Pacific View Memory Care Community

The findings of the change of ownership survey, conducted 03/04/24 through 03/07/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the change of ownership survey of 03/07/24, conducted 08/26/24 through 08/28/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules.Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the change of ownership survey of 03/07/24, conducted 11/21/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

3. Resident 1 moved into the MCC in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and type 2 diabetes mellitus.A review of Resident 1's progress notes and interim service plans (ISPs), from 02/06/24 through 03/04/24, identified the following:A progress note dated 02/16/24 indicated the resident sustained a skin tear on the top of his/her left hand. This constituted an injury of unknown cause.On 03/05/24, Staff 2 (LPN) confirmed the facility had not completed an investigation or incident report to rule out abuse or reported the injury to the local SPD office if abuse or suspected abuse could not be ruled out.The need to ensure injuries of unknown cause were promptly investigated to rule out abuse or neglect was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN). They acknowledged the findings, and no additional documentation was provided.
Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect, investigations included documentation of follow-up action taken, and incidents were reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out for 3 of 3 sampled residents (#s 1, 2, and 3) with incidents including unwitnessed falls and injuries of unknown cause. Findings include, but are not limited to:1. Resident 2 moved into the facility in 03/2023 with diagnoses including dementia and failure to thrive.A review of Resident 2's progress notes, dated 12/18/23 through 03/04/24, and incident reports and interim service plans (ISPs) for the same time period identified the following:A progress note dated 02/21/24 noted the resident's left outer and inner thigh had discoloration. This constituted an injury of unknown cause. There was no documented evidence the facility completed an investigation to rule out abuse or report to the local office if abuse or suspected abuse could not be ruled out.On 03/07/24, the need to ensure all injuries of unknown cause were investigated to rule out suspected abuse, or reported to the local office if suspected abuse could not be ruled out, was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings.2. Resident 3 moved into the facility in 07/2022 with diagnoses including dementia.The service plan, dated 01/17/24, noted Resident 3 required one-person assist for walking with a gait belt. The service plan also noted Resident 3 was a high risk for falls with the following fall interventions in place: staff were to ensure his/her room was clutter free, provide frequent checks, HH PT referral completed, and twin bed was replaced with a full-size bed.Review of the resident's charting notes, dated 12/03/23 through 03/04/24, and incident reports and interim service plans (ISPs) for the same time period identified Resident 3 had 11 unwitnessed falls.The facility provided investigations of the falls; however, the investigations failed to document what follow-up actions were taken and if the service-planned fall interventions were in place at the time of the unwitnessed falls, to reasonably conclude suspected abuse in the form of neglect was ruled out.On 03/06/24, the need to ensure all investigations of incidents included and documented what follow-up action was taken, ensured the service-planned interventions were being followed at the time the incident occurred, and suspected abuse was ruled out or the incident was reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure unwitnessed falls with injuries were promptly investigated to rule out abuse and neglect or reported to the local SPD office as suspected abuse for 1 of 2 sampled residents (# 5) reviewed with reportable incidents. This is a repeat citation. Findings include, but are not limited to: Resident 5 moved into the memory care community in 02/2023 with diagnoses including unspecified dementia.The resident's service plan last updated on 06/25/24, temporary service plans, incident reports, progress notes from 05/10/24 through 08/05/24, observations of the resident, and interviews with care staff identified the following:a. Resident 5 was observed to walk without assistive devices and unassisted by staff multiple times during the survey from 08/26/24 through 08/27/24. Resident 5 had a shuffled and unbalanced gait and wore non-skid socks throughout the survey observations. b. Resident 5's service plan and temporary service plans noted the following fall interventions:* Wear proper footwear;* Wear well fitted clothing, make sure pants were fastened and belt was on properly;* Clutter free environment;* Remove furniture from fall space;* Frequent safety checks;* Watch for (the resident) carrying (his/her) cane and not using it properly;* Cue to use the bathroom and escort to meals and activities; * Two-hour toileting schedule; and* Walk with him/her at all times. c. Resident 5 had the following falls:* 05/17/24: Unwitnessed fall; * 05/28/24: Unwitnessed fall in the resident's room;* 05/28/24: Second unwitnessed fall on the same day; in the resident's room; * 06/08/24: Witnessed fall with four skin tears to the left elbow;* 07/01/24: Witnessed fall in the hallway that