Morningstar Memory Care of Beaverton

The findings of the re-licensure survey, conducted 04/29/24 through 05/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 05/01/24, conducted 10/02/24 through 10/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 daySituations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:OAR 411-054-0040 (1-2) Change of Condition and MonitoringOAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health ServicesOAR 411-057-0155 (1-6) Staff Training RequirementsThe facility put immediate plans of correction in place during the survey.



The findings of the second re-visit to the re-licensure survey of 05/01/24, conducted 02/03/25 through 02/05/25, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of operations which included supervision and training of staff. The facilities failure to ensure quality of services provided to residents and lack of supervision and oversight to staff performing job duties for 1 of 2 sampled residents (#8) put the residents safety at risk. Resident 8 experienced an avoidable skin issue. Findings include, but are not limited to: 1. During the first revisit survey, conducted 10/02/24 through 10/04/24, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the scope, severity and number of citations. Situations were identified which posed a risk to residents' health and safety and constituted immediate plans of correction in the following areas:OAR 411-054-0040 (1-2) Change of Condition and MonitoringOAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health ServicesOAR 411-057-0155 (1-6) Staff Training RequirementsThe facility put immediate plans of correction in place during the survey. Refer to deficiencies in the report.2. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia.Observations of the resident from 10/02/24 to 10/04/24 showed the resident required staff assistance with transfers, incontinent care and needed supervision while in the geriatric chair (a large padded wheeled chair designed to help people with limited mobility) due to his/her leaning forward movement.Observations of the resident, interviews with staff, and review of the resident's clinical record, including incident reports/investigations, observation notes dated 06/30/24 through 10/02/24, the service plan dated 06/23/24, and temporary service plans dated 06/27/24 through 07/30/24 indicated the following:* A 07/30/24 observation note showed the care staff reported the resident had "2 scrapes" on the left knee area;* A 07/30/24 incident report concluded the "scrapes" were a result of the resident's left knee bumping the footrest of the geriatric chair, and a temporary service plan dated the same day instructed staff to "apply pillow at sides of geriatric chair and under legs to prevent legs from falling";* Observations made on 10/02/24 and 10/03/24 revealed multiple staff working on the unit did not ensure Resident 8 had pillows placed on the sides of his/her geriatric chair, and the resident's leg was observed hanging off the chair, rubbing against the chair, and/or becoming wedged between the armrest and the footrest; and* On 10/02/24 at 1:35 pm, a red mark was observed on the resident's outer left leg, approximately 10 cm in length and 1 cm in width, which was reported to Staff 29 (CG) at 2:50 pm.The licensee's failure to ensure adequate administrative oversight of the facility's operation and supervision led to the resident's avoidable skin issue, and the findings were discussed with Staff 22 (Wellness Nurse, RN) on 10/03/24 at 12:56 pm. The staff acknowledged the findings. On 10/04/24 at 10:33 am, the failure of the licensee to ensure adequate administrative oversight of the facility operations and supervision was discussed with Staff 22, Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to:The facility was toured on 04/29/24 at 11:10 am. The following items were not posted as required:* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility; * A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable; and* The Ombudsman Notification Poster. The need to ensure all required items were posted was reviewed with Staff 1 (Administrator) on 05/01/24. Staff 1 acknowledged the items were not posted as required.

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for 3 of 4 sampled residents (#s 2, 3, and 4) and two unsampled residents. Findings include, but are not limited to:a. Records for Residents 2, 3, and 4 were reviewed during survey and found to be incomplete and/or inaccurate in the following areas:* Resident 3 was admitted to the hospital for a fall with a left hip fracture from 01/21/24 to 01/31/24. Review of the discharge paperwork indicated the resident had a "left hip pinning with dynamic hip screw" surgery on 01/22/24. The paperwork further included instructions for managing the surgical wound. Interviews with staff indicated hospice was managing the surgical wound, and staff were following hip precautions at the time of discharge. Review of the resident's clinical record including hospice provider notes from 02/08/24 to 04/16/24, progress notes and short term observation forms (STOs) dated 01/16/24 through 04/29/24, and the service plan dated 02/09/24 revealed no mention of the surgical wound. The change of condition evaluation completed 02/09/24 for the left hip fracture, return from hospital, and hospice admit indicated "no" for skin conditions. There was no documentation in the resident's record of what the hip precautions were, or that they were communicated to all staff.* Interviews with care staff and review of the electronic charting system indicated while some resident service plan information was available on their tablets, staff had to access the full service plan located in residents' hard charts. Resident 2, 3, and 4's hard charts were reviewed and lacked their current service plans. * Interviews with care staff indicated they were informed of resident short term changes of condition via the facility's STO forms. There were no STOs for Resident 3's hip precautions, surgical wound, redness on groin and abdomen, and multiple behavior episodes. There were no STOs for Resident 4's resident-to-resident altercation, return from hospital, hospice admit, or injury fall. * Interviews with care staff indicated they were to call hospice when Resident 3 refused to consent to a medication or treatment order. There was no documentation in the resident's record that hospice was notified of the refusals.* Interviews with care staff indicated they were to attempt non-pharmacological interventions prior to administering PRN psychotropics for Residents 1, 3, and 4. There was no documentation in the residents' records that the interventions were attempted.b. Two unsampled residents' medication orders and STOs were found in Resident 3's hard chart.The need to ensure resident records were complete and accurate was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings, and no further information was provided.Refer to C260, C270, C305, and C330.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct an ongoing quality improvement program that evaluated services, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 10/02/24 through 10/04/24, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be infective.On 10/04/24 at 1:03 pm, Staff 37 (Chief Wellness Officer) was interviewed about the facility's quality improvement program. She reported the facility was supposed to have monthly Quality Assurance and Performance Improvement (QAPI) meetings. However, she reported the facility had "probably not" implemented it.Refer to the deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to investigate incidents, document all required areas of an investigation, and report to the local SPD office if abuse or neglect could not be ruled out for 2 of 2 sampled residents (#s 1 and 4) who experienced resident-to-resident altercations. Findings include, but are not limited to:1. Resident 1 moved to the facility in 03/2024 with diagnoses including agitation associated with dementia.Observations of the resident, interviews with staff, and review of the resident's 04/12/24 service plan, progress notes dated 03/15/24 through 04/27/24, and incident reports were completed and revealed the following:An incident report dated 04/19/24 stated Resident 1 "pushed resident" which caused "resident to fall to the ground". Resident 1 stated that the other resident was "trying to get in [his/her] room" at the time of the incident. In an interview on 04/30/24 at 3:15 pm, Staff 1 (Administrator) stated the occurrence had not been reported to the local SPD office. This surveyor requested Staff 1 report the above incident to the local SPD office, and confirmation was received on 04/30/24 at 3:30 pm. The need to ensure incidents of abuse or neglect were immediately reported to the local SPD office was discussed with Staff 1 on 05/01/24 at 12:35 pm. He acknowledged the findings.
2. Resident 4 was admitted to the facility 11/2021 with diagnoses that included Alzheimer's disease and mood disorder.Progress notes dated 03/04/24 through 04/06/24 and incident reports were reviewed. The following information was documented:* Progress note dated 03/03/24 - "... often acts out and can be aggressive when attempting to do personal care. Resident has a prn Quetipine, which I instructed staff to go give if [resident] becomes aggressive and other means of distraction, comfort measures etc. are not working. Staff will continue to notify [Wellness Director] if behaviors are existing."* Progress note on 03/12/24 - "Spoke to [Resident 4's spouse] today. [S/he] was in the room when this incident occurred. Together we discussed [Resident 4's] recent behavior and [spouse] agreed to me discussing this with [Resident 4's] physician and the possibility of [his/her] medications changing to help avoid aggressive behavior. We discussed efforts to prevent the outbursts such as diversion of offering a dessert or fruit while [s/he] is dressing to encourage cooperation, talking softly while attempting cares and moving passively."* Progress note on 03/15/24 - LATE ENTRY "RN was able to talk to [Resident 4's spouse] about the current behaviors [Resident 4] is exhibiting. We discussed interventions such as offering a snack when resident is agitated to diffuse the situation, remove resident of which anger is directed toward, calm resident by allowing private time in [his/her] room. We also discussed as this was not the first time that we would have to notify Dr. as [his/her] safety and other resident's safety is our highest concern. [Resident 4's spouse] is interested in the Physician looking at [his/her] current medication to assess whether or not a medication adjustment is needed. This RN contacted [physician's] office to explain the recent behaviors [Resident 4] is exhibiting, awaiting a return phone call." There was no additional documentation regarding an incident that involved a resident to resident altercation.In an interview on 04/30/24 at 12:15 pm Staff 1 (Administrator) stated there had been a resident to resident altercation where Resident 4 tossed a magazine and Jenga blocks onto another resident's chest. An incident report, dated 03/14/24, was provided. The incident report did not specify how the facility ruled out abuse and neglect and did not state it was reported to the local SPD office. The surveyor requested the incident be reported to the local SPD office. Verification the facility reported the resident to resident altercation was received on 05/01/24 at 12:24 pm.The need to ensure resident to resident altercations were immediately reported to the local SPD office was discussed with Staff 1 on 04/30/24. He acknowledged the findings.
2. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia. Observations of the resident from 10/02/24 to 10/04/24 revealed the resident required staff assistance with transfers, incontinent care and needed supervision while in the geriatric chair (a large padded wheeled chair designed to help people with limited mobility) due to his/her leaning forward movement.Observations of the resident, interviews with staff, and review of the resident's clinical record, including incident reports/investigations, observations notes dated 06/30/24 through 10/02/24, 06/23/24 service plan and temporary service plans dated 06/27/24 to 07/30/24 indicated the following:* A 06/23/24 service plan showed the resident was a high fall risk and staff were to provide safety checks, ensure the bed was at the lowest height, the fall mat was in place, and to scoot the resident to the middle of the bed and place a pillow under the fitted sheet;* On 07/27/24, an observation note showed the resident was on alert charting for an unwitnessed fall; and* A 07/27/24 incident report indicated the resident had redness on the right shoulder area which resulted from the fall.There was no documented evidence the facility's investigation included all required components and ruled out abuse and neglect. Also, the investigation failed to review whether all fall interventions were in place at the time of the incident. There was no documented evidence the occurrence was reported to the local SPD office if abuse and/or neglect could not be ruled out.The need to investigate incidents of suspected abuse and neglect of care and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 22 (Wellness Nurse, RN) and Staff 37 (Chief Wellness Officer) on 10/03/24 and 10/04/24. Staff 22 confirmed she had not reported the above incidents to the local SPD, at which time the surveyor requested Staff 22 to immediately report the incidents. Confirmation that the incidents were reported was received prior to the survey team exiting the facility.

