Kellyville RCF

10 Tag infoAssisted 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 08/11/25. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthHS: Hours of sleepLPN: Licensed Practical NurseMT: Medication Technician or Med TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseSP: Service planSPT: Service Planning TeamTAR: Treatment Administration Record

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:

The RCF kitchen was toured on 06/03/25 and observed to need cleaning and repair in the following areas:

a. The stationary dish machine was not operating at the required rinse temperature of 180 F. for 25 seconds, per the manufactures data plate. During an interview with Staff 3 (Kitchen Manager) at approximately 10:15 am, the process for washing dishes included using the three-compartment sink to wash, rinse and sanitize then staff ran the dishes through the dish machine. Surveyor observed the process for using the three-compartment sink and determined the kitchen staff were not aware of the proper procedure for using a three-compartment sink. Therefore, the facility lacked a system for properly sanitizing dishware and cooking equipment.
Staff 3 was not aware of the dish machine not operating per the data plate and was not aware staff were using the three-compartment sink incorrectly. Surveyor and facility staff reviewed guidance on how to properly use the three- compartment sink. Staff 3 was observed providing education to Staff 4 and 5 (both Facility Chef’s).

Prior to survey exit the staff were observed using the sink properly to ensure sanitation levels. Staff 2 (Assistant Manager) called the service provider to schedule maintenance on the dish machine.

b. Staff 4 and 5 were observed to touch multiple food items with gloved hands without changing gloves between each use and without hand hygiene between glove changes.
c. Exterior of dry food storage bins and the service cart that housed the bins were damaged and visibly dirty.
d. The interior of the ice machine had a buildup of brown and orange colored matter. Surveyor requested verification of when the ice machine was last inspected and cleaned. Staff 2 was unable to provide verification of when it was last serviced.
e. An upright black refrigerator lacked a temperature gauge to verify the internal temperature was below 41 F.
f. Staff were not using alcohol wipes to sanitize the probe thermometer after each use.

The need to ensure the kitchen was maintained in good repair and in a sanitary manner in accordance with the Food Sanitation Rules was discussed with Staff 1, Staff 2 and Staff 3 on 06/03/25 at 12:35 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2024 with diagnoses including Type II diabetes, history of stroke, and hypertension.

Review of the record revealed the new move-in evaluation failed to address the following elements:

* Presence of depression, thought disorders or behavioral mood problems;

* History of treatment;

* Effective non drug interventions;

* Personality, including how the person copes with change or challenging situations;

* Ability to understand and be understood;

* Pain, including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Fall risk or history;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident’s behavior including, but not limited to: noise, lighting, and room temperature.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator), Staff 3 (Facility RN), and Staff 4 (Program and HR Director) on 11/05/24 at 1:30 pm. The findings were acknowledged.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

?Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 09/2024 with diagnoses including Type II diabetes, history of stroke, and hypertension.

The resident's current service plan, dated 09/23/24, was reviewed, observations of the resident were made, and interviews were conducted with staff. The service plan was not reflective of the resident's needs and preferences and/or did not provide clear instruction to staff in the following areas:

* Number of staff required to assist with bathing, dressing, toileting, and evacuation;

* Equipment required for transfers;

* Assistance required with oxygen use;

* Changing and cleaning of oxygen tubing and filter;

* Use of a wheelchair arm trough; and

* Use of a pillow under left foot for positioning in wheelchair.

The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 3 (Facility RN), and Staff 4 (Program and HR Director) on 11/05/24 at 1:30 pm. The findings were acknowledged.

2. Resident 2 moved into the facility in 05/2018 with diagnoses including dementia and type II diabetes.

Observations of the resident, interviews with staff, and the 10/22/24 service plan and Temporary Service Plan (TSPs), from 08/23/24 thru 10/21/24, reviewed during the survey, revealed Resident 2's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services the following areas:

* Use of scoop mattress;

* Dressing assistance;

* Two staff to assist with transfers;

* Eating assistance;

* Verbal communication status;

* Side rail status; and

* Use of a wrist brace.

On 11/06/24 at 9:00 am, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Manager), Staff 3 (Facility RN), Staff 4 (Program and HR director) and Staff 26 (Facility RN). Staff acknowledged the service plan was not reflective of the resident's status and lacked clear direction to staff.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure actions or interventions were determined, documented, and communicated to staff on each shift, and interventions were monitored for effectiveness with weekly progress noted to resolution for 1 of 3 sampled residents (#2) who experienced short-term changes of condition. Findings include, but are not limited to:

Resident 2 moved into the facility in 05/2018 with diagnoses including dementia and Type II diabetes.

During the acuity interview on 11/04/24, the resident was identified to have multiple falls.

Review of the resident's clinical record including observation notes from 08/05/24 through 10/31/24, the 10/22/24 service plan, and temporary service plans (TSPs) from 08/23/24 thru 10/21/24 was completed during the survey.

The 10/22/24 service plan indicated the resident “has history of multiple falls and continues to have them...reasons for the fall include needing to use the bathroom.”

The resident had nine non-injury falls between 08/23/24 and 10/31/24. The facility failed to monitor the resident’s repeated falls consistent with his/her evaluated needs and service plan. There was no documented evidence the facility determined the cause of falls, ensured interventions were implemented, and monitored the interventions for effectiveness. Additionally, there was no documented evidence the facility monitored the resident for the repeated falls with weekly progress noted until resolution.

The need to ensure the facility determined, documented, and communicated to staff on each shift actions or interventions, interventions were monitored for effectiveness, and weekly progress was noted until resolution for short-term changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Manager), Staff 3 (Facility RN), Staff 4 (Program and HR director) and Staff 26 (Facility RN) on 11/06/24 at 9:00 am. Staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (#2) related to incontinence care. Findings include, but are not limited to:

Resident 2 moved into the facility in 05/2018 with diagnoses including dementia and Type II diabetes and was identified during the acuity interview as dependent on staff for incontinence care.

The surveyor observed on 11/05/24 at 10:15 am, Staff 10 (CG) and Staff 23 (CG) and on 11/06/24 at 9:34 am, Staff 15 (CG) and Staff 20 (CG) provide incontinence care for Resident 2. During the observations, Staff 10 and 20 donned gloves without performing hand hygiene. Staff 10 and 20 wiped and cleaned the resident’s perineum area after having a bowel movement and changed gloves without hand hygiene between glove changes, then proceeded to remove the resident’s soiled brief, wipe and cleanse the resident’s perineum area and touched the resident’s body, clean incontinent products, and wheelchair while using the soiled gloves. Staff 10 and 20 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donning gloves.

The above observations were discussed with Staff 1 (Administrator) and Staff 2 (Assistant Manager), Staff 3 (Facility RN), Staff 4 (Program and HR director) and Staff 26 (Facility RN) on 11/06/24 at 9:47 am. Staff acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 2) who had documented medication refusals. Findings include, but are not limited to:

Resident 2 moved into the facility in 05/2018 with diagnoses including dementia with behavioral disturbance, central pain syndrome, and Type II diabetes.

Resident 2’s 10/01/24 through 11/03/24 MARs were reviewed during the survey and showed the following:

*Staff documented the resident refused physician-ordered, scheduled Acetaminophen (for pain), Memantine (for Alzheimer’s disease), Metformin (for diabetes), Atorvastatin (for stroke/heart attack), Donepezil (for Alzheimer’s disease) and Pregabalin (for neuropathic pain) on 10/08/24 and 10/10/24;

*Staff documented the resident refused physician-ordered, scheduled Acetaminophen (for pain), Donepezil (for Alzheimer’s disease), Latanoprost (for glaucoma), Risperidone (for behavioral disorder associated with dementia), and Pregabalin (for neuropathic pain) on 10/29/24; and

*There was no documented evidence the facility notified Resident 2's physician of the refusals.

On 11/06/24 at 11:04 am, Staff 27 (MT) reported when a resident refused his/her medication, she informed the facility nurse.

On 11/06/24 at 11:21 am, Staff 26 (Facility RN) confirmed there was no documentation Resident 2’s prescriber had been notified.

On 11/06/24 at 11:22 am, the refusals were reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager), Staff 3 (Facility RN), Staff 4 (Program and HR director) and Staff 26. Staff acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure staffing levels based on the special needs contract for 15 residents who were under a special needs contract. Findings include, but are not limited to:

During the acuity interview at 9:10 am on 11/04/24, 15 residents were identified as being under a special needs contract.

