The Springs at Happy Valley

The findings of the initial licensure survey, conducted 02/05/24 through 02/07/24, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:* OAR 411-054-0090 (1-2) Fire and Life Safety. The facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the first re-visit to the initial licensure survey on 02/07/24, conducted 05/29/24 through 05/30/24, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second revisit to the re-licensure survey of 02/07/24, conducted 08/14/24 through 08/15/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day




The findings of the third revisit to the re-licensure survey of 02/07/24, conducted 09/26/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and controlled substance documentation discrepancies were promptly investigated, all required elements were addressed in investigations, and incidents were reported to the local SPD office or the local AAA office when abuse and/or neglect could not reasonably be ruled out for 1 of 2 sampled residents (# 2), whose records were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 03/2023 with diagnoses including hereditary spastic paraplegia and hypothyroidism.The resident's 11/16/23 service plan, 11/09/23 through 01/30/24 progress notes, incident reports and investigations, 01/01/24 through 02/05/24 MARs, and Controlled Substance Distribution logs were reviewed, and staff were interviewed.a. The following incidents were identified:* A 12/08/23 progress notes stated the resident "had a skin tear on leg requiring bandage. Cause unknown ..."On 02/06/24 Staff 2 (Health Services Administrator) was asked for an investigation related to the 12/08/23 injury of unknown cause. She provided an incident report related to bleeding from a wound on the resident's left big toe, which occurred on 12/07/23. The reported stated, "Resident doesn't know what happened or why [s/he] was bleeding." The investigation attached to the incident report referred to a "skin tear on leg requiring bandage. Cause unknown ..." The investigation indicated abuse and/or neglect had been ruled out related to "service plan followed, safety check clear."In an interview on 02/06/24, Staff 2 reported the 12/08/23 progress note regarding a skin tear on the resident's leg was a "mistake" and didn't happen. She was unable to provide any documentation to support this statement. Without any documentation to support Staff 2's claim that the 12/08/23 incident did not occur, there appeared to have been two separate injuries of unknown cause, neither of which was reported to the local SPD office.On 02/07/24 Staff 2 was requested to report both the 12/07/23 and the 12/08/23 incidents as injuries of unknown cause to the local SPD office. Confirmation of the reports was received prior to survey exit.The need to promptly investigate all injuries of unknown cause and report them to the local SPD office if abuse and/or neglect could not be reasonably ruled out was discussed with Staff 1 (Executive Director), Staff 2 and Staff 6 (Director of Health Services, RN) on 02/07/24. They acknowledged the findings.b. On 02/07/24 the Controlled Substance Distribution Log and the resident's 01/01/24 through 02/05/24 MARs and medication cards were reviewed and revealed the following:* An entry in the Controlled Substance Distribution Log indicated at 4:46 am on 01/07/24 staff recorded one tablet of Endocet (a narcotic pain reliever) was removed from the medication card and 92 tablets remained. The next entry in the Controlled Substance Distribution Log, dated 01/07/24 at 1:48 pm, indicates one tablet was removed from the medication card; however, the number of tablets remaining was documented as 90, which was two less than remained after the 4:46 am distribution was recorded as 92 tablets remaining.* An entry in the Controlled Substance Distribution Log indicated at 1725 (5:25 pm) on 01/24/24 staff removed one tablet of Endocet from the medication card and 39 tablets remained. The next entry in the Controlled Substance Distribution Log, dated 01/24/24 at 2145 (9:45 pm), indicates one tablet was removed from the medication card; however, the number of tablets remaining was documented as 37, which was two less than remained after the 5:25 pm distribution was recorded as 39 tablets remaining.There was no documented evidence those discrepancies, which constituted abuse via potential narcotic diversion and was financial exploitation, were discovered or investigated by the facility.The facility was requested to report these incidents to the local SPD office. Confirmation of the reports was received on 02/07/24 at 7:50 pm.The need to ensure controlled substances were accounted for accurately and in a timely manner, and any discrepancies promptly investigated and reported, if necessary, was discussed with Staff 2 (Health Services Administrator) and Staff 6 (Director of Health Services, RN) on 02/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure evaluations described resident's physical health status, mental status and the environmental factors that help the resident function at their optimal level, and were relevant to the current needs and condition of the resident, for 3 of 5 sampled residents (#s 2, 3, and 5) whose evaluations were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 08/2023 with diagnoses including right above-the-knee amputation and chronic obstructive pulmonary disease.The resident's 01/09/24 quarterly evaluation was reviewed and interviews were conducted. Multiple areas of the evaluation did not describe Resident 3's physical and mental status, environmental factors which helped the resident function at his/her optimal level, and/or were not relevant to the resident's current condition, including:* Escort assistance to activities;* Hearing devices;* Alcohol use and impact on care needs;* Amputation including complications and history;* Pain, including location, how resident expresses pain, and non-pharmaceutical interventions;* Depression;* Verbal aggression;* Decision-making