refused the following medications because s/he was sleeping:

* Carbamide 6.5% (for ear wax) on one occasion;
* Nystatin powder (for rash) on three occasions;
* Refresh eye drops (for dry eye) on three occasions;
* Secura Protective 10% cream (for skin protection) on three occasions;
* Senna (for constipation) on three occasions; and
* Triple antibiotic ointment (for infection prevention) on four occasions.

On 02/14/25 at 12:45 pm, Staff 2 (Executive Nurse) stated the expectation was for MTs to attempt to wake the resident and sleeping did not constitute a refusal for a scheduled medication or treatment.

c. The following orders lacked a documented reason for use in the MAR:

* Ketoconazole; and
* Thick-It.

The need to ensure MARs were accurate and included the reason for use, date, and time administered was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 3) who were prescribed and administered PRN medications to treat behaviors. Findings include, but are not limited to:

1. Resident 1 was moved into the facility in 09/2024 with diagnoses including dementia.

The resident had a physician's order for Seroquel, 50 mgs every six hours as needed for agitation and restlessness.

Resident 1's MARs, dated from 01/01/25 through 02/10/25, and Observation notes, dated from 11/12/24 through 02/10/25, were reviewed.

The resident was administered the psychotropic medication on 14 occasions with no documented evidence staff had first attempted non-drug interventions with ineffective results.

On 02/12/25 at 11:07 am, Staff 3 (Wellness Director/LPN) verified by looking in the electronic MAR system that there were no non-drug interventions listed for staff use nor was there documentation of non-drug interventions attempted with ineffective results prior to the administration of the PRN psychotropic.

The need to attempt non-drug interventions prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

2. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

The resident's 12/14/24 through 02/09/25 MAR and prescriber orders were reviewed, and staff were interviewed.

Resident 3 had a physician order for alprazolam 0.25 mg - take one tablet by mouth every four hours as needed for anxiety, agitation, or sleep. The MAR indicated the resident received the PRN medication on 12/14/24, 12/29/24, and 01/03/25. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication.

The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT; failed to document other less restrictive alternatives evaluated prior to the use of the device; and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (#3) who had full length side rails. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer’s disease.

Resident 3 was observed to have a hospital bed with a single full side rail that ran the length of the left side of the bed, and the right side of the bed was positioned against the wall. The full side rail was visualized to be in the elevated position on 02/11/25 at 10:00 am with the resident calling for help with his/her left leg draped over the side rail.

There was no documented evidence the following required elements were completed related to the full bed rail:

* Assessment by facility RN, PT, or OT;
* The facility documented other less restrictive alternatives evaluated prior to the use of the device; and
* The facility had instructed caregivers on the correct use and precautions related to the use of the device.

The full side rail was replaced with a half side rail on 02/12/25. On 02/13/25, Staff 2 (Executive Nurse) confirmed she had completed the resident's "Lenity Oregon Device Assessment” related to the half side rail that replaced the full bed rail.

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives were evaluated prior to the use of the device and caregivers were instructed on the correct use and precautions related to the device was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following:

During the entrance conference on 02/10/25 at approximately 2:30 pm with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN) and Staff 27 (CG), the following was identified:

* The MCC consisted of three distinct cottages – Lily, Rose, and Daisy. Sixteen residents were living in Lily, 14 residents were living in Rose, and 13 residents were living in Daisy;
* Two residents required two-person assist for transfers at all times – one resident resided in Lily and one resident resided in Daisy;
* One resident, who resided in Rose, required occasional two-person assist for transfers; and
* Eighteen residents were reported to require high levels of caregiving assistance due to requiring hospice services, cognitive decline, history of falls/fall risk, feeding assistance, history of behaviors, and history of resident-to-resident altercations.

Observations of cares provided to residents and interviews with staff throughout the survey revealed five residents who required two-person transfer assistance. Daisy cottage had one resident who required two-person transfer assistance, Lily cottage had two residents, and Rose cottage had one resident who required two-person assistance at all times and one who required occasional two-person assistance.

The facility's posted staffing plans, the staffing schedule from 01/25/25 through 01/31/25, and the corresponding timeslips were reviewed. The facility's posted staffing plan indicated three caregivers and one medication technician were scheduled to work the 10:00 pm to 6:00 am shift daily. This equated to one caregiver in each cottage and a MT to assist with caregiving duties as needed.

