Pelican Pointe

The findings of the kitchen inspection, conducted 06/04/24 to 06/05/24, 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.
The findings of the first revisit to the kitchen inspection of 06/05/24, conducted on 10/17/24, are documented in this report. The facility was found in substantial 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, record review, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation occurred of the main kitchen 06/04/24 through 06/05/24 and the following was identified:a. The following areas were in need of cleaning and/or repair:* Can opener blade had debris and was peeling; * Kitchen entrance/exit doors and frames had black scuffs, gouges, and peeling paint, which exposed the door surfaces; and* Two open areas were observed around the sprinkler heads above the preparation area and the steam table.b. Poor infection control practices observed, but not limited to: * Dining room had preset tables with food contact surfaces of cutlery exposed to potential contamination; and* Two cooks and/or servers with beards lacked coverings for their facial hair.During an interview on 06/04/24 at 11:00 am, Staff 3 (Executive Chef) stated the Fire Marshal had come to test the sprinkler integrity and had taken the covers. Staff 1 (ED) stated that the facility would reach out to the Fire Marshal and question what best practice was for the openings. No additional information was provided at time of survey exit. On 06/05/24 at approximately 9:25 am, the above areas were reviewed with Staff 1 who acknowledged the identified areas.

The findings of the change of ownership survey conducted 06/03/24 through 06/06/24 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 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

Based on observation and interview, it was determined the facility failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:The Residential Care Facility (RCF) was toured on 06/03/24. The following were not posted as required:* Name of administrator or designee in charge posted by shift;* Facility staffing plan; and* Ombudsman poster.During an interview on 06/03/24 Staff 1 (ED) reported she was unaware that separate postings were required for the RCF and assisted living communities.The need to ensure all required items were posted was reviewed with Staff 1 (ED) on 06/03/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop and implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:In an interview with Resident 1 on 06/03/24 s/he reported that the heating and cooling system in his/her unit hadn't been working right since s/he moved into the facility four weeks prior. Resident 1 stated s/he had told "the helpers" several times and wasn't sure who else to tell.In an interview with Staff 5 (Environmental Services Director) on 06/04/24 he reported he was aware of Resident 1's heating and cooling system malfunction and that there was an electrician coming to address the issue on 06/06/24. Staff 5 reported he had no documentation of the work order in his log, and he had not communicated to Resident 1 regarding the resolution of his/her complaint. The need to ensure the facility developed effective methods of responding to and resolving resident complaints was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:During the survey, conducted 06/03/24 through 06/06/24, there were no observations of individual or group activities being provided for residents in the Residential Care Facility (RCF).Upon entrance, an activity calendar was requested and the calendar provided was specifically for the Assisted Living facility and not the RCF. In an interview with an unsampled resident on 06/05/24 at 2:30 pm, s/he stated that there had been no activities taking place in the RCF side of the facility and all activities took place in Assisted Living. Throughout the survey residents were observed remaining in their rooms or sitting at tables in the common area of the RCF. The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/05/24 at 3:00 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements for 1 of 1 sample resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 1 moved into the facility in May 2024 with diagnoses including diabetes, chronic pain disorder, and failure to thrive.Resident 1's move-in evaluation documentation was reviewed on 06/05/24. The following required elements were not addressed:* Effective non-drug interventions for mental health issues;* Personality: including how the person copes with change or challenging situations;* Housework and laundry;* Fluid preferences;* Fall risk or history;* Emergency evacuation ability;* History of dehydration or unexplained weight loss;* Unsuccessful prior placements;* Elopement risk or history;* Smoking; and* Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, and room temperature.In an interview on 06/06/24, Staff 1 (ED), acknowledged the Evaluation Form had multiple areas that were not completed.The need to ensure initial evaluations included all the required elements was discussed with Staff 1 on 06/06/24. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2024 with diagnoses including arthritis and anxiety.Interviews with Resident 2 and care staff, and observations made of the resident during the survey revealed s/he was independent in all of his/her ADL's. Resident 2's current service plan, dated 05/16/24 was not reflective of the resident's current status in the following areas:* Interests, hobbies, social, leisure activities.The need to ensure service plans were reflective of the resident's current status was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/05/24 at 3:00 pm. The findings were acknowledged.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and/or provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:1. Resident 1 moved into the facility in 05/2024 with diagnoses including diabetes, chronic pain disorder, and failure to thrive.The resident's current service plan dated 05/08/24 was reviewed, observations were made, and interviews with staff were conducted. Resident 1's service plan was not reflective and/or did not provide clear direction to staff in the following areas:* Wheelchair use;* Interests, hobbies, social, leisure activities;* Assistance required with ramp; and* Inability to chew hard foods.The need to ensure service plans reflected the residents' needs and provided clear direction to staff was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:Resident 3 was admitted to the facility in April 2024 with diagnoses including diabetes. The resident required sliding scale insulin injections once daily by unlicensed staff. Review of the current delegation records for Resident 3 on 06/05/24 revealed there was no documented evidence Staff 9, Staff 12 and Staff 14 (MT's) had current evaluation of skills to determine continued competency for insulin administration. Witness 1 (CoBridge RN Consultant) reported that all required re-evaluation of delegations would be completed by end of day 06/05/24 and that only current delegated staff would administer insulin to the resident.On 06/05/24, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 3 (Health Services Director). They acknowledged the findings.

Based on interview and record review it was determined the facility failed to ensure an Acuity Based Staffing Tool (ABST) included evaluated care needs of all residents, and was completed for each resident before move-in. Findings include, but are not limited to: The ABST was reviewed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/04/24, and the following was identified:The ABST did not include two residents. In an interview on 06/04/24, Staff 1 reported that a resident who moved into the facility on 06/03/24 did not have a completed ABST. Staff 2 reported that another resident was erroneously omitted from the ABST and included in the ABST for the assisted living facility.The need to implement an ABST based on the evaluated care needs of all residents, including completing an ABST assessment before a resident move-in, was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 9 and 10) completed all required pre-service orientation training, and 1 of 3 newly hired direct-care staff (#10) completed all required pre-service dementia training. Findings include, but are not limited to:Staff training records reviewed on 06/04/24 at 8:30 am with Staff 4 (Business Office Manager) identified the following:1. There was no documented evidence Staff 10 (CG), hired on 04/23/24 had completed the following required pre-service orientation topics:* Resident rights and values of CBC care; * Abuse reporting requirements; and* Approved HCBS course (effective 04/01/24).2. Staff 9 (CG) lacked documented evidence of completing the following pre-service orientation topic: * Approved HCBS course (effective 04/01/24).3. Staff 10, hired on 04/23/24, lacked documented evidence of required pre-service dementia training on the following topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Strategies for addressing social needs & engaging them in meaningful activities; and* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 4 (Business Office Manager) on 06/04/24 at 3:45 pm and Staff 1 (ED) and Staff 2 (VP of Operations) on 06/05/24 at 3:00 pm. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct-care staff (#s 8, 9, and 10) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 06/04/24. The following deficiencies were identified: Staff 8 (CG), hired 02/12/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:* Changes associated with normal aging; and* First Aid/abdominal thrust.Staff 9 (CG), hired 03/26/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire: * First Aid/abdominal thrust. Staff 10 (CG), hired 03/26/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire: * Changes associated with normal aging; * General food safety, serving and sanitation; and* First Aid/abdominal thrust.The need to ensure newly hired direct-care staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 4 (Business Office Manager) on 06/04/24 at 3:45 pm and Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/05/24 at 3:00 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to consistently provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:The facility provided documentation of fire and life safety training for staff conducted on 05/25/24. No other documentation was provided.In an interview with Staff 5 (Environmental Services Director) on 06/04/24, he reported that no fire drills had been conducted in the past three months since the facility had been reopened after a remodel. Staff 5 also reported he was unaware that he needed to conduct fire drills and staff fire and life safety training separate from the rest of the building which was a separate license. The need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternate months for each licensed facility was discussed with Staff 5 on 06/04/24 and Staff 1 (ED) on 06/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, in fire safety topics. Findings include, but are not limited to:In an interview on 06/05/24, Staff 5 (Environmental Services Director) reported he had not yet provided the required instruction on fire safety procedures and evacuation methods to Resident 1, who moved into the facility on 05/08/24. He stated he was developing a system to instruct residents within 24 hours of move in and re-instructing them at least annually.The need to ensure residents received fire safety instruction within 24 hours of move-in, and were re-instructed annually, was reviewed with Staff 1 (ED) and Staff 5 on 06/05/24. They acknowledged the findings.