resulted in pain requiring PRN morphine to be administered;* 07/11/24: Unwitnessed fall resulting in a skin tear to the right arm;* 07/19/24: Unwitnessed fall in the resident's room which resulted in injuries to the head and a open wound to the left forearm; and* 07/22/24: Unwitnessed fall in the resident's room which resulted in redness to the right side of the forehead. The facility investigations for the above falls failed to determine if the service planned fall interventions were being implemented at the time the falls occurred therefore, the facility was not able to reasonably rule out suspected abuse and was required to report the falls to the local SPD office. In an interview with Staff 1 (ED) on 08/28/24 at 2:15 pm, the facility had not reported any of the above falls to the local SPD office. Survey requested the facility to self-report the above falls. Verification was received prior to survey exit on 08/28/24. The need to ensure a prompt facility investigation reasonably concluded and documented the falls were not the result of suspected abuse was discussed with Staff 1 (ED) and Staff 21 (Vice President of Operations) on 08/28/24 at 2:15 pm. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation, and food service on 03/04/24 and 03/05/24 revealed the following areas in need of cleaning or repair:* The faucet located above the three-compartment sink in the dish area and the faucet located to the left of the stove were constantly dripping;* The wall located to the right of the stove had exposed dry wall present, thus making it an uncleanable surface; and* The heating unit, directly above the food on the steam table, was rusted.The need to ensure the kitchen was maintained in accordance with the Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 19 (Director of Dining Services) on 03/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1) whose new move-in evaluation was reviewed. Findings include, but are not limited to:Resident 1 moved into the MCC in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and chronic pain syndrome.A review of Resident 1's move-in evaluation, dated 01/31/24, identified the facility failed to address the following required elements:* Spiritual preferences and traditions;* Mental health issues, including history of treatment and effective non-drug interventions; and* Pain, including non-pharmaceutical interventions and how a person expresses pain or discomfort.The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

3. Resident 1 was admitted to the MCC in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and type 2 diabetes mellitus.Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/31/24, and interim service plans and progress notes from 01/31/24 through 03/04/24 were completed.a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts:* 02/16/24 - Skin tear to left top hand; and* 02/28/24 - Difficulty swallowing, throat pain, and "feeling under the weather."b. The following short-term changes of condition lacked communication of the determined actions or interventions to staff on all shifts and documentation of progress noted at least weekly through resolution:* 02/06/24 - Excoriation/abrasion on the left glut.The need to ensure actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift, and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to evaluate, determine and document what action or interventions were needed for short-term changes of condition, communicate the actions and/or interventions to staff on each shift, monitor the condition at least weekly, with progress noted until the condition resolved, and/or failed to monitor residents consistent with their evaluated needs or service plans for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 03/2023 with diagnoses including dementia and failure to thrive.Resident 2's progress notes, dated 12/18/23 through 03/04/24, incident reports and interim service plans (ISPs) for the same time period, and service plan, dated 01/16/24, were reviewed during the survey.The following changes of condition lacked documented evidence the facility evaluated and determined what action or intervention was needed for the resident's condition, communicated the resident's condition to staff on each shift, and/or monitored the condition at least weekly through resolution.* 12/18/23 - Pain in rectum;* 12/28/23 - "Suspecting a UTI" [urinary tract infection];* 01/30/24 - "Collect urine sample to rule out UTI";* 01/31/24 - Chest scan identified a small spot of pneumonia and a new antibiotic would be prescribed;* 02/01/24 - New medication furosemide;* 02/06/24 - Blood blister 2x2 cm; and* 02/21/24 - Discoloration to the outer and inner left thigh.The need to ensure the facility evaluated, determined actions or interventions needed, communicated the actions/interventions to staff on each shift, and monitored the condition through resolution was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.2. Resident 3 moved into the facility in 07/2022 with diagnoses including dementia.The service plan, dated 01/17/24, noted Resident 3 required one-person assist for walking with a gait belt. The service plan also noted Resident 3 was a high risk for falls with the following fall interventions in place: staff were to ensure his/her room was clutter-free, provide frequent checks, HH PT referral was completed, and twin bed was replaced with a full-size bed.The following evaluated conditions lacked documented monitoring and review of the interventions