Based on interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule out abuse, document all required areas of an investigation and report to the local SPD office, if abuse or neglect could not be ruled out, for 3 of 3 sampled residents (#s 6, 7 and 8) with incidents or injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia. Interviews with staff were conducted, and the resident's record was reviewed including the current service plan, temporary service plans, 06/30/24 through 10/01/24 progress notes, incident reports and investigations. The following was identified: * 09/03/24 - Injury of unknown cause, bilateral elbows; * 09/04/24 - Injury of unknown cause, bruising on upper back; and* 09/04/24 - Injury of unknown cause, right elbow skin tear. There was no documented evidence the facility's investigation included all required components and ruled out abuse and neglect. There was no documented evidence that the occurrences were reported to the local SPD office if abuse and/or neglect could not be ruled out.In an interview on 10/02/24 with Staff 37 (Chief Wellness Officer), the facility's investigation process was reviewed, and it was acknowledged that the facility had not been ruling out abuse and neglect, including neglect of cares, during their investigations. At the request of the survey team, all incidents above were reported to SPD prior to survey exit. The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out, and if not, the injuries were reported to the local SPD office, was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

3. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia.The resident's 06/30/24 to 10/02/24 progress notes, short term observations, and temporary care plans, and investigations were reviewed. The following was identified:The resident's progress notes indicated the resident experienced the following injuries of unknown cause:* 09/01/24 - "[T]wo small skin abrasions"; and* 09/05/24 - "[S]kin laceration to [left] elbow."The above injuries were of unknown cause and required an immediate investigation to rule out abuse and/or neglect. At 10:15 am on 10/03/24 Staff 36 (ALF Administrator) stated no investigation had been completed for either injury. Survey requested the above injuries of unknown cause be reported to the local SPD office, and confirmation was received at 11:23 am on 10/03/24. The need to ensure immediate investigations were completed for injuries of unknown cause and/or reported to the local SPD if abuse or neglect could not be ruled out was discussed with Staff 27 (ED), Staff 36, and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs as identified in the evaluation, provided clear direction regarding the delivery of services, were readily available to staff, and were implemented for 3 of 4 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.The resident's service plan dated 03/15/24 was reviewed, observations of the resident were made, and interviews were conducted. The following was identified:a. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:* Use of hearing aids;* Home health services;* History of venous stasis wounds;* Time and date of shower to coincide with outside provider;* Assistance with laxative;* Bowel incontinence; and* Assistance required for transfers.b. The current service plan available to the staff in the resident's hard chart was dated 12/15/23. An updated service plan dated 03/15/24 was provided by Staff 1 (Administrator) on 04/29/24 at 3:04 pm. The need to ensure service plans were reflective of residents' current needs and were readily available to staff was discussed with Staff 1 on 05/01/24. He acknowledged the findings.
3. Resident 4 was admitted to the MCC in 11/2021 with diagnoses which included dementia. Interviews with care staff and observations of Resident 4 during the survey revealed s/he was non-ambulatory, incontinent, dependent on staff for ADL care, and had hospice services. a. Resident 4's service plan and quarterly evaluation, dated 04/03/24, revealed they were not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:* Hospice;* Ambulation;* Pain;* Activities;* Transfers;* Bathing; and* Significant change of condition.b. The most recent service plan was not available to staff in the Resident's binder.The need to ensure the service plan was current, reflective of Resident 4's current care needs as identified in the evaluation and provided clear direction to staff was discussed with Staff 1 (Administrator) during an interview on 04/30/24 at 12:15 pm. He reviewed the service plan and acknowledged it needed to be updated. No further information was provided.
2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.The resident's service plan dated 02/09/24 and short term observation forms (STOs) dated 01/16/24 to 04/29/24 were reviewed, observations of the resident were made, and interviews were conducted. The following was identified:a. The resident's current service plan was not reflective of his/her needs and preferences and/or was not implemented in the following areas:* Behaviors;* Hearing/vision status and assistive devices;* Sleeping schedule;* Diet texture;* Hospital bed;* Nail care;* Skin;* Activities;* Meal routine; and* Use of gait belt for transfers.b. Interviews with care staff indicated they had access to some resident ADL tasks via work-issued tablets; however they accessed the full service plan in residents' hard charts. Resident 3's current service plan was not available to staff in his/her hard chart.The need to ensure service plans were reflective and available to staff and services were implemented was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings, and no further information was provided.
3. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia. The resident's 09/01/24 service plan and temporary care plans dated 06/30/24 to 10/02/24 were reviewed. Observations of the resident were made, and interviews with staff were conducted. The service plan was not implemented in the following areas:* Use of bilateral heel protectors;* Use of gait belt for transfers; and* Use of barrier cream for redness to the buttocks. The need to ensure services were implemented for residents was discussed with Staff 27 (ED), Staff 36 (ALF Administrator), and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings, and no further information was provided.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services and was implemented for 3 of 3 sampled residents (#s 6, 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia.Observations of the resident, interviews with staff and review of the 06/23/24 service plan and temporary service plan, dated 06/27/24 through 07/30/24, revealed Resident 8's service plan was not reflective of the resident's status and did not provide clear directions regarding the delivery of services including what, when, how and how often the service should be provided, and were not implemented in the following:* Use of pillows on the side of legs while on the geriatric-chair;* Grooming status; and* Personal hygiene, including washing face and brushing teeth.On 10/04/24 at 10:33 am, the service plan was discussed with Staff 22 (Wellness Nurse, RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer). They acknowledged the service plans were not reflective of the resident's status, lacked clear directions, and were not implemented.

2. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia. The resident's clinical record was reviewed, including service plan dated 07/01/24 and progress notes and temporary service plans dated 06/30/24 through 10/01/24, the resident was observed, and interviews with staff were conducted.The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not being implemented in the following areas:* Assistance required for dressing, ambulation and toileting; * Use of hearing aides;* Fall prevention interventions; * Presence of the large stuffed dog in apartment; * Moving/hoarding items from other resident's rooms; * Frequency of snacks; and* Location of pain. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were being implemented, was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