skills including frequency of call light use;* Preferred meal and wake times;* Swallowing difficulty;* Transfer, bathing, dressing, and evacuation assistance;* Toileting assistance and location of toileting care; and* Presence of weakness.The need to ensure evaluations described resident's physical health status, mental status, and the environmental factors that helped the resident function at their optimal level, and were relevant to the current needs and condition of the resident was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 03/2023 with diagnoses including hereditary spastic paraplegia and hypothyroidism.The resident's 11/14/23 quarterly evaluation was reviewed, and interviews were conducted. Multiple areas of the evaluation did not have relevant information related to the resident's condition and specific needs, including:* Diagnosis of paraplegia;* Use of a slide board for all transfers;* Repositioning for pain management; and* A skin issue on the resident's right gluteal fold.The need for evaluations to identify the resident's physical health status and be relevant to the needs and current condition of the resident was discussed with Staff 2 (Health Services Administrator), Staff 6 (Director of Health Services, RN), Staff 7 (Assistant Director of Health Services, RN), Staff 10 (Resident Services Coordinator), and Staff 11 (Resident Services Coordinator) on 02/06/24, and with Staff 1 (ED) and Staff 2 on 02/07/24. They acknowledged the findings.3. Resident 5 was admitted to the facility in 02/2023 with diagnoses including peripheral vascular disease and polymyalgia rheumatica.The resident's most recent quarterly evaluation, dated 11/09/23, was reviewed, and interviews were conducted. Multiple areas of the evaluation did not have relevant information related to the resident's condition and specific needs, including:* Scheduled wound care treatments;* Pain management;* Use of a Pure Wick external catheter;* Dressing assistance required;* History of dehydration;* Mobility assistance;* Evacuation assistance required; and* Left leg amputation.The need for evaluations to identify the resident's physical health status and be relevant to the needs and current condition of the resident was discussed with Staff 2 (Health Services Administrator), Staff 6 (Director of Health Services, RN), Staff 7 (Assistant Director of Health Services, RN), Staff 10 (Resident Services Coordinator), and Staff 11 (Resident Services Coordinator) on 02/06/24, and with Staff 1 (ED) and Staff 2 on 02/07/24. 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 and provided clear direction for staff, for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 08/2023 with diagnoses including anxiety and shoulder fracture.Observations of the resident, interviews with staff, and review of the resident's service plan, dated 12/05/23, and progress notes, dated 10/01/23 to 01/19/24, were completed. Staff indicated the resident required some assistance with bathing and dressing since s/he had injured his/her arm. The resident could make his/her needs known and would call for additional staff assistance as needed. The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:* Right eye vision impairment;* Ileostomy assistance needs;* Self-administration of medications and what to watch for;* Dressing and shower assistance;* Left shoulder injury and immobility;* Tearfulness/sadness about pet; and* Walker, wheelchair, and cane use and when each were used.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Health Services Administrator), Staff 6 (Director of Health Services/RN), and Staff 10 and 11 (Resident Services Coordinators) and Staff 12 (Regional RN) on 02/06/24. The staff acknowledged the findings.2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including leg swelling and arthritis.Observations of the resident, interviews with staff, and review of the resident's service plan, dated 11/08/23, and progress notes, dated 11/13/23 to 02/03/24, were completed. Staff indicated the resident required consistent assistance with bathing and sometimes assistance with dressing and transfers. The resident, additionally, needed assistance with socks, shoes, and compression stockings. The resident could make his/her needs known and direct his/her own care. The resident would use a call pendant to request additional assistance as needed. The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:* Evacuation assistance;* Urinal use, transfer assistance, and pet care;* Compression stockings and assistance with lower extremities;* Male only caregivers for bathing and personal care;* CPAP cleaning and Oxygen use;* Walker versus wheelchair use; and* Significant edema to lower extremities with drainage and elevating legs.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Health Services Administrator), Staff 6 (Director of Health Services/RN), and Staff 10 and 11 (Resident Services Coordinators) and Staff 12 (Regional RN) on 02/06/24. The staff acknowledged the findings.
3. Resident 3 was admitted to the facility in 08/2023 with diagnoses including right above-the-knee amputation and chronic obstructive pulmonary disease. Observations of the resident, interviews with staff and the resident, and review of the resident's service plan, dated 01/09/24, and progress notes, dated 11/09/23 through 01/30/24, were completed. The service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:* Vision and hearing loss;* Alcohol use;* Depression and non-pharmaceutical interventions;* Above-the-knee amputation;* Skin condition;* Pain management, including location, how resident expressed pain, non-pharmaceutical interventions, and history of refusing pharmaceutical pain interventions;* Frequency of call light use;* Verbal aggression;* Preferred meal times and wake times;* Swallowing difficulty;* Level of assist for bathing, dressing, toileting, transfers, and evacuation;* Injuries while transferring; and* Coordination of medical appointments.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.