for effectiveness:* Resident 3 had 12 falls from 11/26/23 through 03/01/24.There was no documented evidence the facility evaluated each subsequent fall to determine what actions or interventions was needed, communicated the actions or interventions to staff on each shift, reviewed previous fall interventions for effectiveness, and monitored the resident's condition, with progress noted at least weekly, until resolved.The need to ensure residents were monitored per their evaluated care needs, the determined actions or interventions were reviewed for effectiveness, changes of condition were communicated to staff, and conditions were monitored at least weekly until resolved was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/06/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#2) who experienced a significant change of condition related to weight gain. Findings include, but are not limited to:Resident 2 moved into the facility in 03/2023 with diagnoses including hyperlipidemia, hypertension, and unspecified dementia. The resident was identified during the acuity interview as having had weight changes. The resident's current service plan, dated 01/16/24, and weight records dated 11/07/23 through 02/20/24 were reviewed, observations were made, and interviews were conducted during the survey.On 03/04/24 the resident was observed to remain in bed from 8:00 am to 4:30 pm. A caregiver was observed feeding the resident soup while s/he remained in bed.During an interview on 03/06/24 at 5:30 pm, Staff 4 (RCC) reported the resident ate 100% of dinner meal.Review of the resident's monthly weight records from 11/07/23 through 02/20/24 showed the following:* 12/07/23 - 167.1 pounds;* 01/07/24 - 162.1 pounds;* 02/07/24 - 175.2 pounds* 02/20/24 - 180.2 pounds; and* 03/06/24 - 166.2 pounds (obtained during survey).The surveyor was unable to verify the weight with a re-weigh because the resident was tired and requested to be transferred to his/her bed. Later that same day the resident was transported to the hospital.From 01/07/24 to 02/07/24, the resident gained 13.1 pounds, which constituted a severe weight gain of 7.477 % in one month. This weight gain represented a significant change of condition and required an RN assessment.There was no documented evidence an RN completed an assessment which documented and included findings of the assessment, resident status, and interventions made as a result of the assessment and updated the plan of care as appropriate.On 03/07/24 the need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care for 1 of 1 sampled resident (#3) who received home health services. Findings include, but are not limited to:Resident 3 moved into the facility in 07/2022 with diagnoses including dementia and repeated falls.During the acuity interview on 03/04/24, Staff 2 (LPN) reported Resident 3 had frequent falls and was receiving HH PT services.Review of the resident's clinical record, including interim service plans (ISPs), current service plan, and charting notes dated 12/18/23 through 03/04/24 identified the following:* On 12/28/23 the facility sent a request for HH PT/OT to evaluate and treat weakness and help with transfers. The physician signed the order on the same day;* On 01/24/24 the physician signed a second order for HH PT referral; and* On 02/20/24 there was a HH PT provider note left at the facility.There was no documented evidence HH PT/OT left any additional information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care.During an interview on 03/06/24, Staff 2 reported the facility didn't have the initial evaluation and plan of care from the HH PT/OT; however, she confirmed the resident was receiving home health services. Additionally, it was reported the facility was having difficulty with the provider leaving notes after the visits.On 03/06/24, a home health service provider was observed meeting with the resident.On 03/07/24, the need to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for the facility staff to provide supplemental care was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment, which included implementing protocols to prevent the development and transmission of communicable diseases. Findings include, but are not limited to:During the acuity interview conducted on 03/04/24 with Staff 2 (LPN), the facility identified several residents with suspected respiratory illness and/or symptoms of unknown pathogen.a. Per Oregon Health Authority Summary of Long-Term Care Facility Infection Control Policies for Other Respiratory Pathogens, facilities were required to ensure:* "Staff caring for residents with suspect or confirmed respiratory pathogens are required to wear a fit-tested N 95 respirator or surgical mask, eye protection, gown, and gloves."b. Observations of staff during the survey, from 03/04/24 through 03/07/24, identified multiple instances where staff failed to wear a surgical face mask when providing resident care to the residents who were identified with respiratory illness and/or symptoms that had not been evaluated to determine the symptoms were not communicable.Additionally, multiple symptomatic residents were observed dining in groups and participating in group activities with asymptomatic residents.The need to ensure the facility implemented and maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was reviewed with Staff 1 (ED), Staff 2, Staff 3 (RN), and Staff 20 (Infection Control Specialist) on 03/06/24. They acknowledged the findings.