On 02/12/25 at 2:57 pm, Staff 1 and Staff 2 (Executive Nurse) acknowledged the facility had not completed fire drills every other month with evacuation or relocation of residents, including the residents who required two-person transfer assistance. Additionally, when asked how the current overnight staffing plans accounted for the two-person transfers, Staff 2 acknowledged she would adjust the overnight staffing immediately.

The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, had behaviors (including resident-to-resident altercations) and resided in three distinct cottages.

On 02/13/25 at 3:13 pm, the facility provided an updated schedule and staffing plan which included five caregivers and one MT for the 10:00 pm to 6:00 am shift. This updated schedule accounted for the scheduled and unscheduled needs of the residents and the fire safety evacuation standards.

The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents and fire evacuation standards on the overnight shift was discussed with Staff 1 and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time that the staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 3, and 4) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia.

The resident's service plan, Interim Service Plans, and ABST, were reviewed. Staff were interviewed and Resident 1 was observed. The resident's ABST was not reflective of care time needed in the following areas:

* Escorts to and from meals and activities;
* Transfers in and out of the bed and/or chair; and
* Bowel and bladder management.

The need to accurately capture care time on the resident's ABST was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

2. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with the resident’s family and staff, the 10/15/24 service plan and Interim Service Plans, from 11/01/24 through 02/14/25, and Resident 3’s ABST data was reviewed.

The resident's ABST evaluation was not reflective of care time needed in the following areas:

* Safety checks, fall prevention;
* Monitoring physical conditions or symptoms;
* Providing treatments;
* Supervising, cueing, or supporting while eating;
* Transferring from bed;
* Communication; and
* Bowel and bladder management.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

3. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia.

The resident's service plan, Interim Service Plans and ABST were reviewed. Staff were interviewed and Resident 4 was observed. The resident's ABST did not accurately capture care time in the following areas:

* Medication administration;
* Time spent repositioning; and
* Frequency of safety checks.

The need to ensure the ABST accurately captured care time was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 3 of 4 sampled residents (#s 2, 3, and 4) and an unsampled resident, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to:

The facility was a licensed MCC with three distinct cottages.

1. The facility’s ABST was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/12/25 at 2:57 pm and on 02/14/25 at 9:13 am. The following was identified:

a. Resident 2, who moved into the facility on 12/22/24, did not have an ABST evaluation completed until 02/02/25, or 42 days following the resident’s move to the facility. An unsampled resident, who moved into the facility on 02/03/25, did not have an ABST evaluation completed until after survey entered the facility on 02/10/25.

b. Resident 3 experienced significant changes of condition related to weight changes on 12/03/24 and 01/06/25, and the resident required monitoring of physical conditions related to weight changes. There was no documented evidence the ABST was updated with the significant changes of condition.

c. Resident 4’s ABST evaluation did not have evidence it was updated quarterly at the same time as the service plan update.

2. The facility’s posted staffing plan and staffing schedule from 01/25/25 to 01/31/25 were reviewed with Staff 1 and Staff 2 at 2:57 pm on 02/12/25. The following was identified:

The posted staffing plan for the facility MCC was as follows:

* Day shift: 6 CG, 2 MT;
* Evening shift: 6 CG, 2 MT; and
* Night shift: 3 CG, 1 MT.

Review of the facility schedule and corresponding timecards from 01/25/25 to 01/31/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 28.6% of the total shifts reviewed.

The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly with the service plan, and the need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1 and Staff 2 on 02/14/25 at 9:39 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 25 and 30) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Business Office Manager) on 02/11/25.

Staff 25 (CG), hired 01/01/25, and Staff 30 (CG), hired on 12/05/24, lacked documented evidence they had completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure direct care staff completed the required First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 6 on 02/11/25 and with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to:

Six months of fire drill and fire and life safety training records were requested on 02/10/25. The following was identified:

a. There was no documented evidence the facility had conducted a fire drill every other month between 08/2024 and 02/2025.

b. One fire drill had been conducted during the reviewed time period. This fire drill, on 12/19/24, did not include activating the fire alarm system. Documentation of the fire drill failed to address the following:

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time period needed; and
* Number of occupants evacuated.

c. During interviews completed 02/11/25 through 02/13/25, staff were unable to identify the designated point of safety in case of a fire.

d. There was no documented evidence the facility was providing fire and life safety training to staff on alternating months from fire drills.