4. Resident 2 was admitted to the facility in 03/2023 with diagnoses including hereditary spastic paraplegia and hypothyroidism.Interviews with staff and the resident and review of the resident's service plan, updated 11/16/23, and progress notes, dated 11/09/23 through 01/30/24, were completed. The service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:* Diagnosis of paraplegia;* Wound care management;* Use of slide board for all transfers; and* Non-pharmaceutical pain interventions.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Health Services Administrator), Staff 6 (Director of Health Services, RN), Staff 7 (Assistant Director of Health Services, RN), Staff 10 (Resident Services Coordinator), and Staff 11 (Resident Services Coordinator) on 02/06/24, and with Staff 1 (ED) and Staff 2 on 02/07/24. They acknowledged the findings.5. Resident 5 was admitted to the facility in 02/2023 with diagnoses including peripheral vascular disease and polymyalgia rheumatica.Interviews with staff and the resident and review of the resident's service plan, updated 11/18/23, and progress notes, dated 11/10/23 through 02/05/24, were completed. The service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:* Assistance needed with dressing;* Wound care treatments;* Non-pharmaceutical pain interventions;* Shower assistance required; * Use of a Pure-Wick external catheter;* Left leg amputation; and* Significant weight gain.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Health Services Administrator), Staff 6 (Director of Health Services, RN), Staff 7 (Assistant Director of Health Services, RN), Staff 10 (Resident Services Coordinator), and Staff 11 (Resident Services Coordinator) on 02/06/24, and with Staff 1 (ED) and Staff 2 on 02/07/24. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 08/2023 with diagnoses including shoulder fracture. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 12/05/23, and progress notes, dated 10/01/23 to 01/19/24, were completed.The resident experienced short-term changes without documented monitoring at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas:* Left shoulder fracture;* Left shoulder surgery, surgical wound, and dressing; and* Arm immobilization, sling use, and hand checks.The need to ensure short-term changes were monitored to resolution and resident-specific direction was provided to staff was discussed with Staff 2 (Health Services Administrator), Staff 6 (Director of Health Services/RN), and Staff 10 and 11 (Resident Services Coordinators) and Staff 12 (Regional RN) on 02/06/24. The staff acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, instructions or interventions were communicated to staff on all shifts and progress was documented weekly until resolution for 3 of 5 sampled residents (#s 1, 2, and 3). The facility failed to refer to the facility nurse, document the change, and update the service plan as needed for 1 of 5 sampled residents who experienced a significant change of condition (#3). Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 08/2023 with diagnoses including right above-the-knee amputation and chronic obstructive pulmonary disease.The resident's clinical record, including progress notes and incident reports dated 11/09/23 through 01/30/24, was reviewed, the resident was observed, and interviews with staff were conducted.The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:* Skin tear to left lower leg;* Laceration to left lower leg;* Frequent reports of refusing up to 10 medications due to feeling sick;* Vomiting; and* Refusals of care.The following significant changes of condition lacked documentation that the resident was evaluated, the change was referred to the nurse, and the service plan was updated as needed:* 12/06/23: severe weight loss; and* 01/23/24: severe weight gain.The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and monitored through resolution, and the need to ensure there was documentation significant changes of condition were evaluated, referred to the nurse and the service plan was updated as needed, was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 03/2023 with diagnoses including hereditary spastic paraplegia and hypothyroidism.The resident's clinical record, including progress notes dated 11/09/23 through 01/30/24 and incident reports, was reviewed and interviews with staff were conducted. The following was identified:* A progress note dated 12/08/23 indicated the resident "had a skin tear on leg requiring bandage; and* An incident reported dated 12/07/23 reported staff discovered blood on the carpet in the resident's apartment and determined the resident's left toe wound was bleeding.There was no documented evidence staff determined and documented actions or interventions for the injuries, communicated actions or interventions to staff on all shifts, or monitored the injuries with at least weekly progress noted until the conditions resolved.The need to ensure actions or interventions were determined and documented for short-term changes of condition, determined actions or interventions were communicated to staff on all shifts, and changes were monitored with weekly progress noted through resolution was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition and documented findings, resident status and interventions made as a result of the assessment for 1 of 3 sampled residents (#3) who experienced significant changes of condition. Findings include, but are not limited to:Resident 3 was admitted to the facility in 08/2023 with diagnoses including right