Contract staffing requirements provided by Witness 1, were as follows:

* One direct care staff for every four residents served under the contract for day, evening, and night shifts; and

* One and a half staff designated for activities to develop, oversee, and implement activities for residents served under the contract.

Review of the facility’s night shift schedule and timecards revealed the facility was staffing three direct care staff for the residents under the contract, instead of the required four.

At 12:27 pm on 11/05/24, Staff 4 (Program and HR Director) stated the facility had only one staff designated to coordinate activities, instead of the required one and a half.

The need to ensure adequate staffing levels based on the special needs contract was discussed with Staff 1 (Administrator), Staff 2 (Assistant Manager), and Staff 4 on 11/05/24. They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

(Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

(Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation including infectious disease prevention training had been completed prior to beginning job duties for 4 of 4 newly hired direct care staff (#s 5, 12, 15, and 22). Findings include, but are not limited to:

Staff training records were reviewed on 11/05/24 at 11:25 am and the following was identified:

*There was no documented evidence Staff 5 (CG), hired 07/19/24, Staff 12 (MT), hired 09/30/24, Staff 15 (CG), hired 09/09/24, and Staff 22 (Housekeeping), hired 10/22/24 completed approved infectious disease prevention training prior to beginning job duties.

The training program and requirements were discussed with Staff 1 (Administrator) and Staff 2 (Assistant Manager), Staff 3 (Facility RN), Staff 4 (Program and HR director) and Staff 26 (Facility RN) on 11/06/24 at 9:00 am. Staff acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to designate two employees, one representing management and one representing direct care staff, by 07/01/24, who served as points of contact for compliance with LGBTQIA2S+ preservice and biennial training requirements for the facility. Findings include, but are not limited to:

During the entrance conference interview at 9:15 am on 11/06/24, the names of designated management and direct care representatives for LGBTQIA2S+ compliance were requested.

At 12:00 pm on 11/04/24, Staff 1 (Administrator) stated the facility did not have any designated representatives.

The need to ensure designation of two employees for LGBTQIA2S+ compliance was discussed with Staff 1, Staff 2 (Assistant Manager), and Staff 4 (Program and HR Director) on 11/05/24. They acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff

(6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF.

(a) Annual infectious disease training requires the following:
(A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.
(B) Annual in-service training must be documented in the employee record.

(b) Biennial LGBTQIA2S+ training requires the following:
(A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff.
(i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite.
(ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility.

(B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either:
(i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or
(ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility.

(C) ORS 441.116 requires all LGBTQIA2S+ trainings address:
(i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus.
(ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status.
(iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status.
(iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns.
(v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination.
(vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training.
(vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state.

(D) The proposal for training submitted by a facility, entity, or individual shall include:
(i) The regulatory criteria described in paragraph (C) of this section as part of the proposal.
(ii) The following elements must be included in the proposal:
(I) A statement of the qualifications and training experience of the facility, individual or entity providing the training;
(II) The proposed methodology for providing the training either online or in person.
(III) An outline of the training.
(IV) Copies of the materials to be used in the training.
(iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision.

(c) Annual Home and Community-Based Services (HCBS) training requires the following:
(A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations.
(B) Annual in-service training must be documented in the employee record.
(C) These annual trainings will be required as of April 1, 2025.

(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.
(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire.
(b) Requirements for annual in-service dementia training:
(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.
(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.
(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.
(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.
(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:
(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).
(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.
(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency.

(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

?Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material, accessible and maintained in good repair. Findings include, but are not limited to:

The exterior of the facility was toured on 11/04/24 and 11/05/24. The following was identified:

* Exterior concrete pathways contained multiple drop-offs measuring from two to three inches from the concrete to the planting bed surface; and

* Exterior concrete pathway at the south side of the building adjacent to the parking lot had a drop-off of two inches from the concrete to an asphalt surface.

These drop-offs created potential hazards for residents that frequently used the pathways.

On 11/05/24, the building's exterior was toured with Staff 2 (Assistant Manager), and the findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 3 (Facility RN), and Staff 4 (Program and HR Director).

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

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 and the interior of the building was maintained, clean, and free from unpleasant odors. Findings include, but are not limited to:

The interior of the building was toured at 9:25 am on 11/04/24, and the following was identified:

a. Bathrooms in resident units lacked a lever-type door handle.

During an interview on 11/05/24, at 10:15 am, Staff 2 (Assistant Manager) confirmed all bathroom pocket doors in the residents’ units lacked a lever-type door handle.

b. There was a pervasive, unpleasant odor in the facility near the entrance of the Purple Hall.

c. The following areas were in need of cleaning and/or repair:

* The doors and/or door frames of the main entrance/exit door, the elevator, and resident rooms 107, 114, 204, 211, and 215 were scraped, scuffed, or gouged;

* Wooden handrails throughout the facility were gouged or damaged leaving a rough surface;

* The handle of the first and second floor stairwell doors had chips and scratches; and

* Three of the five brown chairs in the common area had rips at the seams of the arms.

The facility was toured with Staff 2 at 10:25 am on 11/05/24. She acknowledged the areas needing cleaning and/or repair.

The need to ensure the interior of the facility was maintained clean and in good repair was discussed with Staff 1 (Administrator), Staff 3 (Facility RN), and Staff 4 (Program and HR Director). The findings were acknowledged on 11/05/24.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) 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 will be kept clean and in good repair.

This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) 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 will be kept clean and in good repair.

This Rule is not met as evidenced by:

?Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

The soiled laundry room was toured on 11/04/24 at 9:40 am. There was no documented evidence the washing machines’ temperatures were being taken or that the rinse temperature reached 140 degrees F. There was no evidence the detergent used in the soiled linen room contained a chemical disinfectant.

During an interview on 11/04/24 at 9:50 am, Staff 17 (CG) stated the process for soiled laundry was to rinse it off in the flushing rim clinical sink, use detergent, remove the washed items, and then spray out the washer with a cleaner.

During an interview on 11/05/24 at 9:45 am, Staff 9 (Floor Supervisor) confirmed a disinfectant was not used to wash soiled linens and clothing.

The need to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled lines and soiled clothing was reviewed with Staff 1 (Administrator), Staff 3 (Facility RN), and Staff 4 (Program and HR Director) on 11/05/24. The findings were acknowledged.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry

(b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure privacy, dignity, and respect related to resident bathroom doors not locking and staff noise on evening and night shifts for multiple sampled and unsampled residents. Findings include, but are not limited to:

1. Observations on 11/04/24 revealed Resident 2 and Resident 3 did not have a locking mechanism on their bathroom doors to ensure privacy. The doors were pocket sliding doors with a metal handle.

During an interview on 11/05/24, at 10:15 am, Staff 2 (Assistant Manager) confirmed bathroom pocket doors were in all resident units, and the doors did not have locks to ensure privacy and dignity.

The observations were reviewed with Staff 1 (Administrator), Staff 3 (Facility RN), and Staff 4 (Program and HR Director on 11/05/24. The findings were acknowledged.

2. On 11/05/24 at 10:30 am, a group interview was conducted with six unsampled residents. The residents in the group all agreed caregiving staff gather and talk loudly during the evening and night shifts. The residents found the loud talk disrupting.

During an interview at 11:25 am on 11/04/24, Resident 1 stated staff gathered together on evening and night shifts and “were very noisy” and “talked too loud...they shout down the hallway.” S/he further stated the noise was disruptive to his/her sleep.

During an interview at 12:27 pm on 11/05/24, Staff 1 (Administrator) stated she thought the noise happened during shift change from evening to night shift, and she had previously spoken with staff about it.

The need to ensure residents’ right to privacy and to be treated with dignity and respect was reviewed with Staff 1, Staff 3 (Facility RN), and Staff 4 (Program and HR Director). They acknowledged the findings.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities:
(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities:
(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

This Rule is not met as evidenced by:

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 01/30/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it was confirmed that the facility failed to administer medications as ordered by their physician. Findings include the following:During an unannounced site visit on 01/20/2023 Compliance Specialist (CS) reviewed the April 2022 Medication Administration Record (MAR) for Resident #4 (R4) as well as their Chart Notes for the same period. CS found that all evening medications after 5pm on 04/19/2022 were left blank on the MAR, there is no indications in either the Pass Notes or in R4 ' s chart notes as to why medications were not administered. There was also an instance of a PRN medication with specific parameters marked as given on 04/08/2022 and there are no indications on the MAR, in Pass Notes or in Chart Notes that the parameters were met in order to administer medication. A review of R4 ' s bowel program it appears that Staff #7 (S7) marked on three occasions that the monitoring program had not started on two of those instances were on 04/05 and 04/11/2022 even though on prior dates staff were performing the bowel program.In an interview with Witness #1 (W1) it was stated that the facility was not following R4 ' s bowel protocol correctly and that they are making medication errors.