2. Resident 2 moved into the facility in 03/2023 with diagnoses including hyperlipidemia, hypertension, and unspecified dementia.Review of the resident's 02/01/24 through 03/06/24 MARs and current prescriber orders identified the following medication was not carried out as prescribed:Aspirin 81 mg, give one tablet per day had been discontinued on 03/01/24; however, the medication had been transcribed on the March 2024 MAR and was being administered from 03/02/24 through 03/06/24.The need to ensure the facility had current orders for all medications the facility was responsible to administer was discussed with Staff 1 (ED) and Staff 2 (LPN) on 03/07/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and chronic pain syndrome.Resident 1's current physician orders and MAR, dated 02/01/24 through 02/29/24, were reviewed and revealed the following:The resident had physician orders dated 02/15/24 for the following medications:* Acetaminophen 325 mg - Take two tablets by mouth every four hours as needed for pain and/or fever over 101 degrees. If ineffective after one hour, may give oxycodone for severe pain;* Oxycodone 5 mg - Take one tablet by mouth every six hours as needed for moderate pain. Must try Tylenol first, then if ineffective after one hour, may use oxycodone; and* Lidocaine 5% patch - Place one patch onto the skin every day for 12 hours on and remove for 12 hours (for leg pain).a. Between 02/15/24 and 02/29/24, Resident 1's MAR indicated the resident was administered oxycodone prior to or instead of acetaminophen on seven occasions. The facility failed to ensure physician written parameters were carried out as prescribed.b. Between 02/21/24 and 02/25/24, the resident's Lidocaine patch was documented as not available and was not administered on five occasions. The facility failed to ensure physician orders were carried out as prescribed.On 03/06/24 at 3:01 pm, the surveyor and Staff 10 (MT) reviewed the electronic MAR and medication supply. Staff 10 confirmed the Lidocaine patch was not administered because the medication was not available.The need to ensure all medications were carried out as prescribed and written was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT and documentation of the use of the device was included in the resident's service plan for 1 of 2 sampled residents (#1) who had side rails. Findings include, but are not limited to:Resident 1 was admitted to the facility in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and chronic pain.Resident 1 was observed to have a hospital bed with full side rails. The side rails at the head of the bed were elevated throughout the survey. The side rails at the foot of the bed were in the lowered position during all observations.There was no documented evidence the following required elements were completed:* Assessment by an RN, PT, or OT; and* Documentation of the use of side rails in the resident's service plan.On 03/07/24, Staff 2 (LPN) confirmed she had completed the resident's "Supportive Devices with Restraining Qualities Assessment."The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, and was included in the resident's service plan, was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:On 03/05/24 and 03/06/24, fire and life safety records, dated 08/2023 through 02/2024, were reviewed. The fire drill records lacked the following components:* Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed;* All staff members on duty and participating; and* Number of occupants evacuated.Due to the escape route not being documented, there was no evidence alternative routes were used during fire drills.Additionally, any problems encountered with residents being resistive to participate in drill were not documented; thus, the facility was unable to determine if the evacuation standard had been met.The need to ensure fire drills included documentation of all required elements was discussed with Staff 1 (ED) on 03/06/24. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 231.

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The interior of the MCC was toured on 03/04/24. The following areas were observed to need cleaning and/or repair:* Benches throughout the MCC were stained and had scrapes or gouges in the wood;* Armchairs near room 5 were stained, fabric was faded, and the wood had scrapes or gouges;* Side table near room 5 had gouges in the finish, chipped paint, and a spill which was sticky to the touch;* Armchairs in the activity room were stained and had frayed and worn fabric; and* Dining chairs throughout the MCC had staining and food debris/spills.The environment was toured with Staff 1 (ED) and Staff 4 (RCC) on 03/05/24. The findings were discussed again with Staff 1, Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the above areas needed to be cleaned and repaired.