Based on observation and record review, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, garbage was stored in covered refuse containers, cleaning chemicals and disinfectants were secured in locked storage, and measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to:The facility grounds and interior of the Residential Care Facility (RCF), comprised of units Diamond and Willow, were toured on 06/03/24 and 06/04/24, resident council notes were reviewed, and observations were made throughout the survey. No resident units in Willow were occupied, but doors between the units were open and residents from Diamond were occasionally observed in Willow. The following was identified: * Broken furniture and other refuse were stacked in a pile behind the designated smoking area for staff and was observable from the pathway used by residents.* Multiple cigarette butts were on the ground to the right of the front entrance.* Piles of bird droppings were on the walkway at either side of the front entrance.* The inner courtyard of Diamond contained window screens and large pieces of peeled paint on the ground.* The pathway in the inner courtyard of Diamond was uneven and had drop-offs.* A large painted planter box in the outer courtyard of Willow had large areas of peeling paint, with exposed and splintered wood. There was lumber stacked underneath the planter box.* A bottle of disinfectant was in an unlocked eyewash station of Diamond.* Cleaning chemicals were stored in an unlocked room next to the rear corridor connecting Diamond and Willow.* Two resident room window screens, observed from the inner courtyard of Diamond, had large holes, approximately 3" in diameter, allowing insects to enter the building.* Throughout the survey a door to the outer courtyard on Diamond was intermittently observed propped open, allowing insects to enter the building.* Ants were observed on the floor in the Willow common area, as well as in the bathroom by the Willow kitchenette.* On 06/04/24 flies were observed in an uncovered garbage dumpster, the lid of which was pinned behind the dumpster and the fence. On 06/05/24 this was shown to Staff 5 (Environmental Services Director), who covered the garbage dumpster. The morning of 06/06/24 the dumpster was observed to be uncovered.* Resident Council notes dated 05/20/24 had the following comments from two unsampled residents: - "Can the bug situation in RCF be addressed. Large bugs in there!" - "Air doors to get flies out of dining area. Ongoing problem!"The findings were reviewed in a tour of the facility on 06/05/24 with Staff 1 (ED) and Staff 5. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:A tour of the Residential Care Facility (RCF) interior, comprised of units Diamond and Willow, was conducted on 06/03/24. The following were found to need cleaning and/or repair:* Dining chairs in both units had scrapes and gouges in the wood.* Dining tables in both units had black build-up on wood surfaces.* Acoustic ceiling tile in the short corridor by the Diamond medication room had a large brown stain, approximately 18" in diameter, and the ceiling tile next to it was missing.* Moss was growing on the inside of the windows facing the Willow inner courtyard, and window tracks had brown build-up.On 06/05/24 these findings were reviewed on a walk-through of the RCF with Staff 1 (ED) and Staff 5 (Environmental Services Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents' rooms had a lockable storage space for the safekeeping of residents' small valuable items and funds. Findings include, but are not limited to: Interviews with Resident 1 on 06/03/24 and Resident 2 on 06/04/24 identified that resident closets had a locking mechanism but residents were not given keys. There were no other lockable storage spaces in the residents' rooms.The need to ensure resident rooms had a lockable storage space was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:On 06/03/24 a gas fireplace was observed in the common sitting area between units Willow and Diamond. The fireplace was located where residents could come into incidental contact with it. The fireplace glass measured 235.0 degrees F when measured with the surveyor's thermometer. On 06/04/24 Staff 1 (ED) and Staff 5 (Environmental Services Director) acknowledged the surface temperature was too hot and immediately disabled the fireplace until a long term solution could be found.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes to alert staff when residents exited the (Residential Care Facility) RCF. Findings include, but are not limited to:The interior of the RCF, comprised of units Diamond and Willow, was toured on 06/03/24 and 06/04/24.Diamond and Willow each had two double doors through which residents could exit the building into exterior courtyards. In addition, each unit had two doors through which residents could exit the building into interior courtyards. When the surveyor exited the building through these eight doors, no audible alert was heard.In an interview on 06/05/24, Staff 5 (Environmental Services Director) confirmed that there was not a system in place that alerted staff when residents exited the building through these eight doors. Staff 5 reported that the four double doors had alarms which had been disabled when crash bars were installed.These findings were reviewed with Staff 1 (ED) during a walk-through of the environment on 06/05/24. She acknowledged the findings.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:Integrated Settings: Community Life OAR 411-004-0020 (1)(a) The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (B) Engage in greater community life.

During the survey concerns were identified in the following area and the facility was provided with technical assistance:Optimize Settings: Independence Activities OAR 411-004-0020 (1)(e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction, and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:Physical Setting Individual Accessible: OAR 411-004-0020 (2)(b) Provider owned, controlled, or operated residential settings must have all of the following qualities: The setting is physically accessible to an individual.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:OAR 411-004-0020(2)(d): Individual Privacy: Own Unit (d) Each individual has privacy in his or her own unit. This was regarding no lock on the apartment side of the door to shared bathrooms.

The findings of the health and safety monitoring survey conducted 2/8/21 through 2/10/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the first revisit conducted 5/3/21 to 5/7/21 to the health and safety monitoring survey conducted 2/8/21 through 2/10/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An immediate plan of correction was requested in the following area:OAR 411-054-0070 (1) Staffing RequirementsThe facility put an immediate plan of correction in place during the survey and the situation was abated.


The findings of the second re-visit to the re-licensure survey of 02/10/21, conducted 11/15/21 through 11/16/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed 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:During the entrance conference, 5/3/21, survey requested a copy of the facility's disclosure statement. Upon receipt of the disclosure statement it was noted the "Number of staff per shift" portion of the document was blank. There was no documented evidence a staffing plan was posted in the MCC. During an interview the same day, Staff 19 (ED / ALF) stated the staffing plan "should be posted next to where the survey binder was located," and confirmed it was not there. In addition, the posting for the administrator and designee was inaccurate and contained the name of the former memory care administrator and former resident care coordinator. The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 19 (ED/ALF) on 5/3/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to maintain a complete record for 1 of 3 sampled residents (#1) reviewed for skin breakdown and a urinary tract infection. Findings include, but are not limited to:Resident 1 was admitted to the MCC in 2019 with diagnoses including dementia and a history of skin breakdown.His/her record was reviewed during the survey and found to be incomplete in the following areas:a. Progress notes indicated staff were monitoring the resident's buttocks for redness from 1/22/21 through 2/2/21. Staff 2 (RN) assessed the area on 2/2/21 and documented that no open areas were present. During an ADL observation on 2/9/21 at 11:15 am, Staff 13 and 17 (CGs) stated the resident had a sore on his/her bottom and showed the surveyor a small, white, approximately 2 X 2 inch gauze pad on the right buttock. There was no documentation of any open areas to the resident's buttock or application of a gauze pad. In an interview with Staff 2 (RN) on 2/9/21 at 12:40 pm, she stated the gauze pad "was not there yesterday." She added that staff had not reported the recent skin breakdown or application of a gauze pad. Staff 2 stated she'd perform an assessment. On 2/9/21 at 1:15 pm, Staff 2 (RN) provided a copy of her assessment. She documented that the resident had a 1 cm open skin tear to gluteal cleft. Interventions were noted and alert charting was initiated for the "new area of skin breakdown." Staff 2 acknowledged that staff failed to document about the injury. b. Resident 1's record, reviewed between 1/7/21 and 1/29/21 revealed the following:* 1/7/21: Facility requested a urinalysis (UA) order.* 1/9/21: PCP approved and faxed order to facility. * 1/10/21 and 1/13/21: Staff charting notes verified the order and staff were instructed to obtain it. * No further documentation about the UA was noted in the record until 1/25/21 (12 days later). Staff 2 (RN) charted that the resident had increased behaviors and the PCP would be contacted for a UA order. * 1/26/21: The resident was sent to the ER for being "slightly pale, fatigue, speech is more difficult than normal." The resident returned 1/27/21, but a UTI had not been ruled out. * 1/29/21: The resident was sent to the ER, was diagnosed with the UTI and an antibiotic was started. Between 1/13/21 and 1/25/21, there was no documentation about the UA, if attempts to obtain it were made, and if the PCP and facility RN were notified if unsuccessful. In an interview on 2/10/21, Staff 2 (RN) stated facility staff discussed various strategies to obtain the UA and made multiple unsuccessful attempts. She reviewed the record and acknowledged the lack of documentation. On 2/10/21, the need to ensure facility records were complete was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN). No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to maintain complete and accurate records for 3 of 3 sampled residents (#s 4, 5 and 6) reviewed for injuries and wound treatments, a left shoulder dislocation and falls. This is a repeat citation. Findings include, but are not limited to:Resident 4, 5 and 6's chart records, not limited to but including, service plans, progress notes, incident investigations and MAR's and TAR's were reviewed during the survey and found to be incomplete or inaccurate in the following areas:1. Resident 4 was admitted to the facility April 2017 with diagnoses including dementia. On 4/25/21 staff documented Resident 4 had a scratch "under left buttock". There was no follow up documentation or investigation for the injury of unknown cause.2. Resident 5 was admitted to the facility July 2017 with diagnosis including dementia. a. On 4/21/21 staff documented in Resident 5's progress notes "resident with swollen left shoulder" "PCP to be notified for recommendation" and on 4/26/21 "PCP has been notified, awaiting response". During an interview, 5/4/21 Staff 2 (RN) stated she instructed staff to notify the physician by fax. There was no record of the fax in the resident's facility chart and staff were unable to locate the documentation. b. A 4/29/21 progress indicated an interim service plan (ISP) had been written for Resident 5 regarding a change in the residents sleep-wake cycle. There was no record of the ISP in the resident's chart, facility staff were unable to locate the documentation.3. Resident 6 was admitted to the facility November 2017 with diagnoses including dementia and seizures. * On 4/24/21 the resident was found on the floor with a skin tear on his/her right eyebrow. Progress notes indicated staff had provided wound care, however there was no documentation on the residents April 2021 TAR indicating wound care had been provided. * On 4/26/21 Staff 2 (RN) documented in the residents progress notes "safety precautions implemented." There was no evidence in the residents chart documenting what safety precautions had been implemented. The need to ensure resident records were complete, accurate and not falsified was reviewed with Staff 6 (Regional RN) and Staff 19 (ED/ALF) on 5/5/21 and 5/6/21. They acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.1. Resident 1 was admitted to the MCC in 2019. * On 2/8/21 at 3:20 pm, the surveyor obtained permission and observed two CGs provide ADL care to Resident 1. During the observation, one of the CGs removed an incontinent pad from the resident's bed and placed it on the floor. * On 2/9/21 at 11:15 am, the surveyor obtained permission and observed two CGs provide incontinent care to Resident 1. During the observation, one of the CGs wiped the resident's perineum with wet wipes. The soiled wipes were not immediately placed into a trash bag/receptacle but stacked on top of the resident's bed sheet. The wipes were not disposed of until after care was completed. Additionally, same CG failed to change her gloves after removing a soiled incontinent product and wiping urine from Resident 1's perineum. The CG touched the resident's clothing, clean incontinent brief, door handle, bed linens and resident's wheelchair wearing the same soiled gloves. After care was completed, the CG removed her gloves, wheeled the resident to the dining room and proceeded to assist other residents. No hand hygiene was observed after she provided care to Resident 1.2. Two staff were observed on 2/8/21 at 3:00 pm and 2/9/21 at 3:30 pm pushing a cart that contained snacks and giving them to residents in the MCC. Spoons and forks were placed into a cup on top of the cart with fork tines and spoons facing upward so that when staff handed out the utensil they touched the part that a resident would put in his/her mouth. As utensils were passed to multiple residents, staff failed to perform hand hygiene. The above observations were discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional RN) on 2/10/21. They acknowledged appropriate infection control practices were not implemented. No further information was provided.
3. On 2/8/21 at 4:25 pm, the surveyor observed two caregivers provide incontinent care to Resident 2. During the process, one CG placed the resident's soiled incontinent brief directly on the floor, and then placed soiled disposable cleaning cloths on top of the brief. The CG failed to change gloves after removing the soiled incontinent brief and wiping the resident's perineum. The CG touched the resident's hand, bed linens, incontinent pad and clean brief while wearing the same soiled gloves.On 2/9/21 at 2:20 pm, the surveyor observed two caregivers provide incontinent care to Resident 2. During the process, one CG placed the resident's soiled incontinent brief directly on the floor, and then placed soiled disposable cleaning cloths on top of the brief. The CG later bagged the soiled items and removed them from the room.The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Memory Care Director) on 2/8/21 at 4:50 pm. She acknowledged appropriate infection control practices were not being followed.