4. Resident 1 was admitted to the facility in 03/2024 with diagnoses including agitation associated with dementia.Resident 1's clinical record including progress notes dated 03/15/24 to 04/27/24, and current service plan were reviewed. The following was identified:The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:* 03/13/24 - moved-in to the facility;* 03/15/24 - attempted elopement; and* 03/27/24 - medication dosage change. Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's conditions until resolution.The need to ensure short-term changes of condition are monitored at least weekly through resolution was discussed with Staff 1 (Administrator) on 05/01/24 at 12:35 pm. He acknowledged the findings.
2. Resident 2 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.Resident 2's progress notes dated 01/16/24 to 04/29/24, current service plan, and home health provider notes dated 03/06/24 to 04/24/24 were reviewed. The following was identified:a. There was no documented evidence the facility determined actions or interventions, provided written communication of the change of condition and any actions or interventions to staff on all shifts, and monitored at least weekly to resolution the following short term changes of condition:* 02/29/24 - started a course of antibiotics. b. There was no documented evidence the facility provided written communication of changes of condition and any actions or interventions to staff on each shift, and monitored at least weekly to resolution the following short term changes of condition:* 02/24/24 - venous stasis ulcers to right lower extremity; and * 03/26/24 - skin tear to left lower shin. The need to ensure the facility determined and documented actions or interventions for short term changes of condition, provided written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensured documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings, and no additional information was provided.
3. Resident 4 was admitted to the facility in 11/2021 with diagnoses which included dementia.Resident 4's clinical record and charting notes, reviewed from 03/04/24 through 04/26/24, revealed the following:The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:* 03/14/24 - a resident to resident altercation;* 03/24/24 - fall with injury;* 04/24/24 - redness to perineal area; and* 04/24/24 - prescription change.Although alert monitoring was initiated for some of the changes, the facility failed to determine if service-planned interventions were implemented, were effective or if new interventions were needed, and failed to communicate determined actions/interventions to staff on each shift. There was no documented monitoring of resident's conditions until resolution. Additional information was requested from Staff 1 (Administrator) on 04/30/24 at 12:15 pm. On 04/30/24 at 12:15 pm, Staff 1 (Administrator) reported he reviewed the resident's record and concluded the short-term changes in condition had no documented resolution. The need to ensure the facility determined and documented what action or intervention was needed for the resident's short term changes of condition and monitored the resident until the condition was resolved was discussed with Staff 1 (Administrator) and Staff 3 (RN/Wellness Director) on 04/30/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to determine and document actions or interventions for short term changes of condition, provide written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensure documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, 4) who experienced short term changes of condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.Resident 3's progress notes dated 01/16/24 to 04/29/24, current service plan and short term observations, hospital discharge notes dated 01/31/24, MAR dated 04/01/24 to 04/29/24, and hospice provider notes dated 02/05/24 to 04/16/24 were reviewed. The following was identified:a. There was no documented evidence the facility determined actions or interventions, provided written communication of the change of condition and any actions or interventions to staff on all shifts, and monitored at least weekly to resolution the following short term changes of condition:* 01/21/24 - left hip surgery with surgical wound;* Undated incident - Resident 3 "threw soup at [his/her] neighbor";* 03/29/24 - redness on left side of groin and abdomen;* 04/07/24 - agitation;* 04/10/24 - agitation; and* 04/20/24 - hospice discharge.b. There was no documented evidence the facility provided written communication of changes of condition and any actions or interventions to staff on each shift, and monitored at least weekly to resolution the following short term changes of condition:* 04/15/24 - loose stool;* 04/15/24 - agitation and combativeness; and* 04/23/24 - agitation.The need to ensure the facility determined and documented actions or interventions for short term changes of condition, provided written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensured documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 on 05/01/24. He acknowledged the findings, and no additional information was provided.