Based on interview and record review it was confirmed that the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include the following:During an unannounced site visit on 01/20/2023 Compliance Specialist (CS) reviewed the facility ABST for Resident #3 and #5 (R3 & R5) against each residents current service plan. CS found inconsistencies between service plans and ABST questions for both R3 and R5. CS reviewed the facility ABST and found that it is not being updated quarterly or with resident change of condition in accordance with rule.In an interview with Staff #2 (S2) it was stated that the acuity tool answers includes the activities worker and time residents will spend in group activities. S2 and Staff #1 (S1) also confirmed that their staffing plan was not consistent with what the acuity tool states they should be staffing at. Facility Plan of Correction:The facility will be going through the ABST to ensure that only caregiving/MT duties are included in the time and that they are using their ABST to create the staffing plan for the facility

Based on interview and observation it was confirmed that the facility failed to provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area; and have a minimum rinse temperature of 140 degrees Fahrenheit. Findings include the following:During an unannounced site visit on 01/20/2023 Compliance Specialist (CS) observed the soiled linen room, there was no way to check the rinse temperature on the washing machine. CS observed the regular detergent that was being used in the was process.In an interview with Staff #3 (S3) it was state that the chemical disinfectant isn ' t used because they had issues with it not dispensing properly and therefore, they use regular detergent. Facility Plan of Correction:The facility will be looking for a chemical disinfectant supplier for use in their soiled linen process as they are unable to confirm water temps of at least 140 degrees.

The findings of the re-licensure survey conducted 11/15/21 through 11/17/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 11/17/21, conducted 02/22/22 through 02/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the second re-visit to the re-licensure survey of 11/17/21, conducted 07/13/22 through 07/15/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the third revisit to the re-licensure survey of 11/17/21 conducted 08/31/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to document evidence of an immediate investigation which reasonably concluded resident incidents were not the result of abuse or neglect for 1 of 2 sampled residents (# 4) relating to medications. Findings include, but are not limited to:Resident 4 was admitted in 08/2021 with diagnoses including diabetes and hypertension.A review of Resident 4's incident reports and progress notes dated 08/17/21 through 11/15/21 were reviewed. Staff documented in a progress note dated 11/02/21 that Resident 4 was administered an extra dose of Isosorbide Dinitrate (for heart heath) and stated the resident was concerned s/he was "over dosed." There was no documented evidence the facility completed an investigation to rule out abuse or neglect. The need to ensure investigations contained the required documentation was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure falls and injuries of unknown cause were thoroughly investigated to rule out abuse and reported to the local SPD as suspected abuse for 1 of 1 sampled resident (#5) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in 03/2020 with diagnoses including Parkinson's Disease and cognitive impairment.The resident's service plan, dated 01/07/22, and interviews with care staff between 02/22/22 and 02/24/22 indicated the resident required assistance for most ADL care and mobility.Review of incident investigations and progress notes from 01/16/22 through 02/25/22 showed the following: * A progress note and incident report dated 01/24/22 indicated the resident was found on the floor with skin tears on both knees. The incident report indicated Resident 5 was "not interviewable: Dementia, Parkinson's";* A progress note and incident report dated 02/06/22 indicated the resident was found on the floor with a skin tear to the knee. The incident report indicated Resident 5 was "not interviewable: Dementia, Parkinson's".The 01/24/22 and 02/06/22 incidents were unwitnessed, and the resident was evaluated as not interviewable.The incident investigations did not clearly document how potential abuse and neglect were ruled out for the injuries of unknown origin, and the incidents were 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) and Staff 3 (RN) on 02/24/22. The staff acknowledged the findings. The facility was asked to report both injuries of unknown cause to the local SPD office. Confirmation of the reports was provided prior to survey exit.



Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably ruled out abuse for 1 of 1 sampled resident (#8) with a reportable incident. This is a repeat citation. Findings include, but are not limited to: During the acuity interview on 07/13/22, Resident 8 was identified with an injury of unknown cause. The resident's facility record, including progress notes from 04/16/22 through 07/08/22, incident reports, investigations, and interviews with staff, identified the following: * An incident report and investigation dated 07/01/22 indicated the resident had a bruise on his/her left thigh, and staff documented s/he did not know the cause of the bruise. In its documented investigation, the facility did not rule out abuse. In an interview on 07/13/22, Staff 3 (RN) stated the injury of unknown cause was not reported to the local SPD office. The facility was asked to report the injury of unknown cause to the local SPD office, and confirmation was provided on 07/13/22. The need to either reasonably rule out abuse/neglect for injuries of unknown cause or report the injuries to the local SPD office was discussed with Staff 3 and Staff 19 (Administrator) on 07/14/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 08/2021 with diagnoses including Type 2 diabetes.During an interview with the resident on 11/15/21 at 1:45 pm, s/he stated there were "too many carbs" offered on the menu. When asked if there was alternative food choices offered, Resident 4 stated there was but, "they're not always available." An example the resident provided was "the other night" s/he asked for the baked chicken and was told by staff there wasn't any. Resident 4's 08/17/21 through 11/15/21 MARs and physician orders were reviewed. The resident's Insulin Glargine (for diabetes) injection was ordered for eight units, each evening at 7:30 pm. The insulin was increased from eight to ten units a day on 11/10/21. Resident 4 stated during the interview, s/he felt the increase in insulin was due to not being able to limit his/her carbohydrate intake related to the availability of food choices. The need to provide modified, special diets that were appropriate to the residents' needs and choices was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to provide modified special diets that were appropriate to residents' needs and choices for 2 of 2 sampled residents (#s 1 and 4) who required diabetic diets. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 07/2019 with diagnoses including Type 2 diabetes mellitus and a physician's order for "no added sugar, diabetic diet."During an interview on 11/16/21, Resident 1 stated s/he was concerned "there are too many carbs" when asked how s/he liked the food. Resident 1 stated s/he had talked to staff about it "sometimes, but it hasn't changed." Resident 1 was aware of the alternative menu provided by the facility and stated "many of those are carbs too, not enough protein."Observations of the lunch meal on 11/15/21 revealed the resident received an open-faced turkey sandwich which included a slice of white bread, turkey meat and brown gravy. The lunch meal observed on 11/16/21 revealed the resident received pork chow mein which consisted of pork, green beans and white rice. The facility provided a snack cart twice daily for residents to select a snack. The snack cart on 11/15/21 and 11/16/21 included small bags of potato chips, granola bars, flavored yogurt, cookies, muffins and string cheese.During an interview on 11/16/21, Staff 2 (Assistant Manager) stated the menu was created by Staff 2 and Staff 18 (Facility Chef). When asked, Staff 2 stated the menu was not reviewed by a dietician. Staff 2 stated that an alternative menu was available with items to meet diabetic needs and preferences however this menu was "subject to availability" therefore, not all of the items listed may be available at all times.The need to provide modified, special diets that were appropriate to residents' needs and choices was reviewed with Staff 1 (Administrator) on 11/17/21. No new information was provided.