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 for 2 of 4 sampled residents (#s 4 and 7) related to infection control. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 was admitted to the facility 04/2017 with diagnoses including dementia. * On 5/4/21 during an observation of the resident's room dried brown matter was observed smeared across the light switch in the shared bathroom, and dried red and green matter on the resident's armchair; and* On 5/5/21 during observation of ADL care, Staff 24 (CG) and Staff 5 (CG) assisted Resident 4 with a shower, dressing, and incontinent briefs. Staff 24 wore the same pair of gloves during transfer of resident between the wheelchair, toilet, and shower. Once the resident was washed and returned to bed, Staff 24 continued to wear the same gloves while touching the resident's blanket, pillow, and personal items. Staff 24 then picked up the resident's health shake and pudding to hand to the resident, again without removing the gloves. The failure to insure infection control precautions was discussed with Staff 19 (ED /ALF), Staff 20 (RCC) and Staff 6 (Regional RN) on 5/6/21. They acknowledged the findings.
2. Resident 7 was admitted to the facility 11/2017 with diagnoses including dementia and major depressive disorder. a. On 5/4/21 between 11:43 and 11:50 am, Resident 7 was observed in a crouched position picking up what appeared to be food crumbs off the dining room floor and placing them in his/her mouth. The surveyor located staff in another part of the memory care, described the residents' behavior, and requested staff assist the resident. Staff 28 (CG/ALF) walked over to where the resident was crouched, instructed the resident to stand up and escorted the resident to a couch on the opposite side of the memory care. No hand hygiene was provided or offered to Resident 7. b. During a walk through of Resident 7's room, 5/4/21 at 11:54 am, the surveyor observed a laundry basket of soiled clothing next to resident's dresser and a soiled incontinent product on the resident's bathroom sink counter. On 5/4/21 at 12:10 pm Staff 20 (RCC) was informed of the findings and stated she would address the issues. The need to ensure staff exercised universal precautions and infection control standards was discussed with Staff 19 (ED/ALF) and Staff 20 on 5/4/21 and 5/5/21. They acknowledged the findings. 3. Between the dates of 5/3/21 and 5/6/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. The deficiency identified included, but was not limited to:* Multiple MCC staff were observed wearing their facemask under their nose, would readjust over the nose without hand hygiene.The need for appropriate facemask donning was discussed with Staff 19 (ED/ALF) during the survey. She acknowledged the findings.

2. Resident 1 was admitted to the MCC in 2019 with diagnoses which included dementia.Observations of the resident during the survey revealed s/he was dependent on staff for ADL care.The service plan, dated 11/6/20, indicated the resident was incontinent of bowel and bladder, wore an incontinent brief and needed assistance with all toileting needs. Staff were instructed to provide toileting assistance and incontinent care "up to eight times per day."During interviews on 2/8/21 with Staff 16 (CG) and on 2/9/21 with Staff 17 (CG), they stated the resident was incontinent of bowel and bladder and would not always ask to use the toilet. They added that staff needed to anticipate his/her needs.Observations and staff interviews on 2/9/21 revealed the following:* At 8:15 am, Resident 1 was observed in a wheelchair in the dining room. The resident remained in the dining room until 9:30 am.* At 9:30 am, Staff 13 and 17 (CGs) assisted the resident to his/her room and into bed. No toileting assistance was provided. * At 11:15 am, the same CGs changed the resident's incontinent brief while s/he was in bed. The brief was saturated with urine. During the observation, Staff 13 and 17 was asked when the last time toileting assistance/incontinent care had been provided. They replied that Resident 1 received incontinent care at 7:15 am that morning when they got him/her up for the day. * From 11:15 am to 4:45 pm, two surveyors observed the resident either in the dining room or in bed. * At 4:45 pm, Staff 15 and 18 (CGs) entered the resident's room to help him/her up for dinner. As they transferred the resident into the wheelchair, the surveyor observed that the back of his/her shirt was wet. Staff 18 smoothed the resident's shirt and said she was going to take him/her to the dining room for dinner. Staff 15 told Staff 18 that the shirt was wet and needed to be changed. Both staff proceeded to change the resident's shirt. However, no toileting assistance/incontinent care was initiated. The surveyor intervened and asked that the resident be assisted to the toilet. During the toileting observation, the surveyor observed that the resident's pants and incontinent brief were saturated with urine. Staff 15 and 18 acknowledged the resident's clothes and incontinent brief were soiled, proceeded to provide incontinent care, and dressed the resident in clean clothing.On 2/9/21, Resident 1 received toileting assistance/incontinent care one time between 7:15 am and 4:45 pm (9.5 hours). At 4:45 pm, the surveyor intervened and requested that toileting assistance be provided. The above findings were shared with Staff 2 (RN) on 2/9/21 at 5:30 pm, and on 2/10/21 with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN). The surveyor explained that failure to provide toileting assistance/incontinent care for several hours on 2/9/21 was neglect of care. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 3 sampled residents (#s 1 and 2) were protected from neglect. Resident 1 was not toileted for an extended period of time which put him/her at risk for skin breakdown and is considered neglect. The facility failed to assess and monitor Resident 2 following a severe weight loss, which resulted in continued weight loss and is considered neglect. Findings include, but are not limited to:1. Resident 2 was admitted to the MCC in 9/2020 with diagnoses including vascular dementia and failure to thrive.Between 10/1/20 and 12/14/20, the resident lost 13 pounds or 8.65% body weight which represented a severe weight loss. The facility failed to ensure the RN completed an assessment which included findings which may have been contributing to the weight loss.Between 12/14/20 and the start of the survey, the facility did not consistently monitor the resident's meal intake or effectiveness of health shakes, which were offered three times per day. The facility RN documented on four separate progress notes during January 2021 that Resident 2's appetite was "adequate."However, on 1/1/21, the facility documented the resident's weight had dropped to 99.5 pounds, and had dropped to 95.5 pounds when the surveyor requested a current weight during the survey. This was a 20 pound weight loss in four months or approximately 17.3% loss of body weight.The facility's failure to ensure a comprehensive RN assessment was completed and updated following continued weight loss, and the resident's weight and weight loss interventions were monitored for effectiveness, resulted in continued severe weight loss for Resident 2 and was considered neglect of care.The above findings were reviewed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN) on 2/10/21. They acknowledged the findings.Refer to C 270 and C 280.


Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 4 sampled residents (#s 4 and 7) were free from neglect and provided a home like environment. This is a repeat citation. Findings include, but are not limited to:1. Observations, interview and record review, during the survey revealed Resident 4 failed to receive ADL care in the form of showers and nail care.a. Resident 4's last recorded shower prior to survey was 1/29/21. When asked about the resident's shower schedule, Staff 17 (CG) said "S/he gets their bathing done by swing [shift]." Staff 21 (MA) said the shower schedule dated 3/11/21 was the most recent copy and confirmed Resident 4 was scheduled to get showers during day shift on Tuesday and Thursday. When asked if there was any documentation to support that Resident 4 had received a shower since 1/29/21, Staff 21 (MA) said "if there isn't paperwork for it, then it didn't happen." On 5/4/21 at 1:26 pm Resident 4 stated "they don't bathe me very often, I don't want to fall." Resident 4 was observed having a shower on 5/5/21, 95 days following the last documented shower. Staff 5 (CG) and Staff 24 (CG) assisted the resident with this task and could not locate bathing products for the resident. Staff 24 (CG) used products labeled with another resident's name found in the shower on Resident 4. b. Resident 4's feet and toe nails were observed on 5/4/21 after resident stated "no one takes care of my feet." The resident's toe nails were yellow in color, long and curled over the top of the resident's toes, and two toes on the left foot were missing toenails, exposing the nail beds. The facilities failure to provide showers and nail care constituted neglect of care and loss of dignity for the resident. Resident 4's lack of recorded hygiene provision and neglect of care was discussed with Staff 19 (ED/ALF), Staff 20 (RCC) and Staff 6 (Regional RN) on 5/6/21. No further information was provided.
2. On 5/4/21 at approximately 11:45 am Resident 7 was observed in a crouched position picking up small items from the floor and placing them in his/her mouth. There were no staff available to provide redirection for this behavior, which was clearly documented in the residents service plan.The lack of staff available to observe and monitor residents behaviors and provide interventions to redirect certain behaviors resulted in a loss of dignity and respect for Resident 7. On 5/4/21 the need to ensure residents were observed and provided redirection, and ensure all residents were treated with dignity and respect was discussed with Staff 19 (ED/ALF). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to report injures of unknown cause to the local APD office as suspected abuse unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, failed to immediately notify the local APD office of any incident of abuse or suspected abuse and failed to promptly investigate incidents and take measures necessary to protect residents and prevent reoccurrence of abuse, for 2 of 2 sampled residents (#s 2 and 3) with reportable incidents. Findings include, but are not limited to:1. Resident 2 was admitted to the MCC in 9/2020 with diagnoses including vascular dementia and failure to thrive. The service plan indicated Resident 2 was a high fall risk and had a history of falls. The service plan did not identify any skin issues, but progress notes dating back to 11/2020 indicated the facility discovered and treated the resident for multiple skin wounds.Review of Resident 2's progress notes and home health visit notes from 12/8/20 through 2/7/21 indicated the facility discovered the following injuries:* 12/20/20: Skin tear to right lower leg (shin).* 1/26/21: Left knee swollen and painful with movement.* 1/29/21: Skin tear to left shin.* 2/6/21: Bruising to the top of the right foot.* 2/6/21: Swollen left wrist.These injuries were considered injuries of unknown cause. There was no documented evidence the facility either reported the injuries as suspected abuse to the local APD office or conducted an immediate investigation of the injuries which reasonably concluded and documented that the injury was not the result of abuse. The facility failed to investigate the possible cause of the injuries and take measures necessary to protect Resident 2 from further injury.The facility's failure to immediately investigate Resident 2's injuries and document they were not the result of abuse or report the injuries as suspected abuse, and put interventions in place to prevent further injuries, was reviewed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN) on 2/10/21. They acknowledged the findings. The facility was directed to self-report these incidents to the local APD office - confirmation the incidents were reported was received on 2/11/21.
2. Resident 3 was admitted to the MCC in 8/2019 with diagnoses including dementia and Parkinson's disease. The service plan indicated Resident 3 was a smoker and could become agitated but was easily re-directed. Review of Resident 3's charting notes on 2/3/21 and an incident report dated 2/02/21 indicated a staff member reported an incident of suspected abuse between a caregiver and Resident 3 when the caregiver "obstructed [the resident] from being able to exit and grabbed [his/her] wrists to stop them from exiting then pushed [him/her] back away from the door." An interview with Staff 1 (Memory Care Director) confirmed the incident was not reported to the local SPD office. The need to immediately report incidents to the local SPD office when suspected abuse and/or neglect occurred was discussed with Staff 1 on 2/9/21. She acknowledged the findings. Staff 1 was asked to report the 2/2/21 incident to the local SPD office. She provided confirmation of the report prior to survey exit.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were thoroughly investigated in a timely manner and reported to the local Seniors and People with Disability (SPD) office for 2 of 2 sampled residents (#s 4 and 6) reviewed with injuries. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 04/2017 with diagnoses including dementia. Facility documentation on 4/25/21 noted Resident 4 had a "scrape on back of upper left thigh." On 4/26/21 the RN noted "appears to have skipping pattern indicative of a scratch. Resident does not have recollection of scratching [self] or being scratched." No further investigation was completed. There was no documented evidence the facility immediately investigated the injury of unknown cause to rule out abuse or suspected abuse, or had reported the injury to the local SPD if abuse could not be ruled out. On 5/5/21 survey requested the facility report the injury of unknown cause to the local SPD. A fax confirmation the report was sent at 4:56 pm was received prior to survey exit. The need to investigate resident incidents immediately and report them to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 19 (ED), Staff 20 (RCC) and Staff 6 (Regional RN) on 5/6/21 who acknowledged the findings.