Based on observation, interview, and record review, it was determined the facility failed to have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who could determine if a change in the resident's condition required further action, and to ensure changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff, and implemented, and interventions were monitored for effectiveness for 2 of 3 sampled residents (#s 6 and 7) who experienced changes of condition. Resident 6 had repeated falls with injury without interventions or monitoring, which put him/her at risk and constituted an immediate threat to the residents' health and safety. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.The resident's current service plan, updated 07/01/24, progress notes dated 06/30/24 through 10/1/24, temporary service plans (TSPs) and incident reports were reviewed, and staff were interviewed. a. During the acuity interview on 10/02/24, Resident 6 was identified by Staff 22 (Wellness Nurse, RN) and Staff 36 (ALF Administrator) as someone who experienced frequent falls. Documentation in the resident record revealed the resident experienced the following:* 07/11/24 at 6:15 pm - Unwitnessed fall with injuries including two thoracic vertebrae compression fractures (T11 and T12), three fractured ribs, head abrasion and left arm hematoma. The resident was found laying on the bathroom floor near his/her sink, and was subsequently sent to the hospital. The resident returned to the facility on 07/12/24, and a TSP was placed on 07/12/24 instructing staff to provide "1 person ambulation assistance for safety purposes", ensure "room safety check[s] are done every 2 hours while res[ident] is in [his/her] Apt" and "ensure res[ident] is using walker to ambulate." * 09/03/24 at 10:00 am - Unwitnessed fall with injury including bilateral elbow redness. Resident was found lying on the bathroom floor in front of his/her sink. A TSP was placed 09/03/24 which did not include any new fall prevention interventions. * 09/04/24 at 7:25 pm - Unwitnessed fall with injury including skin tear to right elbow. Resident was found in the doorway of his/her room. There was no documentation the resident was evaluated. A TSP was placed 09/04/24 which did not include any new fall prevention interventions. * 09/06/24 - Resident returned from emergency room after a near-fall outside of the medication room on 09/05/24. Progress notes and the incident report described the resident as appearing to be lightheaded, showing signs of dizziness, being unable to bear weight and trembling. The resident was diagnosed in the emergency room with a seizure. A TSP was placed on 09/06/24 which did not include any new fall prevention interventions or resident-specific instructions to staff. * 09/21/24 at 12:30 pm - Unwitnessed fall. Resident was found on the floor in the doorway to his/her room. A TSP was placed on 09/23/24 which did not include any new fall prevention interventions. * 9/28/24 at 8:10 pm - Unwitnessed fall with injuries including head injury, right eye laceration and facial bruising. Resident was found sitting on the floor in front of his/her room. A TSP was placed on 09/29/24 which did not include any new fall prevention interventions. Resident 6 experienced an unwitnessed fall on 07/11/24 which resulted in fractured vertebrae and fractured ribs. The resident continued to experience unwitnessed falls with injuries on 09/03/24, 09/04/24 and 09/28/24, in addition to a near-fall requiring a visit to the emergency room on 09/05/24 and an unwitnessed non-injury fall on 09/21/24. There was no evidence the facility evaluated the resident, determined and documented new interventions to reduce the resident's risk of falling, and communicated these to staff on all shifts, with monitoring of the resident and the interventions at least weekly until resolution. This created a serious risk of harm and immediate threat to the health and safety of the resident. During the survey, 10/02/24 through 10/03/24, the resident was observed to be ambulating unassisted throughout the facility. During an interview with Staff 16 (CG), she showed the "task sheet" on the facility's documentation system where care tasks/needs were shown and documented by the caregiver for each resident. Resident 6's task sheet, including frequency of safety checks and ambulation assistance, had not been updated since 07/01/24, prior to the fall with fracture on 07/11/24 and subsequent falls. The facility's failure to evaluate the resident's fall risk, determine actions or interventions, communicate these to all staff on all shift and monitor interventions for effectiveness created a serious risk of harm to the resident and immediate threat the residents' health and safety. An immediate plan of correction was requested at 2:31 pm on 10/03/24. The facility provided an acceptable plan of correction on 10/03/24 at 6:22 pm, prior to survey exit. The immediate risk was addressed, however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure residents were evaluated, actions or interventions were determined, documented, communicated to staff on all shifts, and implemented, and ensure interventions were monitored for effectiveness was reviewed with Staff 22, Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.b. The resident's record identified that the following short term changes of condition were not evaluated, actions or interventions determined and communicated to staff on all shifts, and/or monitored through resolution: * 07/11/24 - Post-fall injuries including vertebral and rib fractures, left arm hematoma and head abrasion; * 07/12/24 - New medication, losartan (for high blood pressure); * 07/31/24 - Return from urgent care for high blood pressure; * 08/04/24 - Medication discontinued, ibuprofen (for pain); * 08/16/24 - New behavior including hitting staff;* 08/29/24 - Resident to resident altercation; * 09/03/24 - Bilateral elbow redness post-fall; * 09/04/24 - Bruise on upper back; * 09/04/24 - Skin tear to right elbow;* 09/09/24 - New behavior plan; and* 09/15/24 - Loose stools. The need to determine actions or interventions for changes of condition, and monitor at least weekly through resolution was discussed with Staff 22 (Wellness Nurse), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.c. A fax to the resident's doctor on 07/30/24 stated the resident's blood pressure had been taken on 07/30/24 with the following readings: * 205/101 mmhg;* 201/96 mmhg; and * 198/98 mmhg. The resident's MAR stated that the resident's blood pressure should be recorded daily and a nurse should be notified if the systolic blood pressure was greater than 160 mmhg. A progress note dated 07/30/24 at 3:07 pm stated "called Emily [Wellness Nurse, RN] to notify but did not answer." There was no documentation that a designated staff member was accessible to identify whether the change of condition required further action. The need to have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who could determine if a change in the resident's condition required further action was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.
2. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia.The resident's 06/30/24 to 10/02/24 progress notes, short term observations, and temporary care plans were reviewed. The following was identified:There was no documented evidence the facility identified actions/interventions, communicated them to staff on each shift, and/or monitored with weekly progress noted to resolution the following short-term changes of condition:07/11/24 - Noninjury fall;08/27/24 - Redness to buttocks; and09/05/24 - Skin laceration on left elbow.The need to ensure actions/interventions were determined, documented, and communicated to staff on each shift and weekly progress was noted to resolution for short-term changes of condition was discussed with Staff 27 (ED), Staff 36 (ALF Administrator), and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings, and no further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed and included documented findings, resident status and interventions made as a result of the assessment, and the licensed nurse reviewed the service plan with date and signature within 48 hours for 2 of 2 sampled residents (#s 3 and 4) who experienced significant changes of condition related to a fall with injury and admission to hospice. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease. Progress notes dated 03/04/24 through 04/24/24, and the current service plan, dated 04/03/24 were reviewed and revealed the following:Resident 4 experienced a fall with a head injury on 03/24/24, was hospitalized and admitted to hospice effective 04/01/24. The facility failed to ensure an RN assessment was completed for the fall or hospice admission which documented findings, resident status, and interventions made as a result of the assessment. Resident 4's service plan was updated 04/03/24 but was not reflective of the significant changes of condition. The need to ensure an RN conducted an assessment of all residents with significant changes of condition and participated in updating the resident's service plan with the changes was discussed with Staff 1 (Administrator) and Staff 3 (RN/Wellness Director) on 04/30/24. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease. Progress notes dated 01/16/24 to 04/29/24, hospital discharge paperwork dated 01/31/24, and a change of condition evaluation dated 02/09/24 were reviewed and the following was identified:Resident 3 experienced a fall with a left hip fracture and was hospitalized for surgery from 01/21/24 to 01/31/24. The resident was admitted to hospice 02/05/24. The hip fracture, surgery, and hospice admit constituted a significant change of condition for which an RN assessment was required. During an interview at 10:00 am on 05/01/24, Staff 3 (RN) stated there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (Administrator) on 05/02/24. He acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment and interventions were developed based on the condition of the resident for 1 of 2 sampled residents (#6) who experienced a significant change of condition. Resident 6 continued to experience unwitnessed falls with injury which put him/her at risk and constituted an immediate threat to the residents' health and safety. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.The resident's current service plan, updated 07/01/24, progress notes dated 06/30/24 through 10/1/24, temporary service plans and incident reports were reviewed, and staff were interviewed. The most recent evaluation, dated 07/01/24 indicated the resident was independent while ambulating and was not evaluated as having pain or notable confusion. The resident experienced an unwitnessed fall on 07/11/24, with injuries including two thoracic vertebrae compression fractures (T11 and T12), three fractured ribs, a head abrasion and a left arm hematoma.A progress note dated 07/12/24 stated the resident was "needing assistance ambulating due to weakness from [his/her] injury", was "confused", and "showed discomfort." The resident's 07/11/24 fall, change in ambulation status, and increased confusion constituted a significant change of condition, which required a timely RN assessment that included resident status, RN findings, and interventions made as a result of the assessment. An RN progress note dated 07/23/24, 12 days after the significant change of condition occurred, did not address the resident's status, and no new interventions were identified. The failure to complete a timely RN assessment following the significant change of condition, including resident findings and interventions made as a result of the assessment created a serious risk of harm to the resident and posed an immediate threat to the resident's health and safety. An immediate plan of correction was requested at 2:31 pm on 10/03/24. The facility provided an acceptable plan of correction on 10/03/24 at 6:22 pm, prior to survey exit. The immediate risk was addressed, however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need for an RN to complete and document a timely assessment following a significant change of condition, including interventions made as a result of the assessment, was discussed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (# 5) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to:Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 04/29/24, Resident 5 was identified to be administered an insulin injection once daily by a facility UAP.Resident 5's MARs from 04/01/24 through 04/29/24 revealed insulin injections had been given by Staff 7 (Medication Care Manager), Staff 14 (Medication Care Manager), and Staff 15 (Medication Care Manager). There was no documented evidence upon review of the delegation binder that the initial nursing delegation was completed for Staff 14. The initial nursing delegation for Staff 7 was dated 04/19/24 and for Staff 15 was dated 04/20/24, respectively. During the interview on 04/30/24, Staff 3 (RN/Wellness Director) confirmed Staff 14 was not delegated to prepare and administer insulin injections for Resident 5. On 04/30/24 at 1:30 pm, Staff 3 stated she planned to conduct initial nursing delegation for Staff 7 on 04/30/24 during the scheduled evening shift. Staff 3 verbalized Staff 7 would not administer insulin until delegation was completed. Additionally, the initial delegation reviews for Staff 7 and Staff 15 lacked the following documentation:* The client did not require assessment during the procedure;* The procedure did not require interpretation or independent decision making;* The procedure was not life-threatening, and delegation posed minimal risk to the client;* The client's environment supported safe performance of the procedure;* Availability of RN to provide ongoing assessment of the client at frequency deemed necessary to determine ongoing stability and predictability;* Availability of RN to provide ongoing competency validation of Unregulated Assistive Person's performance; and * Documented recommendations on how the client would continue to receive the procedure if the RN was no longer a member of the health care team and the procedure remained ordered for the client.The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (Administrator) and Staff 3 on 05/01/24. They acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#3) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to:1. Observations of meal service were completed on 04/29/24 and 04/30/24 revealed the following:a. Multiple care staff served food and provided direct feeding assistance to residents without donning a protective barrier over potentially contaminated clothing.b. During an interview at 9:18 am on 04/30/24, Staff 14 (MT) stated CGs and MTs were responsible for taking meal trays to residents who preferred to eat in their rooms. At 9:20 am, Staff 13 (MT) was observed taking a plate of food and two beverages to Resident 3's room. The was no protective covering on the food or beverages to prevent contamination during transport.2. Staff 13 was observed providing incontinence care to Resident 3 at 8:38 am on 04/30/24. She did not perform hand hygiene prior to providing hands on assistance to the resident. She changed the soiled briefs and pants, then performed perineal care and donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene in between. After incontinence care she touched multiple surfaces and resident personal items in the room with the soiled gloves still on. The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.
2. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia. Observation of the resident during the survey showed the resident required staff assistance with incontinent care. The surveyor observed on 10/03/24 at 10:46 am, Staff 11 (CG) and Staff 18 (CG) provide incontinence care for Resident 8. During the observation, Staff 11 and Staff 18 donned gloves without performing hand hygiene. Staff 11 then proceeded to remove the resident's soiled brief, wipe and cleanse the resident's perineum area and touch the resident's body, clean incontinent product, clothing and bed linens while using the soiled gloves. Staff 11 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donned gloves.The above observation was discussed with Staff 22 (Wellness Nurse, RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:33 am. They acknowledged appropriate infection control practices were not implemented.
Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 2 sampled residents (#s 7 and 8) whose ADL care was observed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia, and was identified in the acuity interview as dependent on staff for incontinent care.a. Staff 16 (CG) and Staff 30 (CG) were observed providing incontinence care for Resident 7 at 11:22 am on 10/02/24. They did not perform hand hygiene prior to donning single-task gloves. The staff changed the resident's soiled brief, then performed perineal care and donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene in between. Staff 30 placed the soiled incontinence trash on the floor of Resident 7's room. After incontinence care was provided, both staff touched multiple surfaces and the resident's personal items such as the handles of the resident's geriatric chair with the soiled gloves still on. Both staff exited the resident's room and touched multiple surfaces and unsampled residents' wheelchairs and other personal items with the soiled incontinence care gloves.b. Staff 16 and agency staff were observed providing incontinence care for Resident 7 at 1:45 pm on 10/03/24. They did not perform hand hygiene prior to donning single-task gloves. The staff changed the resident's soiled brief, then performed perineal care and donned clean briefs and pants without removing soiled gloves and performing hand hygiene in between. After incontinence care both staff touched multiple surfaces and personal items in the resident's room with the soiled gloves. Both staff removed the soiled gloves in the resident's room, but did not perform hand hygiene before exiting the room.The above observations were discussed with Staff Staff 27 (ED), Staff 36 (ALF Administrator), and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged infection prevention protocols had not been implemented.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to:During the re-licensure survey, conducted 04/29/24 through 05/01/24, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:* C282 - RN Delegation and Teaching;* C303 - Medication and Treatment Orders;* C305 - Resident Right to Refuse;* C310 - Medication Administration; and* C330 - PRN Psychotropic Medications.The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and had signed written prescriber's orders for 1 of 4 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to:Resident 4 was admitted in 11/2021 with diagnoses which included Alzheimer's, pain and anxiety.Review of the resident's clinical record revealed the following:a. Resident 4 had an order for Lidocaine 4% patch to be applied topically every 12 hours for pain. The MAR, reviewed from 04/01/24 through 04/29/24, revealed staff were not administering the patch once a day as ordered. The discrepancy was discussed with Staff 3 (RN/Wellness Director) on 04/30/24. She stated she has been trying to clarify the order with the physician. b. The resident had an order for morphine 20 mg/mL to be given to Resident 4 in the amount of 0.25 ml 30 minutes prior to hospice aide providing bed bath. This medication order was not on the MAR. The order date was 04/10/24.In an interview on 04/30/24 at 12:45 pm, Staff 3 stated she was unaware of this order.c. Resident had an order for Haloperidol 1 ML (2 mg) to be given by mouth every evening. Staff were documenting this medication as being given at 8:00 pm nightly. There was no written order for this medication. Failure to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) on 04/30/24. He acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 3 sampled residents (#6) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia. The resident's signed physician orders and 09/01/24 through 10/02/24 MARs were reviewed, and the following was identified:a. The resident had an order for Lidocaine 5% patch (for pain) to be applied topically every 24 hours. The order stated that the patch should be placed on the skin at 8:00 am and removed at 8:00 pm. The patch was not administered as ordered on the following dates:* 09/01/24; * 09/04/24; * 09/06/24; * 09/07/24; * 09/16/24; and* 09/18/24. Staff 22 (Wellness Nurse) was interviewed on 10/03/24 and was not able to provide any additional information. b. The resident had a treatment order dated 08/19/24 stating that the resident needed to be "evaluated in clinic for follow up" due to a new presentation in the resident's behavior. There was no documented evidence the order was followed. c. The resident had a treatment order dated 08/27/24 stating "the facility crush or empty the capsule of medication due and put them in apple sauce" due to repeated medication refusals. There was no documented evidence the order was followed. d. The resident had a treatment order dated 09/03/24 stating "if patient had a fall sustaining injury with new symptoms, they need to be evaluated in clinic. If no available appointments or if it is after hours, patient is advised to follow up in urgent care or ED." The resident had an unwitnessed fall on 09/03/24 and injuries to bilateral elbows. There was no documented evidence that the order was followed. The need to ensure all medication and treatment orders were carried out as prescribed was reviewed with Staff 22, Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified if a resident refused to consent to an order for 1 of 1 sampled resident (#3) who had medication and treatment refusals. Findings include, but are not limited to:Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease. The resident's 04/01/24 to 04/29/24 MAR and current medication and treatment orders were reviewed. The following was identified:Staff documented the following medication and treatment refusals between 04/01/24 to 04/29/24:* Cyclosporine eye drops (for dry eyes): on 12 occasions;* Desitin cream (for rash): on six occasions; * Divalproex (an anticonvulsant) on 11 occasions;* Furosemide (a diuretic) on 10 occasions;* Lactase (for lactose intolerance) on five occasions;* Melatonin (a sleep aid) on six occasions; * Metoprolol (for high blood pressure) on two occasions;* Quetiapine 25 mg tab (for mood) on five occasions;* Quetiapine 50 mg tab on six occasions;* Refresh eye drops (for dry eyes) on 35 occasions; and* Vitamin D3 (supplement) on one occasion.During an interview at 9:45 am on 04/30/24, Staff 13 (MT) stated if a resident was receiving hospice services, MTs would notify the hospice provider via phone call of the refusals. There was no documented evidence hospice was notified of the above medication and treatment refusals. During an interview at 10:30 am on 05/01/24, Staff 3 (RN/Wellness Director) confirmed the lack of documentation regarding Resident 3's medication and treatment refusals.The need to ensure the physician or other practitioner was notified if a resident refused to consent to an order was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included documented reasons for use and resident specific parameters and instructions for administration of PRN medications for 2 of 4 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease and hypertension.The resident's current prescriber orders and 04/01/24 through 04/29/24 MAR were reviewed and the following medications lacked reasons for use:* Cal-Cit/vitamin D3;* Melatonin;* Omeprazole;* Oxycodone;* Polyethylene glycol;* Potassium chloride; and* Quetiapine. The need to ensure all medications on the MAR included the reason for use was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.
2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.The resident's 04/01/24 to 04/29/24 MAR and current prescriber orders were reviewed and the following was identified:a. The following medications lacked a reason for use:* Cyclosporine;* Divalproex;* Furosemide;* Lactase;* Melatonin;* Quetiapine;* Refresh plus;* Vitamin D3; and* Acetaminophen. b. The resident was prescribed PRN lorazepam and haloperidol for agitation. The MAR lacked resident-specific parameters instructing unlicensed staff as to which medication should be administered first.The need to ensure residents' MARs included documented reasons for use and resident specific parameters and instructions for administration of PRN medications was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