The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending per the Oregon Fire Code (OFC) unless the resident’s mental capability did not allow for following such instruction. Findings include, but are not limited to:

Fire and life safety records were reviewed on 02/11/25.

During an interview on 02/11/25 at 2:38 pm, Staff 1 (Administrator) reported that residents had not been receiving fire and life safety training on admission, nor had the facility been re-instructing residents at least annually.

The need to instruct and re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have an emergency preparedness plan that included analysis and response to emergency hazards in event of a prolonged power failure, and failed to conduct a drill of the emergency preparedness plan at least twice a year. Findings include, but are not limited to:

In an interview on 02/11/25 at 11:20 am, Staff 7 (Facility Services Director) stated the facility frequently experienced “rolling blackouts”, including six times the previous summer.

During interviews on 02/11/25 and 02/12/25, care staff expressed concern that the facility did not have an emergency plan in event of a power outage. They stated a power outage, lasting approximately ten hours, occurred at the facility on 02/04/25, and staff did not know how to complete tasks such as documenting medication administration.

During an interview on 02/12/25 at 3:00 pm, Staff 1 (Administrator), Staff 2 (Executive Nurse) and Staff 7 confirmed the facility experienced a power outage on 02/04/25 and the facility did not implement a system for documenting medications administered while the power was out. They stated that the facility had not been conducting drills of the emergency preparedness plan at least twice per year.

The survey team requested the facility’s emergency preparedness plan in the event of a power outage or other emergency. This was reviewed on 02/13/25 at 10:50 am and the following was identified:

* Multiple areas of the plan were blank, including areas describing how the facility would gather provisions such as water, food or medical supplies for the resident’s needs in case of an emergency; and
* Names and phone numbers of who should be contacted in case of an emergency belonged to staff who were no longer employed by the facility.

The need to ensure the facility developed an emergency preparedness plan that included analysis and response to emergency hazards in event of an emergency such as a prolonged power failure, and to conduct a drill of the emergency preparedness plan at least twice a year, was reviewed with Staff 1 and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure lever-type door handles were provided on all doors used by residents. Findings include, but are not limited to:

The environment was toured on 02/11/25 at 1:45 pm. Multiple unsampled resident rooms, in the Daisy and Lily cottages, were observed to have a sliding barn door to access the bathroom located within the room. The doors did not have a lever-type handle.

During a review of the environment on 02/12/25 at 4:15 pm, Staff 1 (Administrator) and Staff 7 (Facility Services Director) acknowledged that not all doors used by residents had a lever-type door handle.

The need to ensure lever-type door handles were provided on all doors used by residents was reviewed with Staff 1 and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to:

Refer to C 200 and C 340.

Based on observation and interview, the facility failed to ensure each individual resident had privacy in his/her unit. Findings include, but are not limited to:

The environment was toured on 02/11/25 at 1:45 pm. Multiple unsampled resident rooms, shared between two residents, were observed to have a sliding barn door to access the bathroom located within the room. There was no way to lock the door to ensure privacy while using the bathroom.

The environment was toured with Staff 1 (Administrator) and Staff 7 (Facility Services Director) on 02/12/25 at 4:15 pm. They acknowledged that the barn doors on shared resident room bathrooms did not have a way to lock to ensure privacy.

The need to ensure each individual resident had privacy in his/her unit was reviewed with Staff 1 and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to:

Multiple observations were made in Daisy, Rose, and Lily Cottages during the survey of staff using their key to open sampled and unsampled resident unit doors.

During an interview during the survey, Staff 1 (Administrator) confirmed the residents did not have keys to their units.

Review of Resident 1, 2, 3, and 4’s service plans did not indicate if the residents had a key to their unit or if they were evaluated to have one.

Resident 1’s service plan, dated 10/31/24, reflected that the “resident is able to keep track of their own room key” and that staff “are to assist further if requested.” On 02/12/25 at 10:37 am, Staff 27 (CG) confirmed the resident did not have a key to their unit.