2. Resident 6 was admitted to the facility 11/2017 with diagnoses including dementia and seizures. * On 4/24/21 staff documented the resident was found on the floor in his/her apartment crying. Staff identified a "one inch" skin tear on resident's right eyebrow. Staff completed an "Incident Report and Investigation Worksheet" the same day and documented "abuse and neglect ruled out", however there was no evidence a thorough investigation had been conducted to reasonably rule out abuse or suspected abuse. Facility documentation of the incident failed to include measures taken to prevent the incident from reoccurrence, follow up actions or administrator review. The incident had not been reported to the local SPD. On 5/5/21 the surveyor requested the facility report the injury of unknown cause to the local SPD. A fax confirmation of the report was received prior to survey exit. The need to ensure injuries of unknown cause or any incidents of abuse or suspected abuse were immediately investigated and reported if necessary was discussed with Staff 6 (Regional RN) and Staff 19 (ED/ALF) on 5/6/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen on 5/7/21 revealed the following areas were in need of cleaning or repair:* The hand washing sink located across from the walk-in cooler was missing a knob on the cold water faucet, the interior of the sink had white and brown build up, caulking around the sink was black and several holes were observed in the wall directly behind and to the left of the sink; * Two large free-standing floor fans had built up grease and dust stuck to the fan blades and outer covers;* The entrance and exit doors to the kitchen had chipped paint towards the base of the doors and around the edges; * Thick gray matter and dust covered the ceiling tiles and vents throughout the kitchen, including the tiles directly over the steam table;* A pink tray with miscellaneous small items, dirty cups, a straw wrapper and soiled sugar packets were stored on top of the ice machine. The top front cover of the ice machine had separated from the main unit, and a thick layer of dust and grease was on the front cover and door of the machine;* The top shelf of the steam table had an approximate four foot long bare piece of wood screwed onto each side of the shelf to prevent items from falling off. The wood was untreated and not cleanable; * A cluster of ants was observed on a piece of food on the floor directly inside the kitchen next to the exit door;* Floor drains throughout the kitchen had thick black build up and food particles;* The lower portion of the walls throughout the kitchen had food splatters and black streaks; * Caulking around the stainless steal edge of the dishwashing area was black;* The industrial mixer had paint chipping off and rust visible; * The hood vent behind the stove had grease and dust built up; and* Floors throughout the kitchen had thick black build up in the tile grout, food particles and grease build up was observed under the food prep table, steam table and dishwashing station. The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 29 (Executive Chef). He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide assistance with activities of daily living for 2 of 4 sampled residents (#s 4 and 7) who required assistance with bathing and grooming. Findings include, but are not limited to:1. During the entrance conference acuity interview on 5/3/21, staff indicated Resident 4 needed assistance with ADLs, had a recent decline in mobility, needed two staff for transfers, had a recent history of skin issues and Parkinson's Disease. The service plan, dated 3/14/21, and a change of condition evaluation dated 4/15/21, indicated the following:* S/he was incontinent of bowel and bladder and required "two person assist with toileting";* "Will need two person with getting into the shower one person assistance with showering";* Staff were to monitor for long, jagged, or sharp nails and provide trimming/filing as needed; and* The resident's oral care instructions were about caring for his/her dentures.A review of the unit shower schedule dated 3/11/21 revealed that Resident 4 was on the schedule to receive a shower on Tuesday and Thursday during the day shift. The most recently recorded shower for Resident 4 was 1/29/21.During interviews with staff and the resident on 5/4/21, the following occurred: * At 9:30 am Staff 14 (MA) who was scheduled for the day shift stated "We get to him/her around 6:30 am, the night shift is supposed to change and clean him/her up. Day staff starts taking lunches after breakfast, and have to wait for two staff [for care to be provided]";* At 10:35 am Staff 17 (CG) said Resident 4 would not leave the room or ambulate voluntarily since his/her friend died. Swing shift was supposed to provide the resident's showers. Staff needed to provide all care in the resident's room, and recently the resident received a hoyer for transfer assistance; and * Resident 4 was interviewed and stated that "they don't bathe me very often, and I don't want to take their time ....no one takes care of my feet." In reference to showering "it's been some time, but I'm afraid to fall."Observations and staff interviews revealed Resident 4 failed to receive ADL care to meet the resident's needs and according to the service plan. The resident was provided a shower on 5/5/21, 95 days since the last recorded shower. The above findings were shared with Staff 19 (ED/ALF), Staff 20 (RCC) and Staff 6 (Regional RN) on 5/6/21. They acknowledged the findings.
2. Resident 7's 3/18/21 service plan instructed staff to provide the following care:* "[Resident] needs assistance from staff with getting dressed/Undressed. If staff do not assist [him/her] [s/he] will not change [his/her] clothes;" * "[Resident] will be assisted with hair care;"* "[Resident] often times likes to sit or lay on the floor." "At times it appears [s/he] is trying to pick things up (dirt, etc) off the floor that is not there." Redirection for this behavior included offering him/her snack or drink, provide "attention" and "encourage activities." On 5/5/21 the resident was observed to be wearing the same shirt and pants as s/he had worn the previous day on 5/4/21. Both the shirt and pants had spills and drips on them, including dried food. On both 5/4/21 and 5/5/21 the resident's hair was uncombed, clumped together and appeared unclean. On 5/4/21 at 11:43 am, resident was observed picking small items off the floor and placing them in his/her mouth. No staff were present to provide redirection.The need to ensure the facility provided assistance to residents for all activities of daily living on a 24-hour basis was discussed with Staff 19 (ED/ALF) and Staff 20 (RCC) on 5/6/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction for staff to follow, were readily available for staff to review and/or were followed by staff for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the MCC in 2019 with diagnoses which included dementia and a history of skin breakdown. Review of the service plan revealed the following:a. The service plan, available to staff in the service plan binder, was dated 8/8/20. During an interview on 2/8/21 at 3:45 pm, the surveyor asked Staff 3 (RCC) if the service plan had been reviewed and updated since 8/2020. She stated she was updating the 2/2021 service plan but was not finished with it yet. She was unsure if the 11/2020 review occurred. On 2/9/21 at 9:00 am, Staff 3 provided the surveyor a copy of a service plan dated 11/6/20. She said it was in the computer but was never printed and placed in the service plan binder for staff. b. Observations and interviews with staff revealed the service plan was not followed, failed to provide clear direction to staff, and was not reflective in the following areas:* Use of walker for ambulation;* Toileting assistance/incontinent care;* Meal assistance; * Assisting the resident to wear long sleeve shirts;* Roommate;* Floating the resident's heels; and * Placing a rolled towel between his/her ankles.The need to ensure a current service plan was available to staff, provided clear direction, was reflective of current needs, and followed by staff was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional RN) on 2/10/21. They acknowledged the findings. No further information was provided.
2. Resident 2's current service plan, dated 12/23/20, was reviewed along with Interim Service Plans (ISPs) and home health visit notes. Additionally, care staff were interviewed and observed providing care to Resident 2.The following instructions from previous ISPs were not added to the service plan when it was reviewed on 12/23/20:* Float right heel when in bed;* Resident requires two-person transfers;* Reposition several times daily;* Check portable oxygen tank every shift;* Provide frequent checks for incontinence and toileting;* Toilet at least twice per shift;* Resident is now on a pureed-texture diet;* Notify the med tech if the resident refuses to eat;* Rotate (reposition) every 2 hours; and* Get resident up for meals.The service plan was not reflective of Resident 2's current status and care needs, lacked information about the resident, failed to provide specific instructions for staff about how to provide care for the resident or were not followed in the following areas:* The use of "proper footwear" for fall prevention was not described;* "Apply Calzine cream as directed" was unclear;* The proper use of heel protectors;* "Watch and protect feet, especially right foot" was unclear;* Use of sit-to-stand mechanical lift (the apparatus was broken);* Position resident upright at 90 degrees when providing food and fluids;* Oxygen flow rate should be set at 2 liters per minute (LPM);* Specific transfer instructions given resident had sustained a fractured upper arm;* Use of a gait belt for transfers;* Use of a seat cushion;* Use of pillows in the wheel chair for bolsters;* Apply barrier cream after every toileting;* Current skin issues;* Current weight loss;* Current status of catheter;* Proper positioning and monitoring of oxygen tubing following resident's development of sores behind the ear; and* Whether the resident should be dressed in slippers given his/her multiple foot wounds.The need to ensure the service plan provided clear and accurate information and instructions for staff and was followed by staff was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN) on 2/10/21. They acknowledged the findings.
3. Resident 3's current service plans, dated 8/21/19, 11/15/20 and 2/4/21 were reviewed along with Interim Service Plans (ISPs). The service plans dated 11/15/20 and 2/4/21 were not readily available to staff as they were not located in the staff "Service Plans" binder or ISP binder. There were no signature sheets to verify staff had reviewed the most current service plans.The following instructions from previous ISPs were not added to the service plan when it was reviewed on 2/04/21:* Ask resident about pain; ask him/her "does your head hurt, is your head bothering you?";* Encourage resident to use the call light: ensure s/he knows where it's at;* Encourage resident to wear non-slip socks when s/he is in bed;* Ensure resident has water on his/her night stand each night when s/he goes to bed; and* Provide frequent checks throughout the night.The service plan was not reflective of Resident 3's current status and care needs in the following areas:* Recent history of multiple falls and current interventions;* Use of nectar thick liquids;* Use of an anti-coagulant medication;* Use of a nebulizer treatment;* Use of oxygen;* Ambulation and mobility status was unclear (use of wheelchair for mobility); and* Recent weight loss.The need to ensure the service plan provided clear and accurate information and was readily available to staff was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN) on 2/9/21. They acknowledged the findings.


4. Resident 5 was admitted to the facility in July 2017 with diagnoses including Alzheimer's Disease. Review of Resident 5's 4/21/21 service plan revealed it was not accessible to staff, had not been updated quarterly, was not reflective of the resident's status and care needs, did not provide clear instruction to staff and was not followed. Observations during the survey and interviews with multiple staff revealed service plans were inaccessible to caregivers, as they were kept in a locked medication room for which caregivers did not have a key. Documented on the 4/21/21 "change of condition" service plan was a notation that indicated the quarterly service plan was due 4/16/21. During an interview with Staff 20 (RCC), she indicated the 4/21/21 "change of condition" service plan was only updated regarding meal assistance. The 4/21/21 service plan was not reflective of the resident's current status and care needs and did not provide clear direction to staff in the following areas: * Two-person transfers;* Dentures;* Chronic left shoulder dislocation;* Hospital bed;* Evacuation ability;* Fall risk; * Use of white board for communication; * Frequency of toileting; and * Routines for sleep. The service plan did not provide clear instruction to staff regarding the frequency of toileting. Resident 5's service plan indicated s/he was on a mechanical soft diet. During the lunch meal on 5/4/21, the resident was observed to be served whole enchiladas and stalks of cauliflower and broccoli, which were not consistent with a mechanical diet. The need to ensure service plans were accessible to staff, completed quarterly, reflective of residents' current status and care needs, provided clear direction to staff and followed was discussed with Staff 19 (ED/ALF) and Staff 20 (RCC) on May 6, 2021. They acknowledged the findings.
5. Resident 4 was admitted to the facility April 2017 with diagnosis including dementia and Parkinson's disease. Resident 4's current service plan, dated 4/16/21, failed to reflect the resident's care needs or was not followed in the following areas:* Ambulation and mobility;* Nail care;* Oral care;* Bathing; * Transfers; and * Meal assistance. Observation of and interviews with the resident on 5/4/21 and 5/5/21 revealed that the resident was not receiving nail care, did not wear dentures daily, and received his/her first shower since 1/29/21 on 5/5/21. The resident was unable to eat meat that was not cut up by staff due to having one remaining tooth and difficulty cutting food his/herself due to Parkinson's disease tremor. Two meals were observed, with uncut portions remaining when staff removed the meal service items. The need to ensure service plans were reflective of the resident's current care needs, updated with changes and followed was discussed with Staff 6 (Regional RN), Staff 19 (ED/ALF) and Staff 20 (RCC) on 5/6/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction to staff, were readily available for staff to review and were followed by staff for 4 of 4 sampled residents (#s 4, 5, 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility November 2017 with diagnosis including dementia and seizures. Resident 6's current service plan, dated 3/19/21, failed to reflect the residents care needs in the following areas:* Grooming;* Bed baths;* Oral care;* Diet texture; * Providing incontinent care in bed; and * Supervision and redirection regarding a male resident who frequently sat next to the resident, touching his/her hands and thighs. On 5/3/21 Staff 16 (CG) was observed to conduct a one-person transfer of the resident from his/her wheelchair to a couch in the common area. Resident 6 was evaluated to require a two person transfer with gait belt. 2. Resident 7 was admitted to the memory care May 2017 with diagnosis including Alzheimer's disease and major depressive disorder. Resident 7's service plan indicated the resident was to receive "finger foods". On 5/5/21 the surveyor observed staff serve the resident what appeared to be noodles in meat sauce, with a scoop of extra meat sauce near the side of the plate. Resident 7 picked up a spoon, stuck the spoon in the meat sauce, then placed the spoon on the table. The resident then attempted to pick up the noodles and sauce with his/her fingers and place the food in his/her mouth, dropping the noodles on the table. Resident 7 ate less than 25% of his/her meal during the observation. The need to ensure service plans were reflective of the resident's current care needs, updated with changes and followed was discussed with Staff 6 (Regional RN), Staff 19 (ED/ALF) and Staff 20 (RCC) on 5/5/21. They acknowledged the findings. 3. During the entrance conference, 5/3/21, Staff 2 (RN) stated copies of resident service plans were kept in binders in a room near the memory care entrance for staff to access. During an interview on 5/5/21, Staff 20 (RCC) stated the most recent or updated service plans were kept in the binders in the small room for "about a week" then transferred into a different binder in the medication room, which was kept locked. She further stated that often MA's would take the binders into the med room to review or transfer information and not return them. The need to ensure all staff had access to the resident service plans was discussed with Staff 19 (ED/ALF) and Staff 20 on 5/6/21. 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 regarding the delivery of services for 2 of 3 sampled residents (#s 3 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2019 with diagnoses which included dementia. Interviews with staff, review of the clinical record, and observations revealed the service plan did not provide clear direction and was not reflective in the following areas:* Smoking assistance and supervision;* Use of air mattress; and * Injuries.The need to ensure the service plan was reflective of Resident 3's current status and provided clear direction to staff was discussed with Staff 30 (ED) and Staff 32 (RCC) on 11/15/21. They acknowledged the findings.
2. Resident 8 was admitted to the facility in January of 2020 with diagnoses including traumatic brain injury. Interviews with staff, review of the clinical record, and observations revealed the service plan did not provide clear direction and was not reflective in the following areas:* Transfer with a sit to stand;* 2-person transfers; and* Use of fall mat when in bed.The need to ensure the service plan was reflective of resident current care needs and provided clear direction to staff was discussed with Staff 31 (RN) and Staff 32 (RCC) on 11/15/21. They acknowledged the findings.