above-the-knee amputation and chronic obstructive pulmonary disease.A review of the resident's clinical record, including the current service plan, dated 01/09/24, progress notes, dated 11/09/23 through 01/30/24, and weight records from 08/01/23 through 02/01/24, was completed, and staff were interviewed. The following was identified:a. Review of weight records revealed the following: * An 11.3% weight loss in 90 days, which occurred between 09/06/23 (86.2 pounds) and 12/06/23 (76.4 pounds); and* A 9.1% weight gain in 30 days, which occurred between 12/06/23 (76.4 pounds) and 01/23/24 (83.4 pounds).The surveyor requested the facility weigh the resident, and s/he weighed 80.2 pounds.During an interview on 02/06/24, Staff 6 (Director of Health Services, RN) stated she became aware of the weight loss on 12/06/23 and requested the resident be re-weighed, but this did not occur. There was no documentation that the resident refused to have him/herself weighed. She acknowledged that no RN assessment was completed. There was no documented evidence interventions had been put in place or the weight change had been monitored.On 02/06/24, Staff 7 (Assistance Health Services Director, RN) stated the severe weight gain on 01/23/24 did not flag in their system so no assessment was completed.Staff 7 completed an RN assessment on 02/07/24 and updated the resident's service plan. The need to ensure an RN assessed all significant changes of condition including findings, resident status, and interventions made as a result of the assessment in a timely manner was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 1 of 2 sampled residents (#7) who had a significant change of condition. This is a repeat citation. Findings include, but are not limited to: Resident 7 was admitted to the facility in 10/2023 with diagnoses including non-Hodgkin lymphoma and chronic atrial fibrillation.Review of the resident's 04/07/24 through 05/29/24 clinical record showed the following:* Resident 7 was seen by a home health RN on 04/25/24. An outside provider note indicated a stage 2 pressure sore was present on resident's buttocks.* On 04/29/24 a temporary service plan was written directing staff to monitor the resident's stage 2 pressure sore. * Resident 7 was seen by Staff 36 (RN) on 05/03/24, eight days after the facility was made aware of this significant change of condition. The need to ensure an RN assessed all significant changes of condition a timely manner was discussed with Staff 2 (Health Services Administrator) and Staff 35 (RN Quality Support) on 05/30/24. They acknowledged the findings.



Based on observation, interview and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented the resident status and interventions made as a result of the assessment for 1 of 2 sampled residents (# 14) who had a significant change of condition. This is a repeat citation. Findings include, but are not limited to:Resident 14 was admitted to the facility in 04/2024 with diagnoses including alcoholic cirrhosis of liver with ascites.During the acuity interview on 08/14/24 at 2:00 pm, Resident 14 was identified to have experienced weight loss.Weight records dated 04/02/24 through 07/23/24 and a significant weight change assessment dated 08/06/24 were reviewed and the following was identified: * On 04/02/24 Resident 14's weight was 140 pounds; and* On 07/23/24 Resident 14's weight was 118 pounds.The resident experienced a weight loss of 22 pounds, or 15.8% of his/her total body weight, in three months. This was considered a severe weight loss and a significant change of condition for which an RN assessment was required. A facility RN assessment was not completed until 08/06/24, 14 days after the facility was made aware of this significant change of condition.During an interview at 11:30 pm on 8/15/24, Staff 36 (Regional RN) acknowledged the RN assessment was not completed timely and lacked documentation of the resident status and interventions.Observations of the resident on 8/15/24 showed the resident in and out of his/her apartment. The resident could take himself/herself to the dining room and back up to his/her apartment. Resident 14 indicated s/he sometimes ate in the dining room and sometimes in his/her . The resident had food and fluids in the apartment, as well as the food provided by the facility. The resident stated s/he had a good appetite and expressed concern regarding his/her weight loss, and indicated s/he wanted to gain weight. The facility failed to ensure an RN completed a timely assessment that documented the resident status and interventions made as a result of the assessment.The need to ensure all significant changes of condition were assessed timely by an RN with the resident status and interventions documented was discussed with Staff 36 on 08/15/24. He acknowledged the findings.1. A TSP was reviewed, and significant change of condition was reviewed for completion. 2. If a significant change of condition is noted, the evaluation will immediately be triggered and data will be added by health services staff (licensed practical nurse, resident care coordinator, administrator), then the registered nurse will be notified of significant change of condition, and the evaluation will be reviewed and completed within 48 hours of discovery.3. Significant change of conditions and their critera (weight loss, weight gain, hospice status, fractures, etc. per OAR will be monitored daily by licensed practical nurse, registered nurse, administrator or designee.4. The registered nurse or designee will be responsible assure compliance.