2. Resident 1 moved into the facility in 03/2024, with diagnoses including agitation associated with dementia.Review of Resident 1's MAR, dated 04/01/24 through 04/29/24, and current physician's orders, indicated the resident was prescribed PRN psychotropic medications including lorazepam 0.5 mg twice daily "for severe anxiety."a. The record lacked resident-specific parameters to direct staff on how the resident displayed severe anxiety. b. There was no documented evidence non-pharmacological interventions were tried and ineffective prior to administration of the PRN lorazepam on 15 occasions between 04/01/24 and 04/25/24.In an interview with Staff 12 (Medication Manager) on 04/30/24 at 11:00 am, it was confirmed there was no documented evidence of non-pharmacological interventions having been tried prior to administration of the PRN lorazepam. The need to ensure PRN medications given to treat a resident's behaviors had written, resident-specific parameters and there was documentation that non-pharmacological interventions had been tried with ineffective results prior to administration was discussed with Staff 1 (Administrator) on 05/01/24 at 12:35 pm. He acknowledged the findings.
3. Resident 4 was admitted to the facility 11/2021 with diagnoses including dementia and mood disorder.Review of the resident's 04/01/24 through 04/29/24 MAR and 04/03/24 hospice orders showed the following:* Olanzapine ODT 5mg tab, ½ tablet (2.5 mg) by mouth every six hours as needed for agitation or hallucinations. The olanzapine was administered nine times between 04/03/24 and 04/11/24. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or hallucinations. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator) and Staff 3 (RN/Wellness Director) on 05/01/24. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure written resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 1, 3, and 4) who had orders for PRN psychotropic medications. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.Review of the resident's 04/01/24 to 04/29/24 MAR and current prescriber orders indicated the resident was prescribed the following:* Haloperidol concentrate 2 mg/ml, take 0.25 ml by mouth every four hours as needed for hallucinations, agitation, nausea, and/or vomiting.a. The record lacked resident-specific parameters to direct staff on how the resident displayed agitation.b. There was no documentation that non-pharmacological interventions were tried with ineffective results prior to administration of the PRN haloperidol on two occasions between 04/01/24 and 04/29/24.The need to ensure resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administration of PRN psychotropic medications was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an ABST assessment was completed for each resident. Findings include, but are not limited to:On 04/30/24 at 9:55 am, Staff 1 (Administrator) was interviewed regarding the facility's ABST. He stated all residents were entered into the facility's ABST, however, there were six residents whose data was not saved. Upon ABST review on 04/30/24 at 10:00 am, all residents residing in the MCC were entered into the ABST. However, the required ABST elements reflected zero minutes in each category for Resident 3, Resident 4, and four unsampled residents.The need to ensure an ABST assessment was completed for each resident was discussed with Staff 1 on 05/01/24. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for multiple sampled and unsampled residents or with a significant change of condition for 2 of 2 sampled residents (#s 6 and 7) who had a significant change of condition. This is a repeat citation. Findings include, but are not limited to:The facility's ABST was reviewed at 10:29 am on 10/03/24 with Staff 36 (ALF Administrator). The following was identified:* Twenty-four of the facility's 36 residents did not show evidence of being updated quarterly; * Resident 6's ABST did not show evidence of being updated with his/her significant change of condition that occurred on 07/11/24; and* Resident 7's ABST did not show evidence of being updated with his/her significant change of condition that occurred on 09/01/24.The need to ensure residents' ABSTs were updated no less than quarterly and with significant changes of condition was discussed with Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff demonstrated competency in assigned job duties within 30 days of hire for 1 of 2 staff (#33) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed with Staff 36 (ALF Administrator) at 1:36 pm on 10/03/24. The following was identified:Staff 33 (CG), hired 06/17/24, did not have documented evidence of completing abdominal thrust training within the first 30 days of hire.The need to ensure staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to:Six months of fire drill and fire and life safety training's were requested on 04/29/24. During an interview at 1:54 pm on 04/29/24, Staff 4 (Business Office Manager) stated the former maintenance director maintained the fire and life safety records but no one currently working at the facility knew where the documentation was. She provided documentation of a building-wide fire drill that took place on 04/25/24; however she stated the fire drill was for staff only and no residents were evacuated or participated. The documentation did not address any of the following required rule components:* Date and time of day; * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; and * Number of occupants evacuated. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code fire and life safety instruction was provided to staff on alternate months was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.
Based on interview and record review, it was determined the facility failed to conduct fire drills per OFC and to instruct staff in fire and life safety topics on alternate months from fire drills. This is a repeat citation. Findings include, but are not limited to:Facility fire drill and fire and life safety records from 06/30/24 to 10/02/24 were requested and reviewed with Staff 36 (ALF Administrator) at 10:18 am on 10/03/24. a. A fire drill completed on 08/29/24 lacked the following documentation:* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; and * Number of occupants evacuated.b. Staff 36 confirmed at 10:18 am on 10/03/24 there was no documented evidence staff were trained in fire and life safety procedures on alternate months from fire drills.The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

Based on observation, 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, C295, C303, C361, C420, Z155, and Z164.

Concerns were identified in the following areas and the facility was provided with technical assistance:H1517: Individual Privacy: Own Unit. OAR 411-004-0020(2)(d): (d) Each individual has privacy in his or her own unit.

Concerns were identified in the following areas and the facility was provided with technical assistance:H1518: Individual Door Locks: Key Access. OAR411-004-0020(2)(e)(2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Concerns were identified in the following areas and the facility was provided with technical assistance:H1580: Limitations: Threats to health and safety. OAR 411-004-0020(2)(d) to (2)(j): Ensure the residential setting applies individually based limitations when conditions may not be met due to threats to the health and safety of an individual or others.Refer to H1518.