Based on observation and interview, it was determined the facility failed to ensure a one-way flow of soiled laundry to preclude potential contamination and to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:A tour of the laundry facilities throughout the MCC and interviews with staff between 03/04/24 and 03/07/24 revealed the following:The facility had two laundry rooms where linens were washed. Soiled linens were cleaned in a separate room across from the "Dirty Utility Room" (DUR). The DUR laundry room had two doors leading to the hallway and a single residential washing machine with no indicator of rinse temperature. On 03/05/24, Staff 10 (MT) reported facility staff only used the door directly across from the DUR to bring in soiled linens and take out clean laundry.Throughout the MCC, interviews with both housekeeping and caregiving staff indicated the facility used a single laundry detergent with no other chemicals added when laundering all linens. During the walk-through with Staff 1 (ED) on 03/05/24, she confirmed the rinse cycle for soiled linens does not reach the required temperature.On 03/07/24 at 2:09 pm, Staff 7 (Housekeeping Supervisor) stated, "I looked into [whether the laundry detergent had a chemical disinfectant] and called our guy. It absolutely does not have a chemical disinfectant."The need to ensure a one-way flow of soiled laundry to preclude potential contamination and to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1, Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They 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 they were installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:The MCC was toured on 03/05/24 and an electric fireplace was observed in the dining room. The fireplace was on the high setting, and although the glass was cool to the touch, the fireplace had a heating element that produced a stream of hot air. The fireplace was located in a place where a resident could come into incidental contact with the fireplace and the hot air it produced.The temperature of the hot air was measured on 03/05/24 with a digital thermometer on both the high and low setting with Staff 12 (MT/Care Partner) present. When the fireplace was switched to high, the temperature of the hot air reached above 190 degrees F. When the fireplace was switched on low, the temperature of the hot air reached above 135 degrees F. Staff 12 was instructed to ensure the heating unit remained off for resident safety. During additional observations, the heating unit remained off.The need to ensure wall heaters and associated heating elements did not exceed 120 degrees F when they were installed in locations that were subject to incidental contact by residents was discussed with Staff 1 (ED) on 03/05/24 and again on 03/07/24. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to: C 231, C 240, C 420, C 513, C 530, and C 540.
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 231.
Refer to C 231.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired direct care staff (#s 14, 15, 16, and 17) completed all required orientation training topics within required timelines, 2 of 2 non-direct care staff (#s 5 and 18) completed infectious disease prevention training and 3 of 3 long-term direct care staff (#s 8, 10 and 11) completed a total of 16 hours of in-service training annually, which included annual infectious disease prevention training. Findings include, but are not limited to:Training records were reviewed with Staff 1 (ED) on 03/05/24. The following deficiencies were identified:a. The following newly-hired direct care staff failed to complete orientation training for infectious disease prevention:* Staff 14 (CG), hired 02/08/24;* Staff 15 (CG), hired 02/09/24;* Staff 16 (CG), hired 02/14/24; and* Staff 17 (CG), hired 02/28/24.b. The following long-term and/or non-direct care staff failed to complete infectious disease prevention at hire and/or annually thereafter:* Staff 5 (Activities Director), hired 01/11/13; and* Staff 18 (Housekeeping), hired 11/06/23.c. The following long-term direct care staff failed to complete 16 hours of annual in-service training that included at least 10 hours of CBC provision of care topics and annual infectious disease prevention training:* Staff 8 (MT), hired 02/15/21;* Staff 10 (MT), hired 02/04/21; and* Staff 11 (MT), hired 11/12/21.The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties, all non-direct care staff completed annual infectious disease prevention training, and long-term direct care staff completed 16 hours of annual in-service training, which included at least 10 hours related to provision of care topics and annual infectious disease prevention training, was reviewed with Staff 1 on 03/05/24. She 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 252, C 270, C 280, C 290, C 295, C 303, and C 340.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height. Findings include, but are not limited to:The facility was endorsed as a secure Memory Care Community for residents with a diagnosis of dementia. The building and its residents had access to an outdoor recreation area.The outdoor recreation area was toured on 03/05/24. There was a wooden fence surrounding the perimeter of the secured area, which was built on a hill. The fence had different height measurements based on the positioning on the hill, with areas near the dining room door and gazebo measuring below six feet.The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height was discussed with Staff 1 (ED) on 03/05/24. She acknowledged the height of the fence was less than six feet in areas.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their rooms. Findings include, but are not limited to:The MCC was toured on 03/04/24 through 03/07/24. All resident units lacked a means to individually identify their rooms and assist the residents in recognizing their rooms.On 03/06/24 and 03/07/24 an unsampled resident was observed being unable to locate his/her room and was standing in front of their unit door. The need to ensure the memory care community individually identified residents' rooms to assist residents in recognizing their rooms was reviewed with Staff 1 (ED) on 03/05/24 and 03/07/24. She acknowledged the findings.