1.) Resident's #3 & #8 Service Plans have been reiewed and updated to reflect the resident's current care needs and provide clear direction to staff.2.)Resident's Service Plans will be reviewed and updated every 90 days and with change of condition. Service Plan meetings will be conducted with resident representatives and will be attended by the RCC and HSD or ED to assure accuracy.3.) Resident Service Plans will be evaluated and audited every 90 days and as needed.4.) The Executive Director and Health Services Director will be responsible for ensuring the corrections are completed and monitored on resident Service Plans.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 1 of 3 sampled residents (#1). Findings include, but are not limited to:Resident 1 was admitted in 2019 and resided in the MCC during the survey.His/her most recent service plans, dated 8/8/20 and 11/6/20, lacked evidence that a Service Planning Team reviewed and participated in the development.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional RN) on 2/10/21. They acknowledged the findings. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 4 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to:Resident 5 and 6's current service plans were reviewed during the survey. Resident 5 and 6's service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 4 (Regional RN) and Staff 19 (ED/ALF) on 5/6/21. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to monitor a resident consistent with his or her evaluated needs and service plan, for 1 of 3 sampled residents (#2) with a change of condition requiring monitoring. Resident 2 experienced a severe weight loss which was not monitored by the facility, resulting in continued weight loss over the next 60 days. Findings include, but are not limited to:Resident 2 was admitted to the MCC in 9/2020 with diagnoses including vascular dementia and failure to thrive. The record indicated the resident was on monthly weights, but weights were not consistently obtained. The resident was ordered a pureed-texture diet, which s/he received.Review of progress notes and weight record indicated Resident 2's weight on 10/1/20 was 115.5 pounds. On 12/14/20, a MT documented the resident's weight was 102.5 pounds, noting this was a loss of 13 pounds. This represented a loss of 8.65% body weight, and was considered a severe weight loss and a significant change of condition. The MT updated the service plan and instructed staff to continue to get the resident up for meals and provide meal assistance as needed.On 12/16/20, Staff 2 (RN) documented: "Poor appetite continues, with 13 pound weight loss this quarter. Weight currently 102.5 pounds. Health shakes TID." Review of the MARs confirmed health shakes were being provided to the resident three times per day between meals beginning on 12/16/20. Between 12/16/20 and 1/1/21, the facility RN documented two times on the resident's weight loss and interventions, noting both times "Continues to have meals in the dining room this week." There was no evidence the facility monitored the resident's meal intake or the quantity of health shakes consumed. On 1/1/21, the facility recorded Resident 2's weight to be 99.5 pounds. This was an additional loss of three pounds from 12/14/20 and a total loss of 16 pounds over the past 90 days, or 13.85% body weight. This represented a severe weight loss for Resident 2. There was no documented evidence the facility evaluated Resident 2's additional weight loss, and no new interventions were implemented. The only monitoring related to the resident's weight loss, aside from that s/he was eating in the dining room, were progress notes referring to how Resident 2 had done on a particular day: (1/7/21) the resident drank health shakes and ate snacks when offered, (1/14/21) ate well for breakfast, lunch and dinner with assistance, (1/17/21) ate a few bites of food and two health shakes, (1/19/21) ate well and drank two health shakes, (1/20/21) ate well and (1/28/21) resident eating and drinking. The facility RN documented in "RN Assessment of Resident" notes "Appetite adequate" on 1/7/21, 1/13/21, 1/18/21, 1/21/21 and 1/25/21. Resident 2's weight was not obtained at the beginning of February 2021.During the survey, staff were observed to offer the resident a health shake between meals. The staff initially assisted the resident with drinking the shake and then placed the shake out of reach of the resident on a table. The resident was not offered, nor did s/he consume more of the shake; no more than 25% of any shake was consumed during the survey. Staff did get the resident up for almost all the meals and provided hands-on assistance. The resident consumed approximately 50% of each meal.The surveyor requested a current weight for Resident 2 on 2/10/21. Staff 7 (MT) reported the resident's weight at that time was 95.5 pounds. This was an additional loss of four pounds since 1/1/21, a 6.8% loss of body weight in the past 60 days (since the first weight loss was identified) and a total loss of 20 pounds since admission.The facility's failure to monitor Resident 2's weight and interventions for effectiveness, and failure to evaluate the resident's additional weight loss, was reviewed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN) on 2/10/21. They acknowledged the lack of monitoring and evaluation of interventions resulting in continued weight loss.

2. Resident 5 was admitted to the facility July 2017 with diagnoses including Alzheimer's Disease. Progress notes dated 4/11/21 - 5/3/21 and Resident 5's 4/21/21 service plan were reviewed. Multiple staff were interviewed and the resident was observed. An RN progress note dated 4/21/21 stated the resident had a swollen left shoulder which she attributed to "repeatedly dislocating." The note indicated "PCP to be notified for recommendation." The resident was put on alert charting with instructions to "monitor for impaired ROM, pain, redness, warmth and increase in size". Progress note dated 4/22/21: "Appears to be about the size of a soft ball, possibly bigger. "Progress note dated 4/23/21: "Fluid in left shoulder appears to be approximately the size of a soft ball ...No signs or reports of deceased/increased swelling, redness, or pain/discomfort." Progress note written by Staff 23 (MA) on 4/24/21: "Several months ago the resident fell and dislocated the shoulder, the resident was sent to the ER and they were not able to get it back in place. Residents left shoulder was swollen and has never gone down in swelling."On 4/26/21 the RN progress note stated, "The resident is being removed from alert charting for fluid build up to left shoulder. PCP has been notified of issue. Awaiting response. Resident is not in pain/acute distress. "There was no documented evidence in Resident 5's clinical record that the physician had been faxed regarding the dislocation as per the RN note on 4/26/21. During an interview with Staff 23 on 5/4/21, he reported that the resident's left shoulder dislocates and goes back into place frequently. He reported the resident did not complain of shoulder pain with dislocation.During an interview with the RN on 5/4/21, she reported the resident experienced chronic shoulder dislocations since a fall several months ago and that the "softball-size" noted in progress notes was not swelling, but the head of the resident's humerus that had dislocated. She indicated the resident had a small amount of swelling at baseline, which she attributed to a leakage of synovial fluid. There was no documented evidence in Resident 5's facility record that identified the resident had frequent left shoulder dislocations, no evidence the facility had determined what actions and interventions were needed for the resident when the resident's shoulder dislocated and no documented evidence the facility had monitored the 4/21/21 dislocation to resolution.Failure of the facility to determine what actions and interventions were needed for the resident when his/her shoulder dislocated, communicate those actions and interventions to staff and monitor the resident until the condition had resolved was discussed with Staff 2 (RN) on 5/4/21. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure residents with a change of condition were evaluated, resident-specific instructions or interventions were developed, and the conditions were monitored for 2 of 3 sampled residents (#s 5 and 6) who experienced short term changes. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility November 2017 with diagnosis including dementia and seizures. * On 4/24/21 staff documented they found resident on his/her floor "crying" with an approximate one-inch long skin tear above his/her right eyebrow. * On 4/25/21 staff documented resident was being placed on alert for an "injury fall" and skin tear.* On 4/26/21 Staff 2 (RN) documented in the resident progress notes "safety precautions implemented." There was no evidence in the residents record the facility had determined or documented what action or interventions was needed to minimize the resident from future falls, or evidence of documented "safety precautions". The need to ensure actions or interventions were determined and documented when a resident experienced a short term change of condition was discussed with Staff 19 (ED/ALF) and Staff 20 (RCC) on 5/5/21. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment, for 1 of 1 sampled resident (#2) who experienced a severe weight loss. Resident 2 continued to lose weight over the next 60 days. Findings include, but are not limited to:Resident 2 was admitted to the MCC in 9/2020 with diagnoses including vascular dementia and failure to thrive.Between 10/1/20 and 12/14/20, Resident 2 lost 13 pounds or 8.65% body weight which represented a severe weight loss. The facility failed to ensure the RN completed an assessment which included findings which may have been contributing to the weight loss.Between 12/14/20 and 1/1/21, Resident 2 lost an additional three pounds. This represented a loss of 13.85% body weight over the past 90 days and was considered another severe weight loss. There was no documented evidence the facility RN conducted an immediate assessment of this weight loss. No new interventions were implemented to address the weight decline.The surveyor requested a current weight for Resident 2 on 2/10/21. Staff 7 (MT) reported the resident's weight at that time was 95.5 pounds. This was an additional loss of four pounds since 1/1/21, a 6.8% loss of body weight in the past 60 days (since the first weight loss was identified) and a total loss of 20 pounds since admission.The facility's failure to ensure the facility RN completed a comprehensive assessment of Resident 2's weight loss which included findings, resident status and interventions made as the result of the assessment was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN) on 2/10/21. They acknowledged no assessment had been completed and the resident continued to lose weight.Refer to C 270.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2019 with diagnoses including dementia and depressive disorder.Resident 3 had a physician's order, electronically signed and dated 1/31/21, to administer:* Melatonin (sleep aid ) 3 mg every night at bedtime;* Sertraline (anxiety) 25 mg daily; and* Trazodone (Sleep aid/depression) 50 mg every night at bedtime.January 2021 and February 1 - 8, 2021 MARs were reviewed. The resident received the medication as follows: * Melatonin 10 mg every evening;* Sertraline was not on the MAR; and* Trazodone 100 mg every night at bedtime.The failure to follow physician orders as directed was discussed with Staff 1 (Memory Care Director), Staff 2 (RN) and Staff 3 (RCC) on 2/9/21 at 1:30 pm. They acknowledged the findings.
2. Resident 1 was admitted to the MCC in 2019 with diagnoses which included dementia.The resident had an order for Lisinopril 5 mg one tablet daily for high blood pressure. Staff were to hold the medication if the BP was less than 100/60 or heart rate was less than 60. Resident 1's MAR, reviewed from 1/1/21 - 2/8/21, revealed seven occasions when the blood pressure or pulse was outside the parameters. Per the physician order, the Lisinopril should have been held, but staff administered it. The need to ensure medications were administered as prescribed was reviewed with Staff 2 (RN) on 2/9/21, and Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional RN) on 2/10/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#s 4, 5 and 6) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6's 2/17/21 physician orders indicated the resident had been prescribed a pureed diet. During observations of the lunch meals on 5/4/21 and 5/5/21, the resident was served noodles in meat sauce and what appeared to be cut up chicken with steamed vegetables. Neither meal was a pureed consistency. The need to ensure physician orders were carried out as prescribed, including diet texture orders, was discussed with Staff 6 (Regional RN) and Staff 19 (ED/ALF) on 5/6/21. They acknowledged the findings.