2. Resident 7 was admitted to the facility in 10/2023 with diagnoses including chronic atrial fibrillation and irritable bowel syndrome.The resident's 05/01/24 through 05/29/24 MARs, physician's orders, and 04/07/24 through 05/29/24 progress notes were reviewed. Resident 7 had orders for the following treatment:* Barrier cream to bilateral buttocks two times daily for a bed sore.The MAR showed the MTs documented they applied the treatment to the resident, however, the resident's progress notes indicated and staff documented the treatment was completed by caregiver on 21 occasions during the review period. The need to ensure staff who administered treatment was documented by the same person was discussed with Staff 2 (Health Service Administrator) and Staff 35 (RN Quality Support) on 05/30/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the staff who administered medication observed the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication stated otherwise for 2 of 2 sampled residents (#s 6 and 7) whose medications were administered by the facility. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 11/2023 with diagnoses including anxiety and volvulus. The resident's 04/07/24 through 05/29/24 MARs, physician's orders, Outside Provider Forms, and progress notes were reviewed and staff were interviewed. Resident 6 had orders for the following medications: * Triamcinolone (for skin diseases, allergies, and rheumatic disorders) twice a week, after showers; and * Estradiol (for estrogen replacement) three times weekly. Per progress notes, MTs documented the medications were either given to the resident to "self administer", to a facility CG to administer, or to a hospice shower aide to administer. The MT's documented Resident 6 received triamcinolone six times and Estradiol seven times as administered by a CG or a hospice shower aide. On a 05/17/24 Outside Provider Form, a hospice RN wrote that she "delegated" the triamcinolone cream application to the shower aide. Facility staff initialed they administered the cream on 05/26/24. On 05/30/24, Staff 2 (Health Services Administrator) verified Resident 6 refused to be showered by facility staff but accepted showers from the hospices shower aides. The need to ensure staff who administered medications observed the resident take the medications was discussed with Staff 2 and Staff 35 (RN Quality Support) on 05/30/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system for tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose PRN narcotic medication was reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 03/2023 with diagnoses including hereditary spastic paraplegia.On 02/07/24, the resident's 01/01/24 through 02/05/24 MARs were reviewed and compared to the Controlled Substance Distribution Log and medication cards for his/her PRN Endocet (a narcotic pain reliever). The following discrepancies were identified between the Controlled Substance Distribution Log and the MARs:* An entry in the log for administration of two tablets of Endocet on 01/15/24 at 17:30 (5:30 pm) was not on the MAR.* On 01/22/24 staff documented two tabs of Endocet were removed from the medication card at 2100 (9:00 pm). This administration was not documented on the MAR.* Staff documented they removed two tablets of Endocet from the medication card on 01/28/24 at 2051 (8:51 pm). There was no documentation on the MAR of staff administering the medication to the resident on that date or time.* On two occasions, 01/07/24 and 01/24/24, staff documented removing one tablet of Endocet from the medication card but entered the number of tablets remaining as two less than the previous log entry.On 02/07/24 at approximately 3:55 pm, Staff 6 (Health Services Director, RN) acknowledged the discrepancies and stated she would investigate the discrepancies to determine what happened.The need for the MAR and the Controlled Substance Distribution Log to match was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system for tracking controlled substances administered by the facility for 1 of 1 sampled resident (#10) whose PRN narcotic medication was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 10 moved into the facility in 05/2023 with diagnoses including dementia.During the acuity interview on 05/29/24, the resident was identified to receive controlled substances for pain as needed.On 05/29/24 and 05/30/24, the resident's 04/22/24 through 05/29/24 MARs were reviewed and compared to the Controlled Substance Distribution Log and medication cards for his/her PRN hydrocodone/acetaminophen 5-325 mg (a narcotic pain reliever). The following discrepancies were identified between the Controlled Substance Distribution Log and the MARs:* An entry in the log for administration of hydrocodone/acetaminophen on 04/22/24 at 5:30 am was not documented on the MAR.* On 04/23/24 staff documented one table of hydrocodone/acetaminophen was removed from the medication card at 10:36 am. This administration was not documented on the MAR.* Staff documented they removed one tablet of hydrocodone/acetaminophen from the medication card on 04/28/24 at 4:24 pm. There was no documentation on the MAR of staff administering the medication to the resident on that date or time.The need for the resident's MAR and the Controlled Substance Distribution Log to match was discussed with Staff 2 (Health Services Administrator) on 05/30/24. She acknowledged the discrepancies between the log and the MAR.