The findings of the on-site investigation, conducted 12/21/23, are documented in this report. The investigation 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. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the kitchen inspection, conducted 03/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 03/21/23, conducted 09/28/23, are documented in this report. It was determined the facility was 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. The facility was receiving meals from the assisted living community. The memory care kitchenette was remodeled into a medication room.

Based on observation, record review and interviews, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:A. On 3/21/23 at 11:00 am the main kitchen area was observed to need cleaning in the following areas:*Pillar in beverage area;*Walls in beverage service area;*Shelving liner in beverage area;*Interior and exterior of cupboards and drawers of beverage service area;*Floors in the corners, edges and between/under equipment throughout kitchen;*Multiple sprinkler heads with dust/dirt/debris build up;*Walls in dish washing area;*Multiple ceiling tiles with splatter, dirt, stains and dust build up;*Wall corners and edges with build up of dirt and debris;*Industrial slicer had dried food debris on food contact surfaces;*Open stainless steel shelving by prep areas and under steam table;*Hood and vents above grill/stove/fryer with build up of dust/dirt/debris;*Handles and knobs of equipment; and*Gray utility cart used for ice/water pitchers;The following areas were found to need repair;*Cupboard doors and drawers in beverage area were damaged and peeling exposing pressed wood;*Multiple metal racks throughout kitchen were rusted;*Multiple sprinkler heads had gaps in the ceiling;*Multiple sprinkler heads were rusted;*Metal sections of ceiling, holding ceiling tiles, were rusted;*Section of grout in dish machine area had black mold like substance;*Open metal shelving throughout kitchen had worn, dirty aluminum foil wrapped over original surfaces as they were not smooth cleanable surfaces.*Large gaps and holes in ceiling tiles throughout the kitchen allowing for possible areas of potential entry of pests into kitchen;*Ice machine had large dust build up on intake vent;*Hole just above floor tile by prep table;*Cutting boards on steam table were heavily scored/stained; and*Large ice build up in walk-in freezer.- The large industrial and small counter top mixer were observed not covered when not in use. The industrial slicer was also not covered when not in use. Staff 2 (Dietary Services Manager) confirmed there were no covers for those items.- Kitchen staff were observed to serve residents without checking temperature of food items. When asked by surveyor to check temperatures, chicken was at 125 degrees F. Kitchen employee stated that it was well over 165 degrees when brought out of the oven. Kitchen employee put the chicken back in oven to reheat. Kitchen employee was able to state the need of food to be served at no less than 135 degrees F. Kitchen employee rechecked temperature of chicken, it was at 145 degrees F, and she returned to service. Upon interview with Staff 2, she validated that the kitchen employee should have reheated the chicken to 165 degrees before continuing to serve food item and should not have began serving until checking that all items were 135 degrees or hotter. Staff 2 indicated that kitchen staff would received additional education on serving and reheating temperatures.- Trash cans in dish area did not have lids.- Kitchen staff were observed to handle clean dishes after handling dirty dishes and did not wash or sanitize hands.- Container of used and dirty rags were observed stored in the dish area. Staff 1 acknowledged these items should not have been stored there.Staff 2 and 3 (Memory Care Program Manager) toured kitchen with the surveyor and acknowledged the identified concerns. Staff 1 (Executive Director) was provided areas of concern via telephone.B. The memory care kitchenette was toured with the surveyor and Staff 3 on 03/21/23 at approximately 12:30 pm. The following was observed to need cleaning and repair:- The floor was found to have tears and rips in areas and a large seem in the middle that was spreading. This created areas that were not smooth and cleanable surface. - The stove and oven were found to need cleaning. The oven door was damaged and not closing correctly. - The area around and behind the sink was dirty. The soap dispenser had visible food debris on the handle. - The exterior and interior of cupboards and drawers had food debris, splatter or drips.- There was a plate of uncovered food stored up on one of the shelves in the cupboard. - Scoops were found stored in bulk food containers of brown sugar, sugar, and coffee. Staff 3 acknowledged the findings. Staff 1 and 2 were notified of the findings in the memory care.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 09/29/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 9/29/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day