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The resident's record was reviewed and multiple staff were interviewed regarding the resident's current level of functioning and care needs. Resident 3's current service plan, dated 11/11/21, was not reflective or lacked adequate instruction for staff in the following areas:* Assist with oral care prior to bed;* The term "arm brace" was unclear in the service plan;* Instructions for proper use of leg straps and seatbelt for safety when in power wheelchair;* Instructions for proper catheter bag placement when in bed and proper placement and use of privacy pouch for catheter bag when using power wheelchair;* Specific instructions for placement of phone holder on power wheelchair;* Safety instructions for the use of side rails in bed; and* Bedtime assistance/routine regarding use of wedge for phone charger and proper application and use of leg boots/braces.The need to ensure resident service plans were reflective of the resident's current care needs and provided adequate instruction for staff as to how to provide care was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the information lacking from Resident 3's service plan.
3. Resident 4 was admitted to the facility 08/2021 with diagnosis including a right below knee amputation. The 08/17/21 service plan and subsequent Temporary Service Plans (TSP) were reviewed. The service plan was not reflective of the resident's current needs or did not provide clear caregiving instructions in the following areas:* Behaviors; * Skin checks; * Safety devices with potential restraining qualities; * Diet texture following a dental procedure; and * Emergency evacuation.The need to ensure service plans were reflective of the resident's current needs and provide clear caregiving instructions was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs, provided clear instruction to staff and were readily available to staff for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 07/2019 and sustained a left lower extremity fracture. Progress notes dated 08/18/21 through 11/15/21, service plans dated 10/12/21 and 11/03/21, and temporary service plans were reviewed and identified the following:The service plan, dated 11/03/21, was not available for staff to review. The service plan available to staff, located in the "current service plan" binder contained the service plan dated 10/12/21 and was not reflective of the resident's needs in the following areas:* Recent ankle fracture and cast care;* Pain monitoring;* Use of hoyer lift and 2-persons for transfers;* Non-weight bearing status;* Instructions for toileting and bathing related to cast care; and* Change in weight and instructions for weight monitoring.The need to ensure service plans were reflective of residents' current needs and were readily available to staff were reviewed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.
2. Resident 5 was admitted to the facility in March 2020 with diagnoses including Parkinson's Disease and cognitive impairment.Progress notes dated 01/25/22 through 02/22/22, the service plan dated 01/07/22, and temporary service plans were reviewed and identified the following:The service plan, dated 01/07/22, was not reflective of the resident's status and didn't provide clear instructions for staff in the following areas:* Risks, precautions, and instructions for the use of bilateral side rails;* Fall risk interventions and fall history; and* Blood thinner use and precautions.The need to ensure service plans were reflective of residents' current needs was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) on 02/24/22. They acknowledged the findings.



Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs, provided clear instruction to staff and were followed for 2 of 2 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 04/2019 with diagnosis including Type 2 diabetes and diastolic congestive heart failure.Observations, interviews with care staff and the resident, review of the service plan dated 01/05/22 and temporary service plans were conducted during the survey. The service plan, dated 01/05/22, was not reflective of the resident's status, lacked clear instructions for staff and was not followed in the following areas:* Risks and precautions for the use of bilateral side rails;* Two person incontinent care completed in bed;* Skin issues including chronic diabetic ulcers on the left heel and Achilles tendon;* Instructions to float heels and avoid placing pillow under the Achilles tendon;* Instructions for aspiration precautions; and* Diet orders to include nectar thick liquids.Observations made from 02/22/22 through 02/23/22 showed direct care staff were not providing aspiration precautions when the resident was given a cookie to eat while laying down in bed, nectar thick liquids were not being provided and the resident's heels were not floated. The need to ensure service plans were reflective of residents' current needs, provided clear instructions for staff, and staff followed the care plans was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) and Staff 5 (Human Resource Director) on 02/24/22. They acknowledged the findings.



2. Resident 8 was admitted to the facility in 05/2018 with diagnoses including dementia, diabetes, and depression.A review of the resident's progress notes dated 04/16/22 through 07/08/22, the service plan dated 06/15/22, temporary service plans, observations, and interviews conducted between 07/13/22 and 07/15/22, identified that the service plan was not reflective of the resident's status and did not provide clear instruction to staff in the following areas: * Recent falls and fall risk interventions;* Preferred language in Spanish; and* Increased confusion, sleepiness, and resistance to care.The need to ensure that service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 3 (RN) and Staff 19 (Administrator) on 07/14/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and provided clear instruction to staff regarding delivery of services for 2 of 3 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 10/2021 with diagnosis including dementia and chronic obstructive pulmonary disease. Observations, interviews with care staff and the resident, and review of the service plan dated 07/12/2022 were conducted during the survey. The service plan was not reflective of the resident's status, and lacked clear instructions for staff in the following areas: * Dentures; * Dressing; * Transfers; * Toileting;* Safety devices including instructions for staff on the use of and precautions related to siderails; and * Eyeglasses. The need to ensure service plans were reflective of residents' current needs and provided clear instructions to staff was reviewed with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22. They acknowledged the findings.

Service Plan1. All Residents service plans have been updated. 2. The facility will ensure the timely and accurate completion of the service plan, and to provide for appropriate care according to resident needs and desires. The facility will reconstruct each service plan to incorporate all elements identified in person-centered care and individualize each service plan so it is geared directly for that resident. The service plan will reflect the residents status and provide clear instructions to staff for each task listed. Service plans will be completed before resident move-in with updates and changes within the first 30-days. Quarterly evaluations will be completed. Once a service plan is completed (initial/quarterly/TSP), staff will be notifed of changes and will be required to sign once information is reviewed. 3. Quality improvement program has been implemented and will be conducted on a monthly basis to ensure timely completion of service plans. 4. The Administrator and RN will be responsible for completing service plans in a timely manner

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Service plans for 3 of 3 sampled residents reviewed lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) 11/17/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The resident's record was reviewed including progress notes, service plans, evaluations, Temporary Service Plans (TSPs) and the MAR. The following deficiencies were identified:a. Staff documented in progress notes on 10/11/21 that Resident 3's catheter was leaking, and two attempts to flush the catheter were ineffective and the catheter was clogged. Written delegation instructions directed staff to call the RN if there was leaking around the catheter site or no urine was draining into the collection bag.There was no documented evidence the issue with the catheter was referred to the facility RN for evaluation. The facility failed to determine and document what action or intervention was needed for the resident, communicate the action/intervention to staff and monitor the resident's condition and document progress at least weekly until resolved. Staff documented the catheter continued to leak and was not flushed until the resident went to a urology appointment on 10/21/21 where the catheter was replaced.b. Staff documented in a progress note on 11/03/21 that Resident 3 had a "sore" and a closed blister on one of his/her heels. Physician orders instructed the facility to complete a "skin report" (a form that was routed to an RN for review) for any new skin breakdown or blisters.There was no documented evidence the heel issues were referred to the facility RN for evaluation. The facility failed to determine and document what action or intervention was needed for the resident, communicate the action/intervention to staff and monitor the resident's condition and document progress at least weekly until resolved. c. On 11/03/21, 11/04/21 and 11/05/21 staff documented on the MAR that the resident had a blister on the inside right upper thigh. Physician orders instructed the facility to complete a "skin report" for any new skin breakdown or blisters.There was no documented evidence the skin issue on the thigh was referred to the facility RN for evaluation. The facility failed to determine and document what action or intervention was needed for the resident, communicate the action/intervention to staff and monitor the resident's condition and document progress at least weekly until resolved.In an interview on 11/16/21, Staff 3 (RN) acknowledged she was not made aware of the issues with the catheter, heel wounds or blister on the thigh. She acknowledged the facility did not determine and document what interventions were needed for each of the changes of condition and did not monitor and document on the progress of the conditions at least weekly until resolved.The need to ensure the facility had a system for identifying and communicating changes of condition to the facility RN as needed, and that interventions were determined and documented, communicated to staff and the condition monitored until resolution was reviewed with Staff 1 (Administrator), Staff 3 and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored weekly until resolved, and residents were monitored per their evaluated needs for 3 of 4 sampled residents (#s 2, 3 and 4) who experienced changes of condition. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 08/2021 with diagnoses including a right below knee amputation, diabetes and hypertension.a. Staff documented in a progress note dated 09/19/21, "Resident has been crying and has expressed that [s/he] is suicidal."During an interview on 11/15/21 at 1:45 pm, Resident 4 confirmed s/he was feeling depressed that day and stated the plan was to jump out of his/her second story unit window. When asked if s/he was still feeling "depressed," the resident confirmed s/he was not.Documentation of monitoring the incident was requested on 11/16/21. Staff 1 (Administrator) confirmed on the same day at 11:34 am staff were not aware of the incident and there was no documented evidence Resident 4 was monitored or that interventions were implemented.b. Staff documented in a progress note dated 11/02/21 Resident 4 was administered an extra dose of Isosorbide Dinitrate (for heart health) and was upset because s/he "was over dosed."Documentation of monitoring the incident was requested on 11/16/21. Staff 1 confirmed on the same day at 11:34 am there was no documented evidence the resident was monitored through resolution.c. Weight records, dated 08/20/21 and 11/10/21 indicated the resident experienced a 24 pound weight gain. This constituted a 10.57% severe weight gain over three months. In an interview with Staff 3 (RN) on 11/16/21 at approximately 1:45 pm, she reported the staff were supposed to notify her for any weight fluctuations with the residents and confirmed she was not notified of Resident 4's weight gain. The facility failed to ensure the RN was notified of the resident's severe weight gain. The need to ensure appropriate staff were alerted to changes of conditions and residents were monitored per their evaluated needs was discussed with Staff 1 and Staff 3 on 11/17/21. They acknowledged the findings.
3. Resident 2 was admitted to facility 04/2018.On 10/19/21, record review showed care staff documented "redness on left thigh toward hip. Appears to be scratches." There was no additional documentation to indicate staff had monitored the skin issue to resolution. Staff did not notify the RN.In an interview on 11/16/21, Staff 3 (RN) stated she was unaware of the injury. There was no additional documentation of follow-up treatment instructions to staff or monitoring until resolution.The need for staff to notify RN of findings, ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and conditions were monitored until resolution was discussed with Staff 1 (Administrator) and Staff 3 on 11/16/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure interventions were determined, documented and communicated to staff, the determined actions were resident-specific and the resident was monitored consistent with his/her evaluated needs, for 1 of 1 sampled resident (#5) who had changes of condition or required monitoring. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in 03/2020 with diagnoses including Parkinson's Disease and cognitive impairment. The 01/07/22 service plan did not indicate Resident 5 was a fall risk.Review of progress notes and incident reports revealed Resident 5 fell on 01/24/22. The incident report identified "Are care plan adjustments needed: No", and recommended "proper body alignment in recliner chair". There was no documented evidence the determined intervention was added to the service plan and communicated to staff on all shifts.Resident 5 experienced additional falls on 01/26/22, 01/28/22, 02/02/22. Each investigation noted, "Are care plan adjustments needed?: No" After each fall, a temporary service plan (TSP) was created which noted the fall and placed the resident on alert charting, however, the service plan was not updated with interventions to prevent additional falls. Resident 5 experienced another fall on 02/06/22, the incident investigation recommended the interventions of safety checks, hip protectors, and referral to PT/OT. There was no documented evidence the determined interventions were added to the service plan and communicated to staff on all shifts.Observations and interviews with care staff revealed that safety checks and repositioning were being done by staff, however, the service plan wasn't updated with the new interventions. There was no documented monitoring of whether other previous fall interventions were being done across all shifts, if they were effective, or whether new interventions needed to be developed.The facility's failure to ensure interventions were developed, added to the resident's service plan, communicated to staff, and that previous interventions were monitored for effectiveness was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager) and Staff 3 (RN) on 02/24/22. They acknowledged the findings.




Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident and document on the status of the condition at least weekly until resolved, failed to monitor the resident consistent with his/her evaluated needs and service plan following changes of condition, and failed to identify and document significant changes of condition, evaluate the resident and refer the change to the facility nurse, for 1 of 3 sampled residents (#9) with falls, injuries and a significant weight change. This is a repeat citation. Findings include, but are not limited to:Resident 9 was admitted to the facility in 10/2021 with diagnoses including dementia, atrial fibrillation, and chronic obstructive pulmonary disease.Progress notes from 04/15/22 to 07/13/22, Incident Reports, the resident's current (07/12/22) and previous service plans, temporary service plans, and Alert Charting log were reviewed during the survey.a. The service plan indicated the resident could transfer independently using a four-wheeled walker, could verbalize the need to go to the bathroom and could toilet him/herself. The service plan also instructed staff to check on the resident every two hours for safety, and to assist with toileting as needed.In an interview on 07/14/22, Staff 20 (CG) reported the resident could no longer transfer without staff assistance, and required full staff assistance with toileting. Review of the record indicated Resident 9 had the following falls:* 04/28/22: Found on the floor, no injuries noted;* 05/31/22: Found on the floor, no injuries noted;* 06/02/22: Found on the floor, no injuries noted;* 06/18/22: Found on the floor, bruising to the forehead/eye area; and* 07/03/22: Found on the floor, no injuries noted.Resident 9 had five falls between 04/28/22 and 07/03/22 for which the facility failed to monitor whether interventions in the service plan were being followed and were effective. New interventions that were identified were not added to the resident's service plan, communicated to staff and monitored to ensure they were implemented and effective. The facility failed to consistently monitor the resident following the falls for changes in mobility, pain or injuries.b. The resident was being weighed daily. From 06/01/22 to 07/01/22, the resident gained 14 pounds or 8.8% body weight in one month. This represented a significant change of condition. There was no documented evidence the facility evaluated and documented the significant weight gain and referred it to the facility nurse. In an interview on 07/14/22, Staff 3 (RN) acknowledged she was not aware of Resident 9's weight gain. Refer to C 280.The need to ensure the facility had a process for monitoring whether service-planned interventions were being followed and updating the resident's service plan as needed, monitoring the resident following changes of condition, and evaluating, documenting and referring significant changes of condition to the facility nurse, was discussed with Staff 3, Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22. They acknowledged the findings.

Change of Condition1. Resident service plans have been updated and a productive TSP and weight change policy has been implemented and corrected. 2. Once a change of condition is reported to the Med Tech on duty, the Med Tech will be responsible for creating a Temporary Service Plan (TSP) immediately and informing RN by placing all TSP's into the RN inbox.The RN will be responsible for determining proper interventions and documenting all new interventions on the TSP. The facility Administrator is responsible for checking all resident weights on a daily basis. Any significant weight change of three or more pounds will be printed out and reported to the RN. The RN will complete a weight change assessment with full explanation on how and why the weight change occurred. The RN will then notify the residents doctor and facility dietician to determine a plan. The resident will be placed on alert and monitored per doctors request. All residents with a TSP will be placed on alert and monitored on a daily basis until resolved. If a Change of Condition is indefinite, then a Change of condition form will be filled out with clear instructions by the RN, and the resident serivce plan will then be updated with clear documentation that ensure interventions were determined and monitored in accordance to resident needs. Updated service plans will be printed and communicated to staff of any changes. 3. The RN will be responsible for monitoring all TSP's, resident weights and COC on a weekly basis. 4. The Administrator and the RN will be responsible for assessing all TSP's, weights and COC within 24 hours.

Based on observation, interview and record review, it was determined the facility failed to ensure a complete RN assessment was documented for 2 of 2 sampled residents (#s 1 and 4) who experienced significant changes of condition related to weight gain and a fracture. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 08/2021 with diagnoses including diabetes and hypertension. Weight records, dated 08/20/21 and 11/10/21 indicated the resident experienced a 24 pound weight gain. This constituted a 10.57% severe weight gain in three months. The facility failed to ensure an RN assessment was completed for the weight gain which documented findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN conducted an assessment of all residents with significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/16/21 and 11/17/21. They acknowledged the findings.
2. Resident 1 returned to the facility on 11/03/21 following treatment for a diagnosis of left lower extremity fracture.A review of the clinical record showed the following:a. Staff 2 (RN) documented an assessment of Resident 1 on 10/26/21, prior to his/her return to the facility. The assessment lacked some of the required elements including findings, resident status, and interventions made as a result of the assessment.b. Staff 2 completed an assessment on 11/11/21 (eight days after Resident 1 returned to the facility). The assessment was not completed timely and there was no documented evidence the service plan was updated as a result of the assessment.The need to ensure the RN conducts a timely and complete assessment of all residents with significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 on 11/17/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (#5 ) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in March 2020 with diagnoses including Parkinson's Disease and cognitive impairment.The service plan dated 01/07/22 listed assistance for mobility and use of a walker, however, Resident 5 was not identified as a fall risk. Progress notes and physician communications dated 01/17/22 through 02/22/22 and interviews with care staff on 02/22/22 and 02/23/22 indicated the resident had an ongoing decline. Resident 5 experienced a cluster of six falls in four weeks. On 01/21/22 Resident 5 was diagnosed with Covid-19, and then on 01/31/22 was diagnosed with a urinary tract infection. Care staff interviews indicated the resident was frequently falling and spent increased time asleep.An RN progress note dated 02/14/22 documented "resident had become unresponsive, language unintelligible"... and "Advised to just send out 911 due to change in mental status" and "Follow up due to frequent falls, decreased appetite and decreased strength with ADL function."The cluster of falls and overall decline, Covid-19 diagnosis, UTI diagnosis, ER visits, decreased appetite and decreased strength constituted a significant change of condition.The facility failed to ensure an RN assessment was completed for the change of condition which documented findings, resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 02/24/22. The staff acknowledged the findings.




Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN completed an assessment of a resident's significant change of condition, for 1 of 2 sampled residents (#9) who had significant weight gain. This is a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in 10/2021 with diagnoses including dementia, atrial fibrillation, and chronic obstructive pulmonary disease.The resident was being weighed daily. Review of the weight record from 06/01/22 through 07/12/22 indicated the following weights:06/01/22: 159 pounds; and07/01/22: 173 pounds.Between 06/01/22 and 07/01/22, Resident 9 gained 14 pounds or 8.8% body weight in one month. This constituted a severe weight gain and represented a significant change of condition for which a facility RN assessment was required.There was no documented evidence the facility RN conducted an assessment of the weight gain which documented findings, resident status and interventions made as a result of the assessment.On 07/14/22, staff reported Resident 9 ate his/her entire breakfast. During lunch on 07/14/22, the resident was observed to not eat any of the meal, even though caregivers repeatedly offered verbal encouragement and asked if s/he wanted something different to eat. On 07/15/22, the resident was observed to eat approximately 75% of the breakfast and lunch meals, though it took him/her over an hour to finish. The resident had been receiving nutritional shakes twice daily since admission; staff reported the resident enjoyed the shakes and consumed them fully. Between 07/01/22 and 07/12/22, Resident 9's weight remained steady at between 171 and 173 pounds.The resident's weight gain was discussed with Staff 3 (RN) on 07/14/22. Staff 3 acknowledged she had not been made aware of the weight gain and had not conducted an assessment. She stated she believed the resident's weight gain was due to the resident being less active recently and no longer ambulating as much as s/he had done in the past.The need to ensure the facility RN completed an assessment of residents' significant changes of condition was discussed with Staff 3, Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22. They acknowledged the findings. No additional information was provided.
Resident Health Services1. An assessment for each resident with a significant change of condition of weight gain has been completed. 2. Weights will be monitored by the Administrator on a daily basis and reported to the RN. The facility RN will be responsible for completing an assessment of a residents significant weight change of three or more pounds, unless doctors orders state otherwise. Detailed documentation of the findings, resident status and interventions will be placed on the weight change assessment form. The resident physician will be notified and the resident will be placed on alert following doctors recommendation. A TSP will be created stating proper interventions and resident status. If a severe weight gain occurs within a month, a Change of condition form will be completed and the resident service plan will be updated accordingly.3. RN and Administrator will be responsbily for monitoring resident weights and creating a COC in a timely manner. 4. The Administrator and RN will be responsible in conducting a full-assessment on all significant change of conditions.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 2 of 2 sampled residents (#s 3 and 4) who had catheter care and insulin injections provided by unlicensed staff. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The facility had signed physician orders to irrigate/flush the resident's catheter each evening. Records indicated non-licensed caregivers were delegated to provide this nursing task.Delegation records for Resident 3, reviewed on 11/17/21, indicated Staff 3 (RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including:* The stability of the resident's condition based on a nursing assessment;* The rationale that the task can be safely delegated to an unlicensed caregiver;* The rationale for how frequently the resident should be reassessed;* Skill and ability of the caregiver;* The rationale for how frequently the caregiver should be supervised and re-evaluated based on the competency of the caregiver; and* That the RN takes responsibility for delegating the task and ensures supervision will occur for as long as the RN is supervising performance.The process for completing and documenting the delegation process was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. Staff 3 acknowledged the lacking documentation.
2. Resident 4 was admitted to the facility in 08/2021 with diagnoses including diabetes. The facility had a physician order to inject ten units of semglee insulin (for diabetes) every evening at 7:30 pm. Records indicated non-licensed caregivers were delegated to provide this nursing task.Delegation records for Resident 4, reviewed on 11/16/21, indicated Staff 3 (RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including:* The stability of the resident's condition based on a nursing assessment prior to delegating the task;* The rationale that the task can be safely delegated to an unlicensed caregiver;* The rationale for how frequently the resident should be reassessed;* Skill and ability of the caregiver;* The rationale for how frequently the caregiver should be supervised and re-evaluated based on the competency of the caregiver; and* That the RN takes responsibility for delegating the task and ensures supervision will occur for as long as the RN is supervising performance.The process for completing and documenting the delegation process was reviewed with Staff 1 (Administrator) and Staff 3 on 11/17/21. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (# 6) who had insulin injections provided by unlicensed staff. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 04/2019 with diagnoses including Type 2 diabetes. The facility had signed physician orders to administer four units of Lantus, daily. Records indicated non-licensed caregivers were delegated to provide this nursing task.Delegation records for Resident 6, reviewed on 02/24/22, indicated Staff 3 (RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including:* The stability of the resident's condition based on a nursing assessment;* The rationale for how frequently the resident should be reassessed;* The rationale that the task can be safely delegated to an unlicensed caregiver; and* The rationale for how frequently the caregiver should be supervised and re-evaluated based on the competency of the caregiver.The process for documenting the delegation process was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for 1 of 1 sampled resident (#7). Findings include, but are not limited to:During the acuity interview on 07/13/22, staff reported Resident 7 required assistance with medication administration and was prescribed insulin based on the resident's CBG's prior to administration (sliding scale). A review of Resident 7's 06/01/22 through 07/13/22 MAR's identified the MAR's lacked documented evidence for the dosage of sliding scale insulin that had been administered. This represented an unsafe medication system.In an interview on 07/14/22, Staff 3 (RN), Staff 5(Program and Human Resource Director) and Staff 19 (Administrator) were unaware of the issue and had not previously identified the lack of documentation. The need to ensure adequate professional oversight of the medication system was discussed with Staff 3, Staff 5 and Staff 19 on 07/14/22. They acknowledged the findings.Refer to C 303, example 1

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia. Physician orders, the MAR and progress notes were reviewed. The following deficiencies were identified:a. The facility had signed physician orders to obtain Resident 3's weight on the 1st of each month. Review of the MAR from 08/2021 through 11/14/21 indicated the facility failed to obtain the resident's weight on the 1st of each month as ordered, often documenting the resident was "out of facility." b. The facility had signed physician orders to perform daily skin checks in the morning and before bed. Instructions directed staff to complete a "skin report" (a form that was routed to an RN for review) for any new skin breakdown or blisters.Staff documented in a progress note on 11/03/21 that Resident 3 had a "sore" and a closed blister on one of his/her heels. On 11/03/21, 11/04/21 and 11/05/21 staff documented on the MAR that the resident had a blister on the inside right upper thigh.There was no documented evidence the facility completed a skin report as ordered. In an interview on 11/16/21, Staff 3 (RN) reported she had not been made aware of the skin issues on Resident 3's heel and thigh.The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 3 and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the findings.
3. Resident 4 was admitted in 08/2021 with diagnoses including diabetes and hypertension. August 17, 2021 through November 15, 2021 MARs and physician orders dated 08/12/21, 09/27/21, 10/17/21 and 11/10/21 were reviewed. a. Physician orders directed staff to administer 5 mg of Glipizide (for diabetes) three times a day. The MARs reflected Resident 4 was administered Glipizide twice a day from 08/18/21 through 10/18/21. b. The resident had an order for amlodipine besylate (for blood pressure) with parameters to hold the medication for a systolic blood pressure lower than 100. On 11/9/21, staff documented a systolic blood pressure of 92. Documentation showed the medication was administered when parameters indicated it should have been held.The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 3 of 4 sampled residents (#s 1, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 moved into the facility in 07/2019 with diagnoses including congestive heart failure and edema. Physician orders and MARs for Resident 1, reviewed from 11/01/21 - 11/15/21, revealed the following orders were not followed:* Acetaminophen 1000 mg TID (for pain) was not administered as ordered from 11/01/21 - 11/16/21;* Potassium CL ER 10 MEQ (for edema) was not administered as ordered. The facility was administering 20 MEQ; and * Torsemide 20 mg (for edema) was not administered as ordered. The facility was administering 30 mg.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings. Staff 3 provided a copy of orders, signed by the physician on 11/16/21, to clarify current orders.



Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 1 of 2 sampled residents (# 6) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6 moved into the facility in 04/2019 with diagnoses including Type 2 diabetes and diastolic congestive heart failure (CHF). Resident 6 was dependant on staff for all transfers and repositioning while in bed.Physician orders dated 02/17/22 and 02/01/22 through 02/22/22 MAR was reviewed and identified the following orders were not administered as prescribed:* Daily weights related to CHF, notify RN with significant weight change of 3 lbs or more within one day;* Fax daily weights and blood pressure (BP) to NWRC (clinic) every 2 weeks;* Aspiration precautions to include: sit upright to 90 degrees for all oral intake, small bites and sips, eat and drink slowly, swallow completely and alternate small bites and small sips; * Nectar thick liquids; and* Float heels and avoid placing pillow under the left Achilles tendon.The MAR indicated Resident 6 had a 3 pound weight gain from 02/04/22- 02/05/22.Interview with Staff 8 (Nursing Aide), 02/22/22, confirmed there was no documentation that the RN was notified of the three pound weight change from 02/04/22-02/05/22 and no documentation that the clinic was notified of daily weights or BP every two weeks.Observations of Resident 6 completed 02/22/22 through 02/23/22 showed the following:* During both days, thin liquids were served during breakfast and lunch meals;* During both days, Resident 6 was served cookies while laying down in bed and the staff member didn't follow the aspiration protocols to sit him/her upright 90 degrees; and* During both days, the resident's heels were not floated. On 2/23/22 at 11:20 am, surveyor requested Staff 3 (RN) observe Resident 6's heels for potential skin breakdown and aspiration protocols that were not being followed. Resident 6's left side of heel had a reddened area, however was not warm to the touch and the skin was intact. Staff 3 indicated s/he would provide clear aspiration protocols for staff to follow and would ensure the resident's heels were floated, while in bed.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.
2. Resident 9 was admitted to the facility in 10/2021 with diagnoses including dementia, atrial fibrillation, and chronic obstructive pulmonary disease.The resident had signed physician orders for the facility to obtain daily weights, and instructions on the MAR directed the facility to notify the the resident's health care provider for a weight increase of 3 pounds in one day or 5 pounds in one week. Review of the resident's MAR from 06/01/22 through 07/13/22 indicated the resident's weight increased from 161 pounds on 06/15/22 to 164.5 pounds on 06/16/22 - an increase of 3.5 pounds in one day.There was no documented evidence the facility notified the provider as ordered.The need to ensure physician orders are carried out as prescribed was reviewed with Staff 1 (Lead MT) on 07/14/22, and with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, for 2 of 3 sampled residents (#s 7 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 moved into the facility in 01/2020 with diagnoses including Type 2 diabetes.Physician orders dated 12/10/21, pharmacy review dated 03/29/22, subsequent insulin orders dated 05/28/22 and 06/01/22 through 07/13/22 MAR's were reviewed during the survey and identified the following:* Resident 7 was prescribed Lispro 100 insulin per sliding scale where the dosage was based on the resident's CBG obtained just prior to administration. The sliding scale directed the insulin to be held for a CBG less than 150. There was no documentation the medication was held as ordered for 33 occasions where the resident's CBGs were less than 150; and* The facility was not documenting the number of sliding scale insulin units administered; therefore, there was no documented evidence the facility had administered the correct insulin dosage. During an observation and interview on 07/14/22 at 1:17 pm, Staff 10(MT), showed the surveyor the resident's electronic MAR. Staff 10 explained the MAR failed to automatically prompt MT's to enter the reason for holding the insulin which would then reflect on the MAR as if the insulin had been administered. Staff 10 further reported "sometimes when we are working too quickly, some MT's will forget to manually enter an exception note which would then indicate the medication was in fact held."During an interview with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/14/22, it was reported that they were unaware of both issues on the MAR and immediately began problem solving the issue. A review of Resident 7's quarterly diabetic assessment and CBG record between 06/01/22 through 07/13/22 indicated the resident's CBG's stayed within normal range, which indicated no apparent negative impact on the resident. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/14/22. They acknowledged the findings. Systems: Treatment Orders1. Parameters have been added for all insulin orders. A prompt is now showing requiring all med techs to input the insulin units that were given or "Held" if the insulin was not given. The system requires all Med techs to complete each prompt prior to completing the task. All Med Techs have been retrained on how to properly follow doctors orders on the MAR. 2. Med Techs are required to follow specific doctors orders on the MAR. On all sliding scale insulin orders, parameters will be noted in the description of the MAR and Med Techs will be responsible for documenting the number of sliding scale insulin units that was administrated. If the doctors order states to hold insulin if CBG is less than a specific number, the med techs are required to document that the insulin was held. 3. RN and Administrator will review the MAR on a weekly basis to ensure that all meds techs are documenting the insulin units given, correctly. 4. The Administrator, RN and Med Techs will be responsible for maintaining accurate MAR orders and training Med Techs on all new orders.

3. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The record indicated Resident 3 experienced chronic, intermittent body pain for which s/he was prescribed PRN hydrocodone 5mg/acetaminophen 325 mg (a narcotic pain medication).Review of Resident 3's MAR and the Narcotic Disposition Log from 11/01/21 through 11/14/21 indicated multiple instances where the MAR and the disposition log did not match. It appeared medication technicians sometimes failed to document on the MAR when the PRN medication had been packed and given to the resident to self-administer when s/he was out of the facility for the day.The need to ensure the facility maintained an accurate MAR was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the findings.
4. Resident 4 was admitted to the facility with diagnosis including diabetes. The August 2021 MAR and 08/12/21 physician's orders were reviewed. The physician order directed staff to inject ten units of semglee (for diabetes) at 8:00 pm. There were blanks on the MAR on 08/18/21 and 08/19/21. There was no documented evidence if the resident received the medication.The need to ensure resident MARs were accurate was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.
2. Resident 1 was admitted to the facility in 07/2019 and had diagnoses including a recent ankle fracture. The resident's current physician's orders and 11/01/21 through 11/16/21 MARs were reviewed and revealed the following medication orders had not been transcribed to the current MAR:* Bisacodyl suppository (for bowel care);* Diclofenac gel (for pain);* Lidocaine patch (for pain);* Miconazole powder (for rash);* Miralax powder (for bowel care); and* Oxycodone (for pain).The need to ensure resident MARs were accurate was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/21. They acknowledged the findings. Staff 2 provided a copy of orders, signed by the physician on 11/16/21, to clarify current orders.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and documented all medications given for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2's 10/01/21 through 10/31/21 MAR was reviewed.Resident 2's MAR revealed multiple blanks for monitoring the resident's discomfort and monitoring a lesion on his/her middle finger. In an interview with Staff 1 (Administrator) at 1:50 pm on 11/15/21, she acknowledged the blanks on the MAR.The need to ensure an accurate Medication Administration Record (MAR) must be kept of all medications, including date and time given, was reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/17/21. They acknowledged the MARs were not accurate.




