Mill View Memory Care

The findings of the change of ownership licensure survey, conducted 10/30/23 through 11/01/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 11/01/23, conducted on 03/01/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 staff (#s 7, 8 and 9) completed the required annual infectious disease prevention training. Findings include, but are not limited to:Training records were reviewed on 10/30/23. Staff 7 (MT), hired 01/09/20, Staff 8 (CG), hired 05/29/20, and Staff 9 (CG), hired 06/18/20, lacked documented evidence of completing the required annual infectious disease prevention training. The need for all employees to complete annual training on infectious outbreaks and infection control was reviewed with Staff 1 (ED) on 10/31/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:Observations of the facility on 10/30/23 and 10/31/23 revealed the following:* Multiple resident rooms and common bathrooms had scraped doors and/or jambs;* The transition pieces in the activity area between the laminate flooring and carpet were unsecured and separated from the floor; * The carpet throughout the facility was stained, ripped, separated, and fraying; and * The legs of dining room chairs were chipped and damaged. The surveyor toured the environment with Staff 1 (ED) on 10/30/23. She acknowledged the above areas needed to be cleaned and repaired.

Based on observation and interview, it was determined the facility failed to provide a one way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:The facility laundry room was toured with Staff 1 (Ed) and Staff 3 (RCC) on 10/31/23. Observation of the laundry room, designed to be used for processing soiled laundry, identified there was not a one way flow of soiled items. Baskets of laundry and bags of soiled laundry were on the floor throughout the laundry room. There was no clearly identified flow from dirty to clean for laundry processing.The need to ensure the one way flow of soiled laundry was discussed with Staff 1 and Staff 3 on 10/31/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 374, C 513, and C 530.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 6, 10 and 11) had documentation of completed pre-service orientation, pre-service dementia training, and demonstrating competency in all required areas within 30 days of hire. The facility failed to ensure 3 of 3 sampled staff (#s 7, 8, and 9) completed 16 hours of annual in-service training. Findings include, but are not limited to:Staff training records were reviewed on 10/30/23 and 10/31/23.a. Staff 6 (MT), hired 04/23/23, lacked documented evidence of completing required pre-service orientation prior to beginning job duties, including:* Resident Rights and Values of CBC;* Infectious Disease Prevention; and* Fire safety and emergency procedures.Staff 6, Staff 10 and Staff 11 (CGs) hires 05/13/23 and 06/13/23 respectively, lacked documented evidence of completing required pre-service dementia training prior to beginning job duties, including:* 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 when responding to distressful behavioral symptoms. * Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: -Identify and address pain; - Provide food and fluid; - Prevent wandering and elopement; -Use a person-centered approach. * Family support and the role the family may have in the care of the resident.* How to recognize behaviors that indicate a change in the residents' condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident and the residents' service plan, as required in OAR 411-054-0070(4). and* The use of supportive devices with restraining qualities in memory care communities. There was no documented evidence of Staff 6 demonstrating competence in all job duties within 30 days. Staff 6 had demonstrated competence with medication pass.b. Staff 7 (MA), hired 01/20/20, Staff 8 (CG) hired 05/29/20, and Staff 9 (CG), hired 06/18/20, lacked evidence of 16 hours of annual in-service training. The need to ensure staff completed all required pre-service orientation and training, demonstrated competence with in 30 days, and completed annual training was discussed with Staff 1 (ED) on 10/30/23 and 10/31/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure courtyard fencing was constructed to reduce the risk of resident elopement, and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:A tour of the facility courtyard on 10/30/23 revealed the fencing around the perimeter of the secured outdoor area was found with loose dirt and large gaps at the bottom in several areas. There were two patio chairs and two benches which were easily moveable and not of sufficient weight or design to prevent potential elopement.The need to ensure outdoor courtyard fencing was constructed to reduce the risk of resident elopement and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement was discussed with Staff 1 (ED) and Staff 4 (Director of Environmental Services) on 10/31/23. They acknowledged the findings. The facility addressed the issues prior to the end of the survey.