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 152, C 155, C 231, C 295, C 361, C 372, and C 420.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C150, C156, C231, C295, C361, C372, and C420.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 18, 19 and 20) completed all required orientation, pre-service, and competency training within required timelines, and 2 of 2 sampled direct care staff (#s 7 and 10) completed a total of 16 hours of in-service training annually based on date of hire, including six hours of annual dementia care training. Findings include, but are not limited to:Training records were reviewed with Staff 4 (Business Office Manager) on 05/01/24. The following deficiencies were identified:a. Staff 18 Care Manager (CM) was hired 11/01/23, Staff 19 (CM) was hired 04/01/24 and Staff 20 (CM) was hired 04/01/24. The following training requirements were not met:* Staff 18, 19, and 20 did not complete orientation training on "Standard Precautions for Infection Control" prior to beginning job duties;* Staff 19 and 20 did not complete orientation training on "HCBS" prior to beginning job duties;* Staff 18 did not complete orientation training on "HCBS" by 03/31/24;* Staff 19 and 20 did not complete pre-service dementia training on the topic of "Environmental Factors that are Important to a Resident's Well-Being"; and* Staff 18, 19, and 20 did not complete pre-service dementia training on the topic of "Use of Supportive Devices with Restraining Qualities in MCCs" prior to working independently. b. Staff 18 did not complete abdominal thrust within 30 days of hire.c. Staff 6 (Housekeeping Supervisor) was hired 05/10/22. The following training requirements were not met:* Staff 6 did not complete annual training on "Standard Precautions for Infection Control" annually or HCBS by 03/31/24.d. Staff 7 Medication Care Manager (MCM) was hired on 06/05/21. For the calendar year 2022/23, Staff 7 completed 12.5 hours of annual in-service training, of which 4.25 hours were on dementia-related topics.Staff 7 did not complete "Standard Precautions for Infection Control" annually or HCBS by 03/31/24.e. Staff 10 (MCM) was hired on 10/11/21. For the calendar year 2022/23, Staff 10 completed 8 hours of annual in-service training, of which 2.25 hours were on dementia-related topics.The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, and that veteran direct care staff completed 16 hours of in-service training annually based on date of hire, including six hours of annual dementia care training, was reviewed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN/Wellness Director), and Staff 4 on 05/01/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 6 of 8 sampled medication technicians (#s 7, 12, 14, 26, 38, and 39) demonstrated knowledge and performance in any duty they were assigned prior to providing care services to residents, 3 of 3 newly hired staff (#s 33, 38, and 40) completed all required pre-service orientation training, 1 of 2 caregivers (# 23) demonstrated competency in assigned job duties within 30 days of hire, 1 of 3 (#32) long-term care staff completed required Home and Community-Based Services (CBS) training, and failed to develop a system to track annual training for long-term direct care staff. Six MT's were working independently and lacked documentation of competency in medication administration, which put the residents for which they administered medications at risk for serious harm. This is a repeat citation. Findings include, but are not limited to:1. Employee training records were reviewed on 10/02/24 at 5:46 PM with Staff 36 (ALF Administrator). The following was identified:Staff 7 (MT) was hired 06/05/21, Staff 12 (MT) was hired 02/06/23, Staff 14 (MT) was hired 07/26/22, Staff 26 was hired 03/03/22, Staff 38 (MT) was hired 07/01/24, and Staff 39 (MT) was hired 04/29/22. Each of these staff had been working in the facility independently as an MT, which included administering medications to residents. The facility was unable to provide documentation that their knowledge and performance in administering medications had been reviewed and each had been determined competent to administer medications unsupervised. On 10/02/24 at 5:46 PM, the survey team requested an immediate plan of correction (PC) to ensure MT's whose job it was to administer medications to residents were trained by appropriate facility staff and there was documentation to show they had observed and evaluated the MT's ability to perform safe medication administration unsupervised. On 10/02/24 at 6:17 PM, the facility submitted a PC that was accepted by the survey team. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.2. Staff training records were reviewed with Staff 36 at 1:36 PM on 10/03/24. The following was identified:Staff 33 (CG), hired 06/17/24, Staff 38 (MT), hired 07/01/24, and Staff 40 (Cook), hired 09/03/24, lacked one or more of the following pre-service orientation training requirements:* Written job description; and* CBS training.3. Staff 23 (CG), hired 08/05/24, did not have documented evidence of demonstrating competency in job duties within 30 days of hire.4. Staff 32 (Server), hired 12/15/21, did not have documented evidence of completing required CBS training.5. During an interview at 10:03 am on 10/04/24, Staff 36 stated there was no system to track annual training for long-term direct care staff in the memory care community.The need to ensure the facility had a process to ensure all direct care staff had documentation of demonstrated competency in any duty they were assigned, all newly hired staff completed pre-service orientation training, all long-term staff completed HCBS training, and all long-term employees completed annual training requirements was reviewed with Staff 27 (ED), Staff 36, and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to: C 260, C 270, C 280, C 282, C 300, C 303, C 305, C 310, and C 330.
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. This is a repeat citation. Findings include, but are not limited to:Refer to C260, C270, C280, and C303.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service or care plan for 2 of 4 residents (#s 3 and 4) whose records were reviewed. Findings include, but are not limited to:Resident's 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 3 (RN/Wellness Director) on 05/01/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate residents and create individualized activity plans based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, and 4's service plans offered some information about the residents' interests, however, the facility had not fully evaluated the residents': * Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. Observations and interviews indicated the residents were dependent on staff to initiate activities.On 05/01/24 the need to ensure the facility provided meaningful activities based on an activity evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED), who acknowledged the findings.
2. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia. The resident's service plan, dated 07/01/24, stated the resident required "moderate assist" with activities, including requiring staff to assist him/her with activities by reminding him/her of times and activities of the day. On 10/02/24 between 10:30 am and 3:00 pm and 10/03/24 between 10:30 am and 2:30 pm, the resident was observed in the memory care facility. There was no attempt to engage the resident in an activity during the time s/he was observed. The resident was often observed wandering the hallways, sitting alone, or attempting to access the locked kitchenette, which was one of his/her known behaviors. Between the dates of 08/16/24 and 10/01/24, the resident's record showed that the resident exhibited behaviors including:*Hitting staff;*A resident-to-resident altercation; and*Tendency to walk into other resident apartments. Under the section of the activity evaluation titled "identification of activities for behavioral intervention", the evaluation stated the resident "requires redirection from staff to an activity". There was no additional information. The facility did not have documented evidence of an activity plan which included a selection of daily structured and non-structured activities. The need to ensure the facility provided meaningful activities based on an activity evaluation and had an individualized activity plan which included a selection of daily structured and non-structured activities for each resident was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide meaningful and individualized activity plans based on their activity evaluations, for 2 of 3 sampled residents (#s 6 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the memory care community (MCC) in 07/2020 with diagnoses including dementia.The resident's service plan, dated 06/23/24, stated:* Resident "is no longer able to hold conversations or verbally interact with others ..."; and* Resident "enjoys 1:1 interaction with staff." The resident was observed during the survey to require full assistance with activities of daily living (ADLs) due to physical and cognitive limitations and was dependent on staff to initiate activities. On 10/02/24 between 1:10 pm and 4:00 pm and 10/03/24 between 9:15 and 10:45 am, Resident 8 was observed in his/her geriatric chair in the common area near activity table. The television was continuously on. At approximately 1:15 pm on 10/02/24 and at 9:30 am on 10/02/23, there was a staff member-led artificial flowers activity and block activity at the activity table, but the staff did not offer the flowers activity and block activity nor a one-on-one sensory activity to the resident during the observation.The facility provided some information about the residents' interests, however, the facility had not fully developed an individualized activity plan and/or did not provide structured and non-structured activities in the service or care plan as appropriate.On 10/04/24 at 10:33 am, the need to ensure the facility provided meaningful activities based on an activity evaluation and an individualized activity plan for each resident was discussed with Staff 22, Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. Findings include, but are not limited to:The facility grounds of the memory care community were toured on 04/29/23 at 11:10 am. Outdoor furniture was observed in both courtyards, to which residents had free access. The furniture was movable, and not of sufficient weight to prevent injury or elopement. On 05/01/24 at 11:05 am the outdoor courtyards were toured with Staff 1 (Administrator). The need to maintain outdoor furniture of sufficient weight was discussed with Staff 1, and he acknowledged the findings.

The findings of the kitchen inspection, conducted 09/14/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 09/14/23, conducted on 12/6/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/14/23 at 11:15 am, the kitchen was observed to have the following concerns: * Two hotel pans of clam chowder in the walk in refrigerator, stored on the lowest shelf were uncovered while cooling; * Three garbage cans were uncovered when not in use; * The ceiling vents in the dishwashing area and food prep area had accumulation of dust: * The ceiling directly above the dishwasher and the wall above the dishwasher had accumulation of dust; and * Three employees were not wearing beard/hair restraints. The areas of concern were discussed with Staff 1 (Executive Chef) and Staff 2 (Business Office Manager/Acting Interim Administrator) on 09/14/23. The findings were acknowledged.

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

Based on interview and observation, it was confirmed the facility failed to ensure exit door alarms or other acceptable system is provided for security purposes and to alert staff when residents exit the RCF. Findings include, but not limited to: On 6/28/2022 Compliance Specialist (CS) observed facility exit doors to the MCC outdoor courtyards open and close multiple times with no audible alarms or system in place to alert onsite staff. Separate interviews with Staff #1 & 2 (S1-S2) on 6/28/2022, stated that when doors from the facility to the outside courtyard are opened, they are supposed to get an alert on an iPad or IPhone located at the front desk who then alerts staff. S1 showed this CS the iPad system and the phones that they are to get the alerts on and there were no alerts that came through when this CS opened the patio doors. Findings were reviewed with S1 and acknowledged on 6/28/2022 with Staff #1& Staff#3 Facility Plan Of Care Correction Administrator stated the company who provides the system will be contacted 6/28/2022 to get them out to look at the system and fix as quickly as possible. Sustainable plan once system is repaired will be to check system monthly.