The need to ensure the individual resident and only appropriate staff had a key to access their unit was discussed with Staff 1 and Staff 2 (Executive Nurse) during the survey. On 02/14/25, Staff 1 verified the keys were being made and that all residents would have a key to their unit as soon as the facility had the keys.

Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements including the pronouns and gender identity for 1 of 1 sampled resident (#2) who’s evaluation was reviewed. Findings include, but are not limited to:

Refer to C 252.

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 limited to:

Refer to: C 150, C 156, C 160, C 200, C 231, C 295, C 360, C 362, C 363, C 372, C 420, C 422, C 435, and C 513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 25, 28, and 30) completed pre-service orientation and dementia training prior to beginning their job responsibilities, 5 of 5 newly hired staff (#s 12, 25, 28, 30, and 33) had documented evidence of demonstrated competency in all required areas within 30 days of hire, 2 of 2 long term staff (#s 15 and 26) completed a total of 16 hours of annual in-service training, and 1 of 3 long term, non-direct care staff (#9) completed required annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Business Office Manager) on 02/11/25 and 02/12/25. The following was identified:

a. There was no documented evidence Staff 25 (CG), hired 01/01/25, Staff 28 (CG), hired 01/01/25, and Staff 30 (CG), hired 12/05/24, completed all required pre-service orientation topics and pre-service dementia training prior to beginning job duties in the following topics:

* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Fire safety and emergency procedures;
* Environmental factors that are important to a resident’s well-being; * Family support and the role the family many 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.

b. Staff 12 (MT), hired 01/22/25, Staff 25, Staff 28, Staff 30, and Staff 33 (CG), hired 01/20/25, lacked documented evidence they had completed all of the required training and demonstrated competency in all job duties within 30 days of hire, or prior to working with residents independently, in one or more of the following areas:

* 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
* Other duties as applicable.

In an interview on 02/12/25, Staff 5 (RCC) acknowledged Staff 12 did not have documentation of demonstrated competency in medication pass prior to working independently as a MT. Staff 5 agreed to ensure Staff 12 demonstrated competence prior to independently passing medications.

c. There was no documented evidence Staff 15 (MT), hired 01/09/23, and Staff 26 (CG), hired 01/19/20, completed 16 hours of annual in-service training, including at least six hours of dementia care topics.

d. Staff 9 (Activity Aide), hired 01/23/23, lacked documented evidence of completion of annual infectious disease training.

The need to ensure all staff completed pre-service orientation and dementia training, demonstrated competence in job duties within 30 days, had 16 hours of annual in-service training, and completed required infectious disease training annually, was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), Staff 5, and Staff 6 on 02/11/25, 02/12/25, and 02/14/25. 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 262, C 270, C 280, C 282, C 290, C 300, C 302, C 303, C 305, C 310, C 330, and C340.

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 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 4's service plans were reviewed. The service plans were found to be lacking information and staff instructions related to an individualized nutrition and hydration plan.

The need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 4’s records were reviewed and observations were made during the survey. The current activity evaluations did not address one or more of the following required components:

* Past and current interests;
* Current abilities and skills;
* Emotional/social needs and patterns;
* Physical abilities and limitations;
* Adaptations needed to participate; and
* Identification of activities for behavioral interventions.

The current activity plans were not individualized to each resident based on their activity evaluation and not included on the resident's activity service or care plan.

In an interview with Staff 9 (Activity Aide) on 02/12/25 at 3:19 pm, she confirmed that the residents did not have an activity evaluation.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of their rooms. Findings include, but are not limited to:

During the survey from 02/10/25 through 02/14/25, multiple sampled and unsampled residents were observed to be locked out of their room.

During interviews on 02/10/25 through 02/12/25, care staff stated that “most” resident rooms were kept locked at all times.

On 02/11/25 at 12:03 pm in Daisy cottage, an unsampled resident was observed attempting to enter his/her room and found it to be locked. The resident went to the dining room and asked a CG to “unlock my door so I can get my coat.” The CG replied, “not now, after lunch.” The resident appeared to become agitated and began yelling. During an interview at 12:35 pm, the CG stated the resident was not let back in to his/her room because the resident had “already been let back into [his/her] room three times” and the CG needed to finish serving lunch to the other residents.