3. Resident 5's signed physician orders dated 4/21/21 and located in the resident's facility record indicated the resident was to be served a mechanical soft diet. Observation of the lunch meal on 5/4/21 revealed the resident was served enchiladas and vegetables that were not prepared in accordance with the order. The need to ensure physician's orders were carried out as written was discussed with Staff 19 (ED/ALF) and Staff 20 (RCC) on 5/6/21. They acknowledged the findings.
2. On 3/26/21 Resident 4's physician ordered Oyst Calcium be provided to the resident twice daily for osteoporosis. The facility did not administer this medication until 4/16/21, as the medication was not on-site. The need to ensure physician's orders were carried out as written was discussed with Staff 19 (ED/ALF) and Staff 20 (RCC) on 5/6/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included specific instructions for PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:Residents 1 and 2's MARs were reviewed from 1/1/21 through 2/8/21, and the following was noted:* Resident 1 had an order, dated 2/6/21, for PRN CBGs when s/he displayed signs and symptoms of low or high blood sugar. The 2/2021 MAR lacked information about the new order. In an interview with Staff 1 (Memory Care Director) on 2/10/21, she acknowledged the CBG order was never transcribed onto the current MAR; and * Resident 2's MAR lacked resident-specific instructions for PRN Miralax (bowel medication).On 2/10/21, the need to ensure MARs were accurate and included required information was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional RN). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 2 of 3 sampled residents (#s 4 and 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 4's 4/11/21 through 5/3/21 MARs were reviewed during the survey. The following deficiencies were identified:Resident 4 was prescribed Diclofenac Sodium 1% Gel (for knee pain) and Oyst Calcium (for osteoporosis). There were two times when the facility documented the Diclofenac was administered and three times when the facility documented the Oyst Calcium was administered, when the prescriptions were not available on site.The need to ensure MARs were reviewed for accuracy was discussed with Staff 19 (ED/ALF), Staff 20 (RCC) and Staff 6 (Regional RN) on 5/6/21. They acknowledged the findings.

2. Resident 6's 4/11/21 through 5/3/21 MAR's lacked clear parameters on which medication to administer first for PRN pain medication morphine and Tramadol. The need to ensure clear parameters for PRN medications administered by non-licensed staff was discussed with Staff 6 (Regional RN) and Staff 19 (ED/ALF). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 2 of 3 sampled residents (#s 2 and 3) whose TARs were reviewed. Findings include, but are not limited to:a. Resident 2's records indicated that between 1/1/21 and 2/9/21, facility staff administered treatments, including wound care, for the following conditions:* A skin tear to the right shin;* Discharge from the perineal area;* A pressure ulcer on the right heel;* An open area and rash on the chest;* A skin tear to the left shin; and* A skin tear to the top of the right foot.b. Resident 3's records indicated that between 1/30/21 and 2/4/21, facility staff administered treatments, including wound care, for the following conditions:* A skin tear to the right arm;* A skin tear to the stomach; and* A wound to the right hip.The facility failed to document any of the treatments it administered on Resident 2 or Resident 3's TARs.The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Regional RN) on 2/10/21. Staff 2 acknowledged treatments administered by the facility were not being documented on resident TARs.

Based on interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 1 of 3 sampled residents (# 6) whose TARs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility 11/2017 with diagnoses including dementia and seizures. Resident 6 had an unwitnessed fall on 4/24/21 which resulted in a skin tear above the resident's right eyebrow. Staff documented in the resident's progress notes on 4/24/21 and 4/25/21 "cleaned skin tear" and the area had been "cleaned" no signs of infection. The facility failed to document the treatments on the resident's TAR. The facility's lack of an accurate treatment record was discussed with Staff 6 (Regional RN) and Staff 19 (ED/ALF) on 5/6/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to employ a full-time Administrator scheduled to be on-site at least 40 hours per week. Findings include, but are not limited to:During the entrance conference conducted 5/3/21, Staff 19 (ED/ALF) stated the former administrator of record for the MCC had quit on 4/9/21 and the temporary administrator of record was Staff 6 (Regional RN), however she was not in the building. Multiple staff interviews were conducted during the course of the revisit survey. None of the staff interviewed were able to state who was in charge of the memory care. Several staff stated there had been no management oversight of the memory care for "several weeks". In an interview on 5/6/21, Staff 6 acknowledged she did not spend 40 committed hours a week in the Memory Care Community. The need to ensure the facility employed a full-time administrator scheduled to be on-site at least 40 hours per week was reviewed with Staff 19 on 5/6/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, which put residents at risk for serious harm. Findings include, but are not limited to: 1. The memory care consisted of two separate units, "Willow" and "Diamond". During the entrance conference on 5/3/21 the following was identified: Willow had a census of seven. Two residents required two staff for transfers, three residents needed assistance with all ADL's including full assist with meals, and one resident was on hospice. Diamond had a census of 10. Two residents were two person transfers, one resident was on hospice, and three residents needed staff supervision to smoke multiple times throughout day. 2. On 5/3/21 at approximately 1:30 pm Staff 19 (ED) was asked to provide survey with a current staff list and staff schedule for the MCC. Staff 19 stated she only had a copy of the "day shift" schedule and provided a copy of a staff list that had multiple staff marked off. Staff 19 then stated about eight staff had quit recently but was not sure how many of those staff had worked in memory care. The staffing plan provided by the facility was as follows: * Day and Evening shifts 2 MA's and 4 CG's; and* Night shift 1 MA, 4 CG's At 5:49 pm Staff 20 (RCC) provided survey with schedules for all three shifts and a corrected staff list. Staff 20 confirmed the memory care had only been staffing one caregiver on each unit for the night shift. 3. At 6:19 pm survey requested an immediate plan of correction to ensure a minimum of two staff were available on each unit. At 8:11 pm the facility submitted a plan of correction. The plan was accepted, and the situation was abated. 4. Observations and interviews at the time of survey showed the following: * On 5/3/21 Staff 22 (CG) stated a lot of staff had recently quit, there use to be two caregivers scheduled for each side of the memory care on evening shift, but "lately" there had been only one caregiver per side with a float who went back and forth. * On 5/4/21 Staff 26 (CG/ALF) was observed working on the Willow side of the memory care. Staff 26 stated she had never worked in the memory care and thought it was just for one shift.* On 5/5/21 Staff 27 (CG/ALF) was observed working on the Willow side of the memory care and confirmed she was from ALF and had not worked in memory care before. Staff 17 (CG) stated that on most days only one CG was scheduled to work on each side with a float that goes back and forth between Willow and Diamond.* No activities were observed during the survey. 5. Time clock records, 4/12/21 through 5/2/21, were requested, reviewed, and compared to the facility's staffing plan. (The facility was unable to provide an accurate staff schedule for comparison.) *Day shift was short one staff seven times and two staff three times ;*Evening shift was short one staff six times and two staff four times; and *Nights shift was short one staff two times, two staff nine times, and three staff twice . The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 19 (ED) during the survey. No further information was received.
Based on observation, interview, and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to: The memory care consisted of two distinct units, Willow and Diamond, separated by two sets of secured double doors. Diamond had a census of five. Two residents needed assistance with all ADL's. Two residents needed staff supervision to smoke multiple times throughout the day and night.Willow had a census of one resident who was a two person transfer and needed assistance with all ADL's including feeding assistance. The resident spent the day on Diamond for activities and meals but would return to Willow for naps and to sleep at night.The staffing plan provided by the facility was as follows: * Day and Evening shifts 1 MA and 2 CG's; and* Night shift 1 MA, 1 CG's. The staffing schedule from 10/31/21 to 11/16/21 was reviewed on 11/15/21 and revealed there were routinely only two staff scheduled for the Night shift and occasionally two staff for the Day and Evening shifts.The need to ensure a minimum of three staff at all times to meet the scheduled and unscheduled needs of residents and to not leave one unit unattended was discussed with Staff 30 (ED) and Staff 32 (RCC). They acknowledged the findings and immediately increased the staff levels.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 155, C160, C 200, C 231, C 260, C 262, C 270, C 303, C 310, C 315, C 513, Z 155, and Z 164.
Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 260, C 360, C 513, Z 142, Z 155, and Z 164.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:Observation of the facility on 2/8/21 and 2/9/21 revealed the following deficiencies:* Throughout the facility, there were dings, dents and scratches on the walls;* Multiple resident room doors had chipped paint;* Handrails throughout the facility had dings, dents and scratches;* Multiple corners throughout the facility were damaged;* Wood furniture throughout the facility had dings, dents and scratches;* Room 307 B had a broken grab bar in the bathroom with nine screw holes in the wall which had not been repaired; and* Blinds in the living room on Diamond unit were broken. On 2/9/21, the surveyor discussed and reviewed the areas requiring cleaning and repair with Staff 1 (Memory Care Director). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the facility was clean and in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the memory care facility, conducted 5/4/21 and 5/5/21 showed the following:* Chipped, dinged, gouged, scratched and scuffed walls, molding, doors and door frames throughout the facility, including inside resident units and the common areas; and* Dry wall that was previously repaired was observed to have holes and tears in multiple locations.The need to maintain the interior of the facility and all equipment and surfaces were clean and in good repair was discussed with Staff 19 (ED/ALF), Staff 20 (RCC) and Staff 6 (Regional RN) on 5/6/21. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the facility was clean and in good repair. This is a repeat citation. Findings include, but are not limited to:A tour with Staff 30 (ED) of the memory care facility, conducted 11/15/21 revealed the following:Chipped, dinged, gouged, scratched and scuffed walls, molding, doors and door frames throughout the facility, including common areas and inside resident units.The need to ensure the interior of the facility and all equipment and surfaces were in good repair was discussed with Staff 30 on 11/15/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision and overall conduct of the staff.During the revisit survey, conducted 5/3/21 through 5/7/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey. Refer to deficiencies in report.