The findings of the change of ownership survey conducted 7/19/21 through 7/20/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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
The findings of the first re-visit to the re-licensure survey of 07/20/21, conducted 10/13/21 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

2. Resident 2 was admitted to the facility in 1/2021 and was dependent on staff for all ADL care needs and had a history of falls.Resident 2's clinical record revealed:*On 6/19/21, facility charting notes indicated the resident had scratches on his/her ankle; and*On 7/12/21, the Hospice RN documented in the visit note Resident 2 had "abrasions on toes and feet". Staff 2 (RN) conducted an assessment of Resident 2's skin on 7/20/21 and identified additional injuries.There was no documented evidence the facility immediately investigated and documented the injuries were not the result of abuse or neglect. The facility did not report the injury to the local SPD office as suspected abuse/neglect.The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (ED) and Staff 3 (Resident Care Coordinator) on 7/20/21. They acknowledged the facility had not investigated to rule out abuse/neglect. The surveyor directed Staff 1 to self-report the incident. Verification the facility had reported the incidents to the local SPD office was received during the survey.
Based on interview and record review, it was determined the facility failed to investigate or report to the local SPD office suspected abuse or injuries of unknown cause when abuse could not be ruled out for 2 of 2 sampled residents (# 2 and 4). Findings include, but are not limited to:1. Resident 4 has a diagnosis of dementia and history of Urinary Tract Infections. During the survey, Resident 4 was observed to stay in his/her room and had meals delivered to him/her. Resident 4 had increased pain in his/her legs which limited his/her mobility and required staff to assist with ambulation while using a walker. Resident 4 refused to use his/her wheelchair.In interviews with Staff 7 (CG) and Staff 9 (CG), they indicated Resident 4 had a history of behaviors which included physical and verbal abuse to staff, residents, and sexual partners in the community. During an interview with Staff 9 on 7/19/21, she stated Resident 4 was involved in two sexual relationships within the community. Resident 4 was moved to another wing of the MCC due to increased behaviors, including physical altercations with other residents and biting one of his/her sexual partners. Resident 4 was not evaluated to be able to consent to sexual relationships. It was requested by the survey team for the facility to report all known past and present sexual relationships to SPD. All sexual relationships were reported to SPD on 7/19/21.The need to report non-consensual relationships to SPD and intervene in resident-to-resident sexual behavior when there was not a documented evaluation determining the resident's ability to consent was discussed with Staff 1 and Staff 4 (Regional RN) on 7/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate residents for their ability to consent to sexual relationships for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:Resident 4 was admitted to the MCC in 03/2019 with a diagnosis of Alzheimer's disease.Interview with Staff 7 (CG) and Staff 9 (CG) on 7/19/21 indicated Resident 4 was involved in two sexual relationships with other residents at the same time. Review of Resident 4's record did not indicate an evaluation was completed to determine s/he was able to consent to sexual relationships. Interview with Staff 1 (ED) on 7/19/21 revealed the facility did not conduct an evaluation on Resident 4 to determine if s/he was able to consent to a sexual relationship. The facility received verbal consent from Resident 4 and his/her family was notified that s/he was involved in sexual relationships.The need to ensure the facility evaluates residents for their ability to consent with sexual relationships was discussed with Staff 1 on 7/23/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document monitoring of short term changes of condition until resolution and failed to document monitoring of residents consistent with their evaluated needs for 1 of 3 sampled residents (#2) who experienced falls and short term changes of condition. Findings include but are not limited to:Resident 2 was admitted to the memory care community in 1/2021 and was identified to be evaluated as a fall risk and dependent for all care needs.a. Resident 2's service plan included interventions to reduce falls. Resident 2's clinical record revealed s/he fell nine times between 5/5/21 and 7/13/21.There was no documented evidence the service planned fall interventions were monitored and reviewed to determine effectiveness. b. Resident 2's clinical record revealed:*On 6/19/21, facility charting notes indicated the resident had scratches on his/her ankle; and*On 7/12/21, the Hospice RN documented in the visit note Resident 2 had "abrasions on toes and feet".There was no documented evidence the injuries had been monitored at least weekly until resolved. The need to monitor residents per their evaluated needs and to monitor changes in condition to resolution was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 2 sampled residents (#2) who were prescribed PRN medications to treat behaviors. Findings include, but are not limited to:Resident 2 was admitted to the facility in 1/2021 with diagnoses including anxiety and was recently admitted to hospice. Resident 2 had a physician's order for Lorazepam 0.5 mg as needed for anxiety.Resident 2 was administered the psychotropic medication six times in between 7/1 and 7/19/21 with no documented evidence staff had first attempted non-drug interventions with ineffective results.The need to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

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

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 270 and C 330.