The need to ensure residents were not locked outside of their rooms was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 8/2/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and observation it was confirmed that the facility failed to keep all equipment in good repair. Findings include, but is not limited to:In an interview on 8/2/2022, Witness #1 (W1) reported receiving a phone call from a family member of Resident #1 (R1) who stated the facility's A/C unit was not working in Cottage A, staff were shifting residents to other cottages during the day and returning them to their rooms to sleep at night.In an interview on 8/2/2022, Staff #1-2 (S1-2) reported there is a blower that is "out" located in Cottage A (Rose Cottage) that is affecting temperatures in the common area and the walkway that links the facility's 3 cottages together. S1 reported that Resident rooms in Cottage A are not affected by this, their rooms remain at 70 degrees. S1 reported that during the days with temperatures reaching 110 degrees, they try to keep the residents in their air conditioned rooms, however with some of them it is not possible as they prefer to wander throughout the common areas. In order to accommodate these residents, they move them to the other 2 cottages to provide some relief from heat during the day. During an unannounced visit on 8/2/2022, Compliance Specialist (CS) observed several standing fans located in Cottage A's common area and kitchen. *CS used a thermal gun to test temperatures in the common area, kitchen area and adjoining hallway at the time of visit, temperatures were at 78 degrees at 11AM. *CS tested temperatures in five resident rooms, all were consistent at 70 degrees. *CS observed thermostats for the remaining cottages and temp controlled hallways, all were consistent at 70 degrees.S1 acknowledged the findings.Plan of Correction:S1 reported that Comfort Flow was out to assess the issue and they are now waiting on bids for the parts/repairs. S1 stated they already have approval from Corporate Office for whatever bid they receive, they are hoping to receive the bid by 8/3/2022 and will proceed with repairs as soon as parts arrive.

The findings of the re-licensure survey, conducted 8/9/21 through 8/10/21 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, 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 first re-visit to the re-licensure survey of 08/10/21, conducted 11/29/21 through 11/30/21, 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, 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 revisit to the re-licensure survey of 08/10/21, conducted 02/03/22, are documented in this report. It was determined the facility was in substantial compliance with OARS 411 Division 54 for Residential Care and Assisted Living Facilities, OARS 411 Division 57 for Memory Care Communities and OARS 411 Division 004 for Home and Community Based Regulations.