Based on interview and record review, it was determined the facility failed to ensure residents' MARs included medication specific instructions and had parameters for multiple PRN medications prescribed for the condition for 1 of 2 sampled residents (# 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6's 02/01/22 through 02/22/22 MAR reviewed identified the following inaccuracies:* Vitamin C tablet notes to give 1-2 tablets daily, lacked instructions indicating when unlicensed staff should administer the second tablet;* LMX cream prescribed for pain lacked instructions regarding the location of the pain; and* PRN Gvoke Hypopen and PRN glutose gel prescribed for hypoglycemia lacked parameters regarding the sequence of administration. The need to ensure the MAR had medication specific instructions and parameters for multiple PRN medications prescribed to treat the same condition was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) and Staff 5 (Human Resource Director) on 02/24/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident's service plan and evaluated on a quarterly basis, for 1 of 2 sampled residents (#3) with devices with restraining qualities. Findings include, but are not limited to:Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia. During a tour of the resident's room on 11/15/21, bilateral half-length side rails were observed on Resident 3's hospital bed. The side rails were in the up position and fastened securely to the bed.In an interview on 11/16/21, Staff 14 (CG) acknowledged the use of the side rails and explained they were used to position personal items such as the call light and the resident's cell phone charger within easy reach for the resident. Staff 14 also reported the resident used a seat belt for safety and security when in his/her power wheelchair. Staff 14 stated she did not think the resident could remove the seatbelt independently.Resident 3's record included documentation by the facility RN of the use of the side rails and the seatbelt. The initial documentation was dated 03/19/21; only the side rails had been re-evaluated (dated 05/26/21). The use of the side rails was documented in the resident's current service plan; the use of the seat belt was not included in the service plan.The need to ensure all devices with restraining qualities were evaluated quarterly and their use documented in the resident's service plan was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the devices had not been evaluated quarterly and the seatbelt was not documented in the service plan.
2. Resident 6 was admitted to the facility in March 2020 with diagnoses including Parkinson's Disease and cognitive impairment.Observations on 02/22/22 showed two side rails attached to the bed and in the upright position while Resident 5 was seated in a reclining chair. The rails appeared firmly attached to the bed, and did not show a gap between the bed and the mattress.In an interview on 2/23/22, Staff 9 (CG) stated she had not received training on how to the side rails were used.The most recent service plan, dated 1/7/22 referenced the side rails, however it lacked: * Instructions for when and how the side rails were to be used;* Clear documentation of the use, risk and precautions related to the device; and* The evaluation was not updated quarterly, with the most recent review completed on 10/13/21.An interview on 02/23/22, Staff 2 (Assistant Manager), reported s/he did safety checks on all the devices quarterly, to ensure they were working properly, however s/he doesn't complete an evaluation for the appropriate use of the device or the residents' ability to continue using the device. The need to ensure all devices with restraining qualities were evaluated quarterly and the use of the device was documented in the resident's service plan was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) on 02/24/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident's service plan and evaluated on a quarterly basis, for 2 of 2 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 04/2019 with diagnoses including myocardial infarction, diastolic congestive heart failure, chronic respiratory failure and Type 2 diabetes. On 02/22/22 the door to Resident 6's apartment was open while the resident was asleep from 12:50 pm- 3:30 pm. Bilateral half-length side rails were observed on the hospital bed and the side rails were in the up position. The hospital bed was positioned approximately three feet from the ground and in the middle of the room.During an interview on 02/23/22, Resident 6 reported s/he was unable to raise or lower the side rails, was unable to use the side rails to reposition in the bed, and unable to use the side rails during ADL care. S/he stated this was due to lack of strength in the upper body and arms. S/he reported the bed rails were always up and were used to prevent falling from bed. The most recent half-length bilateral side rail evaluation was completed on 04/07/20. The evaluation noted the following:* Bed rails were not usually in use and found in the down position, bed placement at the lowest position;* Risks were avoided by lowering the bed, proper mattress and monitoring gaps between mattress and side rails; * A signature page indicating "safety check" was completed on 01/27/22; * There were no instructions for caregivers on the correct use and the risk and precautions related to the use of the device; * Clear documentation of the use, risk and precautions related to the device were not added to the current service plan; and* The evaluation was not updated quarterly.An interview on 02/23/22, Staff 2 (Assistant Manager), reported s/he did safety checks on all the devices quarterly, to ensure they were working properly, however s/he doesn't complete an evaluation for the appropriate use of the device or the residents' ability to continue using the device. The need to ensure all devices with restraining qualities were evaluated quarterly and the use of the device was documented in the resident's service plan was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 7 and 15) had completed First Aid certification and been trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:The facility's training records were reviewed on 11/16/21 and the following was identified:Staff 7 (MT) hired 08/23/21 and Staff 15 (CG) hired 08/31/21, lacked documented evidence of First Aid and abdominal thrust training. The need to ensure First Aid and abdominal thrust was completed within 30-days of hire was discussed with Staff 1 (Administrator) and Staff 5 (Human Resources Director) on 11/16/21 and 11/17/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records from June 2021 through October 2021 identified the following:* The facility failed to provide fire and life safety instruction to staff on alternate months: and * Problems encountered, comments relating to residents who resisted or failed to participate in the drill were not documented. The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager) and Staff 5 (Human Resources Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to instruct new residents on fire and life safety within 24 hours of admission and provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:Fire drill records, from 06/2021 through 10/2021, were reviewed on 11/16/21 with Staff 2 (Assistant Manager). * There was no documented evidence new residents were instructed on fire and life safety within 24 hours of admission; and* Staff 2 stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 (Administrator), Staff 2 and Staff 5 (Human Resources Director) on 11/16/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents. This is a repeat citation. Findings include, but are not limited to:Fire drill records were reviewed on 02/22/22 with Staff 2 (Assistant Manager). Staff 2 reported the facility had updated the fire drill form, however the facility had not re-instructed residents on fire and life safety training topics.The requirement to provide residents with training in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and to keep a written record of fire safety training, including content of the training sessions and the residents that were in attendance was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C231, C260, C270, C280, C282, C303, C310, C340, C422 and C513.
Based on observation, interview and record review, it was determined the facility failed to ensure its survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 231, C 260, C 270, C 280 and C 303.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair. Findings include, but are not limited to:The exterior patio and walkways of the building were toured on 11/15/21 at 11:15 am. There were multiple sections of the sidewalk with drop-offs of up to one and one-half inches measured from the concrete surface to the planting beds. These drop-offs represented tripping/fall risks for residents.The drop-offs were reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/16/21. They acknowledged the drop-offs.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces in good repair. Findings include, but are not limited to:The interior of the facility was toured on 11/15/21 at 10:20 am. The following deficiencies were identified:* The doors and/or door frames of resident rooms 104, 106, 112, 117, 202 and 215 were scraped, scuffed or gouged;* The doors and/or door frames of the small shower room on "Purple Hall" and the laundry room on "Pink Hall" were scraped, scuffed or gouged;* The fan switch in the shower room on "Blue Hall" was damaged;* Wooden handrails across from rooms 104 - 108, on the second floor next to the Salon and across from room 218 were gouged or damaged leaving a surface that was rough to the touch; and* The bases of the columns in the first floor main hallway were scraped and gouged.The areas needing repair were reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/16/21. They acknowledged the items needing cleaning or repair.
Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces in good repair. This is a repeat citation. Findings include, but are not limited to:The interior of the facility was toured on 02/23/22 at 10:20 am with Staff 2 (Assistant Manager). The following deficiencies were identified:* The doors and/or door frames of resident rooms 103, 104, 106, 107, 109, 112, 117, 202, 210, and 215 were scraped, scuffed or gouged;* Door frames and doors to the shower room and laundry room on the blue, pink, and purple halls were damaged;* Wall base in the dining room near the kitchen entrance was gouged and damaged, and* The bases of the columns in the first floor main hallway were scraped and gouged.The areas needing repair were reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 02/23/22. They acknowledged the items needing repair.

Based on observation and interview, it was determined the facility failed to ensure operable resident windows above the second floor with sill heights lower than 36 inches were designed to prevent accidental falls. Findings include, but are not limited to:The interior of the facility was toured on 11/15/21 at 10:20 am. During the tour, an unsampled resident's room on the second floor was observed with the window open approximately 30 inches wide. Upon inspection, the window was found to lack any means of limiting how wide the window could be opened to prevent accidental falls. The height of the window sill was 25 inches above the floor. Another second-floor unsampled resident's window was inspected and was also found to lack any means of limiting how wide the window could be opened. Window sills on the second floor were all 25 inches above the floor.The need to ensure second floor resident windows were designed to prevent accidental falls was reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/16/21. They acknowledged there were no limiting devices on the windows.

Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in residents' units within a range of 110 - 120 degrees Fahrenheit (F). Findings include, but are not limited to:The interior of the facility was toured on 11/15/21 at 10:20 am. The hot water temperature taken in the common shower room on "Red Hall" with the surveyor's digital thermometer at 10:35 am was 140 degrees F. The hot water temperature taken in the common shower room on "Blue Hall" with the surveyor's digital thermometer at 10:47 am was 132.8 degrees F.The surveyor informed Staff 1 (Administrator) and Staff 2 (Assistant Manager) of the excessive water temperatures on 11/15/21 at 11:15 am. Staff 2 stated she was aware the water temperatures exceeded 120 degrees F but said residents complained when she decreased the temperatures. The surveyor informed her the water temperatures could not exceed 120 degrees F.The hot water temperatures in the two shower rooms were re-tested on 11/16/21 at 10:50 am and found to still be in excess of 120 degrees F. Staff 1 and 2 were notified of the temperatures. Staff 2 stated she would immediately decrease the water temperatures.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes and to alert staff when residents exit the RCF. Findings include, but are not limited to:The interior of the facility was toured on 11/15/21 at 10:20 am. There were four exit doors on the first floor through which residents could exit the building: the front door, the patio door in the dining room and an exit door at the end of each of two hallways. When the surveyor exited through these doors, no audible alert was heard.In an interview on 11/15/21 at 3:00 pm, Staff 1 (Administrator) confirmed there was no system that alerted staff when a resident exited any of the doors except video cameras. However, the video camera monitors were in Staff 1's office and were not monitored consistently or after Staff 1 left for the day. Staff 1 acknowledged the facility needed to install a system that alerted staff when a resident exited the building any time of the day or night.

Based on interview and observation, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:During the unannounced site visit on 6/16/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:Compliance Specialist (CS) observed Staff #3 working without a face mask. Staff #4 was observed with their face mask under their nose. During separate interviews with Residents #1-4, the following was stated: *Sometimes staff pull their masks down, I think they get hot. *Staff sit in the office, right next to each other with their masks off.The above findings were discussed with Staff #1, who was in agreement.