Based on interview and record review, it was determined the facility failed to ensure signed physician orders for all medications and treatments the facility was responsible for administering were documented in the resident's facility record for 2 of 5 sampled residents (#s 2 and 5) whose records were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 03/2023 with diagnoses including hereditary spastic paraplegia and hypothyroidism. The resident's 01/01/24 through 02/05/24 MARs and physician orders were reviewed. The following was identified:* The physician orders in the resident's record were signed on 02/23/23; and* The orders the physician signed stated the orders were "to be in effect for the next 180 days."A comparison between the orders signed in 02/2023 and the medications on the 01/01/24 through 02/05/24 MARs revealed there were multiple medications which were either not on the 02/2023 orders or were different than the signed orders.In an interview on 02/06/24 at 4:20 pm, Staff 2 (Health Services Administrator) and Staff 6 (Health Services Director, RN) indicated they had requested signed orders from the pharmacy. The need to have signed physician orders in the resident's record was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.2. Resident 5 was admitted to the facility in 02/2023 with diagnoses including peripheral vascular disease.During the acuity interview on 02/05/24, Resident 5 was identified to have wounds on his/her lower right leg. Staff 6 (Health Services Director, RN) reported the facility provided wound care treatments one time per week, on Fridays, and the resident went out to a wound clinic for treatment every Tuesday.A review of the resident's facility record, including progress notes dated 11/10/23 through 02/05/24, the 01/01/24 through 02/05/24 MARs, and physician orders revealed the following:* The physician orders in the resident's record were signed on 05/04/23 and did not include wound care orders specific to the resident's current wounds;* A progress note dated 12/15/23, written by Staff 7 (Assistance Health Services Director, RN), indicated the resident had received new written orders for wound treatment;* There were no wound care orders in the resident's chart pertaining to his/her current wounds on the right leg; and* The 01/01/24 through 02/05/24 MARs included documentation of wound treatments being administered weekly.In an interview on 02/06/24 at 4:20 pm, Staff 6 (Health Services Director, RN) reported she had requested current wound treatment orders from the resident's wound clinic.The need to have written, signed orders in the resident's chart for all medications and treatments for which the facility was responsible for administering was discussed with Staff 2 (Health Services Administrator), Staff 6, Staff 7, Staff 10 (Resident Services Coordinator), and Staff 11 (Resident Services Coordinator) on 02/06/24, and with Staff 1 (ED) and Staff 2 on 02/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and signed physician orders for all medications and treatments were in the resident's facility record for 2 of 3 sampled residents (#s 6 and 7) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 7 moved into the facility in 10/2023 with diagnoses including chronic atrial fibrillation and hypertension.1. The resident's 05/01/24 through 05/29/24 MARs and current signed the physician orders were reviewed. a. The physician orders noted metoprolol 100 mg two times daily for high blood pressure and hold for HR (heart rate) less than 55 and/or SBP (systolic blood pressure) less than 95.The MAR showed staff documented they administered the medication when the resident's SBP was less than 95 on four occasions (05/02/24, 05/04/24 morning dose, 05/11/24 and 05/18/24) and when HR was less than 55 on one occasion on 05/04/24 evening dose. In addition, staff documented they did not administer the medication when the resident's SBP and heart rate were within parameters on one occasion on 05/09/24.b. The physician orders directed staff to administer Entresto 24-26 mg two times daily for heart failure and hold for SBP (systolic blood pressure) less than 95.The MAR showed staff documented they administered the medication when the resident's SBP was less than 95 on eight occasions (05/01/24, 05/02/24, 05/04/24, 05/11/24, 05/15/24, 05/18/24, 05/22/24 and 05/24/24). c. Staff documented they administered melatonin daily, however, there was no current signed physician order for the medication administration. The need to have written, signed orders in the resident's chart for all medications and treatments for which the facility was responsible for administering and to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Health Services Administrator) and Staff 35 (RN, Quality Support) on 05/30/24. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 11/2023 with diagnoses including unspecified protein-calorie malnutrition and major depressive disorder. The resident's MARs, dated 04/07/24 through 05/29/24, and physician's orders were reviewed. The following issues were identified: a. Staff were unable to locate the medication or treatment or the medication was unavailable for staff to administer:* Estradiol (for estrogen) on 04/30/24; * Lidocaine patch (for pain) on 04/24/24 through 05/02/24, and 05/15/24; * Proear oil (for irritation/itchiness) on 04/07/24, 04/29/24, and 05/21/24; * Sustane drops (for dry eyes) on 04/23/24, 04/27/24, 04/28/24, 05/09/24 and 05/10/24; and * Creon (for pancreatic enzyme) on 05/23/24. b. Staff did not administer the medication or treatment due to:* 04/10/24: Systane complete 0.6% eye drops as "Hospice was faxed for new [medication] order. This wasn't given to resident on this shift." But it was administered the following day; and* 05/02/24: Estradiol was not administered as "resident was in a meeting."c. A physician's order directed staff to administer Triamcinolone cream (for skin diseases, allergies, and rheumatic disorders) twice per week, after showers. Sundays were the only dates indicated on the MAR for the staff to administer the cream. There was no documented evidence of a second day of the week for Resident 6's showers, or that the cream was administered two days a week after showers per the signed order. d. A physician's order dated 04/25/24 directed staff to administer Estradiol cream three times weekly. Per documentation, staff were administering the cream daily. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was discussed with Staff 2 (Health Services Administrator) and Staff 35 (RN Quality Support) on 05/30/24. They 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 2 sampled residents (#3) who had documented medication refusals. Findings include, but are not limited to:Resident 3 was admitted to the facility in 08/2023 with diagnoses including right above-the-knee amputation and chronic obstructive pulmonary disease.The resident's 01/01/24 to 02/05/24 MARs and all physician orders were reviewed.The resident had a signed physician's order which included directions for staff to notify the physician after "refusal of three consecutive doses of any medication."Resident 3 refused three or more consecutive doses of medication on the following dates: * Six consecutive doses 01/03/24 through 01/08/24;* Seven consecutive doses 01/12/24 through 01/18/24; and* 10 consecutive doses 01/22/24 through 02/02/24. Medications refused included:* Amlodipine 5 mg (for high blood pressure); * Escitalopram 10 mg (for depression); * Ferrous sulfate 325 mg (supplement); * Folic Acid 1 mg (supplement);* Multivitamin (supplement); * Vitamin B-1 100 mg (supplement); * Flutica/Salmet 500/50 MCG (for wheezing); * Gabapentin 300 mg (for nerve pain); * Magnesium oxide 400 mg (supplement);* Omeprazole DR 40 mg (for gastroesophageal reflux disorder); * Oxybutynin 5 mg (for bladder control); * Potassium Chloride ER 10 MEQ (for electrolyte balance); and * Vitamin C 500 mg (supplement).There was no documented evidence the physician was notified after three consecutive refusals for the above medications.The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 02/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the physician or other legally recognized prescriber was notified when a resident refused to consent to a medication or treatment order for 2 of 2 sampled residents (#s 6 and 7) who had medications and treatments administered by the facility. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 moved into the facility in 10/2023 with diagnoses including irritable bowel syndrome. During the acuity interview on 05/29/24, the resident was identified to have a sore on his/her coccyx area. The resident's 05/01/24 to 05/29/24 MAR and 04/07/24 through 05/29/24 progress notes were reviewed, and the following was identified:Staff documented the resident refused the following medication and a treatment:* Melatonin (for sleep aid), on nine occasions; and* Barrier cream on buttocks (for moisture), on 16 occasions.There was no documented evidence staff notified the prescriber of the above refusals.The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was discussed with Staff 2 (Health Services Administrator) and Staff 35 (RN, Quality support) on 05/30/24. They acknowledged the findings, and no further information was provided.
2. Resident 6 was admitted to the facility in 11/2023 with diagnoses including volvulus, exocrine pancreatic insufficiency, and pain in left hip. The resident's 04/07/24 to 05/29/24 MARs, physician orders, and progress notes, dated 04/07/24 through 05/29/24, were reviewed. The resident refused the following medications:* Creon (for pancreatic enzyme) on 04/26/24;* Loperamide (for diarrhea) on 04/26/24;* Lidocaine patch (for pain) on 05/09/24; and * Estradiol (for estrogen replacement) on 05/26/24 and 05/27/24. There was no documented evidence the physician was notified after each refusal for the above medications.The need to notify the physician or other practitioner of resident medication refusals was discussed with Staff 2 and Staff 35 (RN Quality Support) on 05/30/24. No additional information was received.

2. Resident 6 was admitted to the facility in 11/2023 with diagnoses including volvulus, unspecified protein-calorie malnutrition, dry eye, and osteoarthritis. The resident's 04/07/24 through 05/29/24 MARs were reviewed and revealed the following inaccuracies:a. The following PRN medications lacked the sequential order for staff to administer:* Acetaminophen (for pain);* Diclofenac sodium gel (for pain);* Oxycodone (for pain); and * Bisacodyl (for constipation). b. A triamcinolone cream (for skin diseases, allergies, and rheumatic disorders) gave direction for unlicensed staff to "apply to affected area(s)" without specifying where the "affected area(s)" were. c. There were blanks on the MAR for the following: * Check weight daily on one occasion;* Estradiol (for estrogen) on one occasion;* Lidocaine patch (for pain) on two occasions; * Systane 0.3% - 0.4% drops (for dry eye) on one occasion; and* Systane complete 0.6% drops (for dry eye) on one occasion.The need to ensure resident's MARs were accurate with resident specific parameters and instructions for PRN medications and initials of the person administering the medication or documenting why a medication or treatment was not administered was discussed with Staff 2 (Health Services Administrator) and Staff 35 (RN Quality Support) on 05/30/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 6 and 7) whose medications were reviewed. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 10/2023 with diagnoses including non-Hodgkin lymphoma and chronic atrial fibrillation.Resident 7's 05/01/24 through 05/29/24 MAR was reviewed and found to be lacking resident-specific parameters and instructions for the following medications:* PRN suppository (for constipation) indicated it was to be given when Milk of Magnesia was not effective within 24 hours. The resident did not have Milk of Magnesia prescribed;* The MAR directed staff to administer one to two tablets of Tylenol (for pain), PRN. There were no clear directions to unlicensed staff relating to how many tablets to administer; * Multiple PRN treatments for skin, including barrier cream and calmoseptine, lacked clear parameters related to when, where, and in what sequence they should be administered; and * There were two PRN medications for pain without parameters to direct unlicensed staff which medication to use first. The need for resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 2 (Health Services