2. Resident 1 was admitted to the facility in August 2020 with diagnoses including dementia. Review of incident reports and progress notes from 7/15/21 to 7/31/21 showed the following: * An incident report dated 7/15/21 was created after Resident 1 sustained a skin tear to the left hand. The report indicated the resident was unable to recall how s/he had gotten the skin tear. There was no investigation completed related to this incident to rule out abuse and neglect and it was not reported to the local SPD office.The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Regional Director) and Staff 3 (RN) on 8/10/21. The staff acknowledged the findings. The facility was asked to report the incident from 7/15/21 to their local SPD office and a confirmation was provided prior to exit.
Based on interview and record review, it was determined the facility failed to ensure resident incidents were thoroughly investigated in a timely manner and/or reported to the local Seniors and People with Disability (SPD) office for 3 of 3 sampled residents (#1, 2 and 3) who were reviewed with injuries from falls or unknown cause. Findings include, but are not limited to:1. Resident 2 moved into the facility in October of 2020 with a diagnosis dementia.Review of Resident 2's record revealed s/he sustained an injury on 6/15/21 after s/he hit his/her head on the floor as s/he fell out of a recliner sustaining a rug burn on their nose. Resident 2 appeared confused after the fall and an ambulance was called to take him/her to the ER. Interview with Staff 1 (Administrator) on 10/10/21, about the incident on 6/15/21, determined the facility failed to report the injury fall to the local SPD office. The surveyor asked Staff 1 to report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 8/10/21.The need to ensure resident incidents were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 and Staff 2 (Regional Director) on 8/10/21. They acknowledged the findings.
3. Resident 3 was admitted to facility 12/2020 with a diagnosis including dementia. Resident 3's current service plan noted the resident was at risk for falls.Review of Resident 3's record noted multiple unwitnessed falls between 2/23/21 and 8/3/21. There was no documented evidence how the facility determined the fall was not the result of neglect or abuse.The need to thoroughly investigate all incidents to rule out suspected abuse and/or neglect was discussed with Staff 1 (Administrator), Staff 2 (Regional Director), Staff 3 (RN) and Staff 4 (RCC) on 8/10/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to notify RN of a change in condition, document and communicate resident specific interventions, evaluate, and monitor weekly until resolution for 1 of 1 sampled resident (#2) who experienced a severe weight gain. Findings include, but are not limited to: Resident 2 was admitted to the facility in October of 2020 with a diagnosis of dementia. Resident 2's weight record, progress notes and interim service plans were reviewed on 8/9/21 and revealed the following:Residents 2's weight was noted to be 102.8 pounds on 2/24/21. Resident 2's weight on 5/26/21 was documented to be 120.8 pounds.This constituted a 16 pound, or 13.2%, severe weight gain in three months. Review of progress notes and interim service plans determined there was no documented evidence the facility evaluated and monitored the change of condition or implemented interventions related to the severe weight gain. Interview with Staff 1 (Administrator) and Staff 3 (RN) on 8/10/21 revealed there was no RN assessment or monitoring completed for Resident 2's weight gain or notification from staff that Resident 2 had a change of condition.Observation on 8/9/21 and 8/10/21 showed Resident 2 ate 100% during meals. Review of Resident 2's meal record showed s/he consistently ate 100% of all meals.The need to ensure staff notified the RN of a change of condition, documented and communicated resident specific interventions, evaluated, and monitored weekly until resolution was discussed with Staff 1 (Administrator) on 8/12/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#2) who experienced significant changes of condition related to a weight change. Findings include, but are not limited to:Resident 2 was admitted to the facility in October of 2020 with a diagnosis of dementia.Residents 2's weight was noted to be 102.8 pounds on 2/24/21. Resident 2's weight on 5/26/21 was documented to be 120.8 pounds.This constituted a 16 pound, or 13.2%, severe weight gain in three months. There was no documented evidence the RN completed a Change of Condition assessment which included findings, resident status, and interventions made as a result of the 16 pound weight gain. The need to ensure an RN assessment was completed for residents who experience a significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 8/10/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to: Fire and life safety training and records were reviewed with Staff 6 (Maintenance Director) on 8/10/21 at 10:10 am. The following was identified:* No documented evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;* No documented evidence fire drills were conducted every other month;* No documentation of escape route used;* No documentation of problems encountered and comments relating to residents who resisted or failed to participate in the drills; and*No documented evidence of alternate routes being used during fire drills.On 8/10/21, the above areas were reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 513 and Z 142.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident was clean and in good repair. Findings include, but are not limited to:During a tour of the facility on 8/9/21, the following was observed:All dining room tables and chairs in Rose, Daisy and Lilly cottages were missing varnish on the table tops and legs. Multiple dining room chairs had stains on the fabric seats.On 8/10/21, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident was clean and in good repair. This is a repeat citation. Findings include, but are not limited to:During a tour of the facility on 11/29/21, the following was observed:All dining room tables and chairs in Rose, Daisy and Lilly cottages were missing varnish on the table tops and legs. Multiple dining room chairs had stains on the fabric seats.On 11/30/21, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator). 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 C231, C420 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. This is a repeat citation. Findings include, but are not limited to:Refer to C 513.
Refer to C 513.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff completed all required pre-service orientation prior to beginning job duties, and 2 of 2 long term staff completed the required number of hours of annual training. Findings include, but are not limited to:Staff training records were reviewed on 8/10/21 with Staff 2 (Regional Director).a. Training records for Staff 7 (CG) hired 6/4/21, Staff 9 (CG) hired 4/5/21 and Staff 15 (CG) hired 2/1/21, lacked documented evidence the following pre-service orientation elements were completed:* Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control; * Fire safety and emergency procedures; and* Written job description.b. Training records for Staff 11 (MT) hired 10/2/17, and Staff 13 (CG) hired 7/9/18 lacked documentation of completion of 10 hours of training related to the provision of care in CBC and 6 hours of training related to dementia care annually.The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (Administrator) on 8/10/21. She 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 C270 and C280.