The findings of the initial survey conducted 2/1/21 through 2/3/21 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 C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 revisit survey conducted 4/20/21 through 4/21/21, to the relicensure survey of 2/3/21, 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 C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 second revisit to the re-licensure survey of 02/03/21, conducted 06/23/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.

Based on interview and record review, it was determined the facility failed to maintain an accurate Uniform Disclosure Statement (UDS) related to staffing hours provided in the facility. Findings include but are not limited to:On 2/1/20 Staff 2 (MC Administrator) provided the surveyor with a copy of the facility's Uniform Disclosure Statement given to residents and families. The disclosure statement failed to accurately identify the amount of hours staff were scheduled on the memory care unit.The UDS reflected the following: * 6:00 am to 2:00 pm: Direct care staff - 3 and Medication aide - 1;* 2:00 pm to 10:00 pm: Direct care staff - 3 and Medication aide - 1; and * 10:00 pm to 6:00 am: Direct care staff - 2 and Medication aide - 1.The February 2021 staffing schedule was reviewed and identified the following:* 6:00 am to 2:00 pm: Three direct care staff and one medication aide were scheduled on 15 out of the 28 days of February; * 2:00 pm to 10:00 pm: Two direct care staff one medication aide were scheduled all 28 days of February; and* 10:00 pm to 6:00 am: The shift's schedule was reflective of the facility's current UDS.An interview with Staff 1 (ED) and Staff 2 (MC Administrator) on 2/3/21 at 10:30 am revealed the staffing numbers were discussed in January 2021 as census was low. The reduction in staffing hours was to begin on 2/13/21, Staff 2 stated changes were implemented earlier than planned. Staff 1 provided the survey team with documentation the state was emailed on 2/3/21 with a revised UDS.Accuracy of the UDS reflecting the facility's staffing plan was discussed with Staff 1, Staff 2 and Staff 3 (Regional RN) on 2/3/21. An updated UDS was provided to the survey team with verification that an email was sent to the facility's policy analyst.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents related to a failure to follow infection control guidelines to prevent the spread of COVID-19. Findings include, but are not limited to:During the change of ownership survey, conducted 2/1/21 through 2/3/21, multiple Oregon Department of Human Services (ODHS) 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. The following issues were identified:* The facility failed to have a comprehensive screening tool, used to screen all visitors which included a list of all COVID-19 symptoms;* No disinfection and storage of personal protective equipment (PPE); * Failure to discard medical grade face masks after use; and* Failure to wear approved PPE, eye protection.During an interview with Staff 1 (ED) on 2/2/21, the surveyor requested the facility immediately implement the following recommendations:* Update the visitor COVID-19 screening tool to include a comprehensive list of COVID-19 symptoms;* Provide an onsite area for disinfection and storage of PPE that is within close proximity to the screening area;* Provide a foot pedal trash receptacle for staff to discard single use, medical grade face masks or procedural masks; * Discontinue the re-use of medical grade facemasks and only implement re-use strategies for N-95 respirators and only when there is an anticipated shortage of N-95 respirators during a COVID-19 outbreak; * Discontinue the use of safety glasses within the community, while interacting with visitors and providing resident care and only use approved eye protection which includes, goggles with a head strap and face shields that cover the entire facemask; and* Wear medical grade face masks over both nose and mouth.The need to ensure the facility consistently followed infection control practices, related to COVID-19 prevention, was discussed with Staff 1. She acknowledged the findings.

2. Resident 1 was admitted to the facility in December 2020 with diagnoses including dementia.Review of the resident's progress notes, incident reports and investigations for 12/8/20 through 2/1/21 revealed the following:a. A progress note dated 1/6/21 read, "resident hit another resident with cane." An incident report was requested from Staff 2 (MC Administrator) on 2/1/21. An interview on 2/1/21 with Staff 2 confirmed the incident had not been reported to the local SPD office. b. A progress note dated 1/21/21, Resident 1 was quoted to state, "That man hit me," after an incident when the resident, "pulled [a staff member's] hair and started hitting [staff] with a cane." An interview on 2/3/21 with Staff 1 (ED) and Staff 2 confirmed the accusation had not been thoroughly investigated to reasonably rule out abuse. c. An incident report, dated 1/25/21 stated Resident 1 was in an unsampled resident's room and had thrown water on the other resident. An interview on 2/3/21 with Staff 2 revealed the incident was not reported to the local SPD office. d. A progress note dated 1/25/21 stated a staff member "heard a loud slam and responded and found resident laying on [his/her] left side." The note goes on to report, "Resident [complained] of [right hip pain] when staff tried getting [him/her] up." There was no documented evidence a thorough investigation was completed that included ruling out abuse and/or neglect based on service planned needs.The need to thoroughly investigate incidents and reporting incidents to the local SPD office when abuse and/or neglect could not be ruled out was discussed with Staff 1, Staff 2 and Staff 3 (Regional RN) on 2/3/21. They acknowledged the findings. Staff 2 was asked to report the 1/6/21 and 1/25/21 incidents to the local SPD office. He provided confirmation of the reports prior to survey exit.
Based on interview and record review, it was determined the facility failed to ensure investigations of all incidents were thorough and complete and all incidents of suspected abuse or neglect and injuries of unknown cause were reported to the local SPD office in a timely manner for 2 of 2 sampled residents (#s 1 and 2) reviewed with injuries of unknown cause or altercations. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in August 2019 with diagnoses including dementia.Review of the resident's progress notes and physician communications from 11/4/20 through 01/29/21 noted on 1/10/21, a caregiver discovered a bruise of unknown origin on Resident 2's inner thigh. The incident was noted but there was no documentation the incident was investigated or reported to the local SPD office. In an interview with Staff 2 (MC Administrator), he acknowledged an incident report had not been completed to rule out abuse nor was the incident reported. The need to investigate and report incidents to the local SPD office when needed, to rule out abuse and neglect was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Regional RN) on 2/3/21. They acknowledged the findings. Staff 2 was asked to report the incidents to the local SPD office and provided confirmation of the reports prior to survey exit.


Based on interview and record review, it was determined the facility failed to immediately report incidents of abuse to the local SPD office for 1 of 1 sampled resident (# 4) who was involved in an resident to resident altercation. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted to the facility in July 2020 with diagnoses including dementia.Review of the resident's progress notes and incident reports for 4/1/21 through 4/20/21 revealed the following:A progress note dated 4/4/21 revealed, "[a resident] got upset and slap [the other resident.]" An incident report was requested and provided by Staff 1 (Executive Director) on 4/20/21. The incident report did not indicate the altercation had been reported to the local SPD office. During an interview on 4/20/21 at 2:14 pm, Staff 2 (MCC Administrator) stated he thought the incident had been reported to the local SPD office, but was unable to locate the documentation. The need to immediately report incidents of abuse to the local SPD office was discussed with Staff 2 on 4/21/21. He acknowledged the findings. Staff 2 was asked to report the 4/4/21 incident to the local SPD office. Prior to survey exit, Staff 2 provided confirmation that the incident was reported to SPD.C 231 SS=EOAR 411-054-0028(1-3) Abuse Reporting and Investigation1. Immediate actions taken to correct the rule violation include reporting the Resident to Resident altercation incident involving Resident #4 to SPD prior to survey exit on 4/21/21. 2. The system will be corrected so the violation will not happen again by ensuring all incident are investigated timely. If abuse or neglect can not be ruled out, or for incidents such as Resident to Resident altercations, the community will follow the Abuse reporting requirements outlined in the abuse reporting and investigating guide for providers for Oregon. This document has been reviewed with the department management team, and will be reviewed at the next all staff meeting to ensure 100% of staff understand investigation and APS/SPD reporting requirements. 3. Incident reports are reviewed with daily stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan. Community team will verify the correct process for self reporting to APS has taken place for all reportable incidents prior to closing out the incident investigation. In addition to initiating an incident report, Staff who suspect or have witnessed abuse and/or neglect should contact the Memory Care Administrator immediately for direction on follow up. 4. The Memory Care Administrator, Executive Director or Designee will be responsible to see that the corrections are being completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the kitchenettes were clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. During a tour of the kitchenette on level one of the memory care unit on 2/2/21 at 11:30 am, it was determined the following areas were in need of cleaning or repair:* The cabinet door to the garbage can was broken; * Brown and green sediment was observed on the floor in front of the food warmers;* The floor to the right of the dishwasher had dirt and food sediment accumulated; and* The drains in the floor located next to and across from the dishwasher had brown sediment. 2. During a tour of the kitchenette on level two of the memory care unit on 2/2/21 at 11:40 am, it was determined the following areas were in need of cleaning or repair:* The drawer to the left of the warmers was broken and missing a cover;* The drains in the floor located next to and across from the dishwasher had brown sediment;* Cottage cheese was in the refrigerator opened with no date; and* A cup of chocolate milk was in the refrigerator uncovered and with no date.The areas needing cleaning and repair were discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 4 (Executive Chef) on 2/3/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components for 1 of 1 sampled resident (#1) reviewed as a recent move in. Findings include, but are not limited to:Resident 1 was admitted to the facility in December 2020.Resident 1's move-in evaluation failed to address: * List of medications and PRN use; * History of mental health treatment; * Cognition including decision making abilities; * Dental status; * Independent activity of daily living including transportation;* Non-pharmaceutical pain interventions;* Recent losses; and* History of dehydration. The need to ensure new move in evaluations included all required components was discussed with Staff 1 (ED), Staff 2 (MC Administrator), and Staff 3 (Regional RN) on 2/3/2020. They acknowledged the new move in evaluation did not include all of the required elements.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of the residents' current care needs and provided clear direction to staff regarding the delivery of services for 1 of 2 sampled residents (# 1) whose service plans were reviewed. Findings include, but are not limited to:Resident 1's 1/26/21 service plan and temporary service plans were reviewed and were not reflective of the resident's current needs and/or did not provide clear direction to staff relating to the following care areas:* Triggers relating to behaviors; * Interventions for the prevention of altercations with other residents; and * Fall interventions.The need to ensure service plans were reflective and gave clear direction to care giving staff was discussed on 2/3/21 with Staff 1 (ED) and Staff 2 (MC Administrator). They acknowledged the findings.