Administrator) and Staff 35 (RN Quality Support) on 05/30/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility. Findings include, but are not limited to:As of survey entrance on 02/05/24, the ABST did not include data for two unsampled residents.During an interview on 02/07/24, Staff 1 (ED) and Staff 2 (Health Services Administrator) stated they did not realize one of the residents had not been entered into the ABST at all, and acknowledged another resident did not have minutes inputted until after survey entered the facility on 02/05/24.The need to ensure the ABST was updated before a resident moved in to the facility was discussed with Staff 1 and Staff 2 on 02/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed 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, and that resident evacuation needs were met. The second and third floors had multiple residents who were unable to walk down the stairs in the event of an evacuation and no plan was in place on how to assist the residents. This placed the residents at risk and constituted an immediate threat to the residents' health and safety. Findings include, but are not limited to:a. Fire and life safety records dated 08/2023 through 01/2024 were reviewed. The documentation showed no drills were conducted in the assisted living facility during the night shift.Service plans for four sampled residents, all of whom lived on the second or third floor, were reviewed for assistance level needed to evacuate the facility. The service plans indicated the basic assistance needed such as "hands on assistance with wheelchair," but did not reflect what type of assistance and instruction was needed to get the residents down the stairs.Residents who attended the group interview meeting on 02/06/24 indicated they had no idea what they were supposed to do in the case of a fire. Additionally, some residents who participated in the group interview resided on the second or third floors. The residents who resided on the upper floors required assistive devices to walk and were unsure how they would get down the stairs.Thirteen staff were interviewed between 02/07/24 and 02/08/24, including MTs, CGs, Resident Services Coordinators, and the staffing coordinator. All 13 staff indicated they did not know how they would get residents who could not walk on their own down the stairs from the second and third floors. The staff indicated they had not received any specific training related to evacuating residents down the stairs when they could not walk on their own.Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 8 (Plant Operations Director) were interviewed on 02/06/24 and 02/07/24. They also indicated there was not a clear plan of how to evacuate residents from the upper floors who could not walk down the stairs on their own. Staff 1 indicated the facility had "fire blankets" that could be used to carry residents down the stairs, but he was unsure of an exact number or where they were located.Observations of the stairwells in the facility showed no "fire blankets" or other devices in place to assist non-ambulatory residents to evacuate from the upper floors to the first floor. The stairwells consisted of a short section of stairs and a longer section of stairs for each floor. In an interview on 02/07/24, Staff 10 and 11 (Resident Service Coordinators) reviewed the facility resident list with the surveyor and determined there were nine residents on the second floor and 11 residents on the third floor who would need to be carried down the stairs in the case of an evacuation. The staff both indicated the residents who would require more than one staff assistance were related to conditions including weakness, missing limbs, paralysis and inability to bear weight. This constituted a significant risk to resident health and safety and required an immediate plan of correction to ensure residents on upper floors could be safely and effectively evacuated to the first floor if needed in case of a fire.The facility submitted two plans of correction to the survey team. Plan one reflected an immediate plan and plan two to be implemented when a specialized equipment order arrived at the facility. The facility ordered 20 portable transport units (large fabric blankets with multiple handles around the edges) for use in carrying residents down the stairs, as well as four specialized wheelchairs meant for use on the stairs. The facility's immediate plan was set up and trialed by the facility.On 02/07/24 at 4:47 pm, the facility provided both plans of correction related to the immediate jeopardy situation. The immediate jeopardy situation was abated.b. Fire and life safety records, dated 08/2023 through 01/2024, showed drill documentation was lacking in the following areas:* The escape route used;* Problems encountered;* Evidence of alternate routes used;* Evacuation time-period needed; and* The number of occupants evacuated.The fire drills were not completed at least every other month on alternating shifts. Additionally, the records reviewed did not show life safety training was provided to staff on alternating months from the fire drills.The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 3 (Regional Director of Operations), and Staff 8 (Plant Operations Director) on 02/06/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety procedures within 24 hours of admission. Findings include, but are not limited to:Fire and life safety records were reviewed and discussed with Staff 2 (Health Services Administrator) on 02/06/24. Staff 2 indicated the facility handbook was reviewed on admission and included fire life safety training. The resident or responsible party then would complete a form which indicated they received and reviewed the handbook.Sign-off forms were completed for 5 of 5 sampled residents which indicated the facility handbook was reviewed. The forms were not dated as to when they were completed. There was no additional documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission.On 02/06/24, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and as required by the Oregon Fire Code was discussed with Staff 2 and Staff 3 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to: C 280, C 302, C 303, C 305.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 280.