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 155, C 160, C 200, C 231 and C 513.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 152, C 155, C160, C 200, C 231, C 240, C 350, C 360 and C 513.


Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 360 and C 513.
1.) Refer to correction plan for C360 and C513.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 2 of 2 newly hired direct care staff (#s 11 and 12) and annual training was completed and documented for 2 of 2 veteran direct care staff (#s 9 and 10). Findings include, but are not limited to:On 2/9/21, training records were reviewed with Staff 4 (Business Office Manager).Staff 11 (CG) was hired on 1/6/21 and Staff 12 (CG) was hired on 12/16/21. Review of the facility training records revealed Staff 11 and 12 did not complete the following pre-service and competency training before providing care and services independently:* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and use of person-centered approach;* Family support and the role the family may have in the care of the resident;* Identification, documentation and reporting changes of condition; and* Conditions that require an assessment, treatment, observations and reporting.Staff 9 (MT) was hired on 9/18/19 and Staff 10 (CG) was hired on 3/8/18. Review of the facility training records revealed Staff 9 and 10 did not complete 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care.The need to ensure all newly hired staff completed pre-service orientation and all veteran staff completed 16 hours of annual training was discussed with Staff 1 (Memory Care Director) and Staff 3 (RCC) on 2/9/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 26 and 27) completed training on all required pre-service orientation and dementia topics and demonstrated competency in all required areas related to the provision of care within 30 days of hire. This is a repeat citation. Findings include but are not limited to:Staff training records were reviewed with Staff 4 (Business Office Manager) on 5/4/21. Staff 26 (MA), hired 3/30/21, lacked documented evidence the following pre-service dementia care trainings had been completed: * Specific aspects of dementia care and ensuring safety of residents with dementia including the use of person-centered approach; and * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment. Staff 27 (CG), hired 4/10/21, lacked documented evidence the following trainings had been completed: * Pre-service orientation related to fire safety and emergency procedures; * Pre-service dementia training as follows: a. Dementia disease process including progression of the disease, memory loss, and psychiatric and behavioral symptoms.b. Specific aspects of dementia care and ensuring safety of residents with dementia including use of person-centered approach; c. Family support and the role the family may have in the care of the resident;d. Environmental factors that are important to a resident's well-being; and e. How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment. Review of the facility training records revealed the facility failed to document the method used to determine competency for Staff 26 (MA) and Staff 27 (CG) in the following required areas: * The role of service plans in providing individualized resident care;* Providing assistance with the activities of daily living;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation; and* Reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* First aid/Abdominal thrust. The failure of the facility to ensure all newly hired staff completed training on all pre-service orientation and dementia topics and demonstrated competency in all required areas within 30 days of hire was discussed with Staff 19 (ED/ALF) and Staff 4 (RCC) on 5/6/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (#33) demonstrated competence in job duties within 30-days. This is a repeat citation. Findings include, but are not limited to:A review of staff training records revealed:Staff 33 (CG) was hired 07/07/21. There was no documented evidence s/he had demonstrated competency in his/her job duties within 30 days of hire in the following areas: * The role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition; and* Conditions that require assessment, treatment, observation, and reporting.The facility's failure to ensure staff completed all required training was discussed with Staff 30 (ED) and Staff 4 (Business Office Manger) on 11/16/21. 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 262, C 270, C 280, C 303, C 310 and C 315.

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 C 260, C 262, C 270, C 303, C 310, C 315 and C 243.
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 C 260.

Based on observation, interview and record review, it was determined the facility failed to develop an individualized activity plan based on their activity evaluation, for 1 of 3 sampled residents (#2) whose activity plans were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the memory care community (MCC) in 9/2020 with diagnoses including vascular dementia and failure to thrive. The resident required full assistance with activities of daily living (ADLs) due to physical and cognitive limitations.The resident's service plan, dated 12/23/20, stated:* Resident "prefers to just relax and listen to music."* Resident prefers small group size and "will be assisted to and from activities."In the late morning on 2/9/21, Resident 2 was observed awake in his/her recliner in his/her room. Staff did not provide any activities for the resident. Though the resident had a TV in the room, Staff 17 (CG) explained the remote had been misplaced so staff couldn't play any DVDs for the resident and the resident had no means of listening to music in his/her room. After lunch, staff positioned the resident in his/her wheelchair in front of the TV in the common living room with children's cartoons playing on the TV.The requirements regarding activity evaluations and developing individualized activity plans were reviewed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Life Enrichment) and Staff 6 (Regional RN) on 2/10/21. They acknowledged the lack of an individualized activity plan for Resident 2.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 4, 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 4, 5 and 6's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's: * 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. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. No group or individualized activities were observed during the course of the revisit survey. The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 6 (Regional RN) and Staff 19 (ED/ALF) 5/6/21. They acknowledged the findings

The findings of the Health and Safety Monitoring survey conducted 1/7/21 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. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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. Failure to follow infection control guidelines to prevent the spread of COVID-19 put residents at serious risk. Findings include, but are not limited to:During the Health and Safety Monitoring Survey, conducted 1/7/21, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. At the time of the survey, there were residents who had either tested positive for or were showing symptoms of COVID-19. Deficiencies that were identified included, but were not limited to:*Witness 1 ( Hospice Service Provider) did not doff Personal Protective Equipment (PPE) upon exiting a resident's room who tested positive for COVID-19 in accordance with infection control guidelines and walked throughout the facility;*Staff 8 (Resident Assistant) did not follow infection control guidelines when transporting linens and clothing of a resident who tested positive for COVID-19; and*Multiple staff were wearing safety glasses, not face shields or goggles.Infection control practices that had been issued by the Oregon Department of Human Services were reviewed with Staff 1 (Assisted Living Executive Director), Staff 2 (Memory Care Administrator) and Staff 3 (Resident Care Coordinator) on 1/7/21. They acknowledged the need for increased oversight of infection control practices in the building.

Based on observation and interview, it was determined the facility failed to provide a safe and homelike environment for 1 of 1 sampled resident (#1) whose apartment was viewed. Findings include, but are not limited to:During an environment tour of the Diamond side, Resident 1's bed linen was stained with yellow and brown matter. The room had an malodorous smell. In an interview on 1/7/20, Staff 5 (Resident Assistant) stated Resident 1 did not allow staff to enter the room to clean or provide laundry services. The need to provide a safe and homelike environment was discussed with Staff 1 (Assisted Living Executive Director), Staff 2 (Memory Care Administrator) and Staff 3 (Resident Care Coordinator) on 1/7/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 160 and C 200.