2. Resident 1 was admitted to the facility in December 2020. A review of the resident's clinical records, 12/8/20 through 2/1/21, indicated the following changes of condition had not been reviewed by the facility and/or monitored to resolution: * 12/17/20 Fall; * 12/18/20 Fall; * Resident to resident altercations on 1/6/21 and 1/25/21; * 1/24/21 Fall; and* Multiple medication and treatment refusals in January 2021. There was no documented evidence the facility had consistently evaluated the resident, determined actions or interventions specific to each change of condition, and/or monitored the above documented changes of condition to resolution. The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and the changes were monitored through resolution was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 3 (Regional RN) on 02/3/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure actions and interventions were consistently developed and shared with staff for short term changes, interventions were monitored for effectiveness, and/or failed to consistently monitor changes through to resolution for 2 of 2 sampled residents (#s 1 and 2) who had changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in August 2019. A review of the resident's clinical records, 11/4/20 through 1/29/21, indicated the following changes of condition had not been reviewed by the facility and/or monitored to resolution: * 11/4/20 Resident to resident altercation; * 11/10/20 Bruise to right arm;* 11/20/20 Change in transfer status;* 12/18/20 Missed medication;* 1/3/21 Urinary tract infection; and* 1/5/21 Return from hospital with medication changes. There was no documented evidence the facility had consistently evaluated the resident, determined actions or interventions specific to each change of condition, and/or monitored the above documented changes of condition to resolution. In an interview with Staff 2 (MC Administrator) on 2/3/21, he acknowledged there were inconsistencies in providing written instructions to staff for short term changes of condition as well as documenting and monitoring until resolution. The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was updated was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Regional RN) on 02/3/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside service providers in order to ensure the continuity of care, for 1 of 1 sampled resident (# 2) who received outside services. Findings include, but are not limited to:a. Resident 2 was referred to HH Speech on 11/28/20 for a swallowing evaluation. There was no documented evidence the facility coordinated with speech therapy to initiate service. b. Resident 2 received HHPT services for weakness and change to transfer status on 12/7/20. There was no follow up instructions to staff regarding HHPT recommendations for strengthening exercises. In an interview with Staff 2 (Administrator) on 2/3/21 at 12:05 pm, he agreed there was no follow up from the facility with outside service providers to ensure HH Speech was started or that HHPT recommendations were shared with staff. The need to coordinate care with on and off-site health care providers was discussed with Staff 1 (Executive Director, Staff 2 and Staff 3 (Regional RN) on 2/3/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to coordinate with outside service providers to initiate health services ordered by a physician, and to ensure outside providers left written records of services provided and any clinical information necessary for facility staff to provide supplemental care for 1 of 2 sampled residents (# 3) who received outside services. This is a repeat citation. Findings include, but are not limited to:Review of Resident 3's clinical records indicated s/he received an order for PT/OT services on 3/5/21. There was no documented evidence of any outside provider visits until 4/19/21. The delay constituted a failure to coordinate care necessary to support the residents health needs.On 4/21/21, the need to coordinate with outside providers to initiate health services ordered by a physician, and to ensure outside providers left written records of visits and any necessary information for staff to provide supplemental care was discussed with Staff 1 (Executive Director) and Staff 2 (MCC Administrator). They both acknowledged the findings.

2. Resident 1 was admitted to the facility December 2020 with diagnoses including dementia. January 1 through February 1, 2021 MARs and current physician orders were reviewed.The resident MARs reflected one 500 mg tablet of acetaminophen (for pain) to be administered PRN every six hours. There was no documented evidence in the resident's record of a signed physician order. Resident 1 had two PRN pain medications, acetaminophen and ibuprofen, with parameters directing staff to administer the ibuprofen first and the acetaminophen second. Staff administered the acetaminophen first on 1/26/21. The need to ensure physician orders were in the resident's record and were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 3 (Regional RN) on 2/3/21. No additional information was received.
Based on interview and record review, it was determined the facility failed to ensure physicians orders were obtained and carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Review of Resident 2's 1/6/21 and 1/8/21 signed physician orders, 11/4/20 through 1/29/21 progress notes and physician faxes showed the facility did not obtain physician's orders to change Resident 2's diet.A progress note dated 12/14/20, stated the RN would contact Resident 2's physician regarding changing his/her diet from regular to pureed with honey thickened liquids. A fax was sent to the physician on 12/14/20 with this request. The RN changed resident's diet order effective 12/14/20. There was no indication the physician was consulted before the resident's diet was changed.The prescriber sent an order to facility approving the diet change on 1/8/21.The need to ensure all medications and treatments had prescriber's orders prior to administering was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 3 (Regional RN) on 2/3/21. The staff acknowledged the findings.

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 (#1) who had documented medication and treatment refusals. Findings include, but are not limited to:Resident 1's January 1 through February 1, 2021 MARs were reviewed during the survey. The resident's record reflected multiple medication and treatment refusals. There was no documented evidence the facility notified the prescriber each time the resident refused to consent to the orders. The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 3 (Regional RN) on 2/3/21. No additional information was received.

2. Resident 1's 1/1/21 through 2/1/21 MARs were reviewed.Resident 1's MARs revealed two PRN bowel medications lacking specific parameters for use. The need to ensure there were clear parameters to instruct unlicensed staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 3 (Regional RN) on 2/3/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure that MARs/TARs contained resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2's 1/1/21 through 2/1/21 MARs were reviewed.Resident 2's MAR revealed two PRN pain medications lacking specific indications and parameters for use. In an interview with Staff 8 (MT) at 11:20 am on 2/3/21, she acknowledged the lack of parameters for PRN pain medications.The need to ensure there were clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 3 (Regional RN) on 2/3/21. They acknowledged the MARs were not accurate.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. Findings include, but are not limited to:Fire and life safety records for October 2020-January 2021 were reviewed and lacked the following components:*Documented evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;*Fire drills conducted and recorded every other month at different times of the day;*Escape route used; *Problems encountered;*Evacuation time period needed; and*Number of occupants evacuated.The need to ensure the facility was in compliance with all required fire drill components was discussed with Staff 1 (ED) and Staff 2 (MC Administrator) on 2/3/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide evidence that alternating evacuation routes were used during fire drills, residents were instructed about the facility's fire and life safety procedures at least annually, and the facility was able to meet the applicable evacuation levels. Findings include, but are not limited to:Fire and life safety records for October 2020 through January 2021, reviewed on 2/3/21, lacked the following components:*Alternating evacuation routes during fire drills; and *Evacuation levels. Fire and life safety training and documentation was discussed with Staff 1 (ED) and Staff 2 (MC Administrator) on 2/3/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all doors that exited to the courtyards were equipped with operational alarming devices or other acceptable systems to alert staff when residents exited into the courtyard. Findings include, but are not limited to:A tour of the facility, 2/1/21 at 2:15 pm, revealed the exit door alarm on level two of memory care to the courtyard was inoperable due to a broken sensor. During a walk through of the environment, 2/1/21 at 2:25 pm, Staff 2 (MC Administrator) verified the exit door alarm was not functioning and 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 158, C 160, C 231, C 240, C 420, C 422 and C 555.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 231.

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

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 5 and 12) had completed all required pre-service training prior to beginning their job duties. Findings include, but are not limited to:Review of training records for newly hired Staff 14 (CG), hired 12/11/20, and Staff 8 (MT), hired 7/11/19, identified the following deficiencies:* Staff 14 failed to have documented evidence of completing all pre-service orientation and pre-service training prior to providing care and services independently and documentation of competency demonstrated within 30 days of hire; and* Staff 8 failed to have documented evidence of completing pre-service training prior to independently providing care and services and documentation of competency demonstrated within 30 days of hire. On 2/2/21, the need to ensure the facility had systems and processes in place to ensure all pre-service training was completed and documented prior to working independently and documentation of observed competencies were completed within 30 days of hire was discussed with Staff 1 (ED) and Staff 15 (Business Office Manager). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure health care services were consistently provided. Findings include, but are not limited to:Refer to C 252, C 260, C 270, C 290, C 303, C 305 and C 310.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 231.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 231.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 231.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 231.