McMinnville Memory Care

The findings of the kitchen inspection, conducted 05/08/24, 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 and 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.

The findings of the re-visit to the kitchen inspection of 05/08/24, conducted 07/12/24, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/08/24 at 11:10 am, the kitchen was observed and the following was noted: * Lower shelves throughout the kitchen (including under the steam table, coffee station and prep counter next to stove/grill) had accumulation of food debris and spills;* Wall behind the stove/grill had accumulation of grease drips and splatters;* Ceiling between the stove/grill and steam table had an accumulation of dust around the vent and fire sprinkler; * Two blender bases used to puree food had accumulation of dried on food debris; and* One kitchen staff was not wearing any type of hair restraint. The findings were observed and discussed with Staff 1 (Cook) and discussed with Staff 2 (Cook) and Staff 3 (Executive Director) on 05/08/24. The findings were acknowledged.

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

Based on interview and record review, conducted during a site visit on 03/19/24, it was confirmed the facility failed to provide showering assistance for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:Resident 3's service plan, dated 02/20/24, indicated Resident 3 was to receive standby assist for showers twice a week on Tuesdays and Fridays.During an interview on 03/19/24, Staff 5 (Caregiver) stated the facility used shower logs and refusal sheets to keep track of resident showers. S/he further stated it was difficult for staff to find time to shower residents, and showers were skipped when staff were busy providing other services to residents such as toileting and meal assistance.A review of shower log and refusal sheets, dated 01/01/24 through 03/19/24, indicated Resident 3 had received a standby assist shower once on 03/05/24. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Health Services Director), and Staff 3 (Resident Care Coordinator) on 03/19/24.It was determined the facility failed to provide showering assistance for a resident.Verbal plan of correction: Management to conduct a daily review of shower binders, re-do shower schedule and enter it into TAR so a MT has to sign off. To go into effect 03/20/24.

The findings of the Change of Ownership survey, conducted 11/27/23 through 11/30/23, 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 C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 re-visit to the re-licensure survey of 11/30/23, conducted 02/21/24 through 02/22/24, 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident altercations and injuries of unknown cause were promptly investigated to rule out abuse and neglect, and reported to the local SPD office when required, for 3 of 5 sampled residents (#s 3, 4, and 8). Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's 09/27/23 service plan, 09/05/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.The resident required one staff assistance for ADLs and cueing. The resident spent most of his/her day wandering the halls throughout the unit or napping in different locations of the facility. The resident did not consistently initiate or direct his/her own care and needs were frequently anticipated by staff. The resident was able to ambulate and transfer on his/her own.Review of the resident's records showed the following:* A progress note dated 09/08/23 indicated the resident was discovered in another resident's room during staff rounds. Resident 8 was in his/her brief and was "petting" the other resident's head while s/he laid in bed covered with a blanket. Resident 8 was escorted from the room by staff.There was no other information about the incident located in the resident's record. No investigation was completed, and the incident was not reported to the local SPD office.In an interview on 11/29/23, Staff 1 (ED), Staff 2 (Health Services Director/LPN) and Staff 3 (RN) indicated they were not aware of the incident and no investigation was completed. Staff 1 stated she would report the incident to the local SPD office. The staff were unaware of any similar incidents occurring between Resident 8 and any other residents. Staff 2 indicated it was not uncommon for Resident 8 to wander into the hall in only a brief/underwear but there had been no indication it was sexually oriented.The incident was reported to the local SPD office on 11/29/23 and a confirmation of the report was provided to the survey team prior to exit.The need to ensure incidents were investigated promptly to rule out abuse and neglect, and reported to the local SPD office when required, was discussed with Staff 1, Staff 2, and Staff 3 on 11/29/23. The staff acknowledged the findings.
3. Resident 3 was admitted to the facility in 08/2023 with diagnoses including central nervous system degenerative disease (dementia), asthenia (physical weakness), and history of pelvic, femur, and hip fractures. The resident was evaluated at admission to be a fall risk.Between 09/22/23 and 11/27/23, the record indicated Resident 3 was found on the floor on six occasions. In particular, Resident 3 fell on 11/05/23 and sustained a small laceration to the bridge of the nose and fell again on 11/10/23.On 11/16/23, Staff 2 (Health Services Director/LPN) documented the resident had "large scattered bruises in various stages of healing covering back/hip and chest. Resident also has yellowing bruising under both eyes [related to] prior fall."There was no documentation in the record of previous bruising to the back, hips, or chest from prior falls. Therefore, these bruises would be considered injuries of unknown cause that needed to be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injuries were not the result of abuse.Though Staff 1 (ED) and Staff 2 stated in an interview with this surveyor on 11/30/23 they believed the bruises were the result of previous falls, they acknowledged they had not documented that they investigated and reasonably concluded the bruises were not the result of abuse or neglect.The need to ensure the facility conducted an immediate investigation and documented how it reasonably concluded an injury of unknown cause was not the result of abuse or neglect, or reported the injury to the local SPD office as suspected abuse, was reviewed with Staff 1 and Staff 2 on 11/30/23. They acknowledged the findings.
2. Resident 4 was admitted to the MCC in 02/2020 with diagnoses including dementia without behavioral disturbances and major depressive disorder.A review of the resident's charting notes and incident investigations from 09/01/23 through 11/27/23 identified:* 09/16/23 Charting note - "Resident is on alert for slapping and yelling at another resident today at dinner."There was no documented evidence the incident was immediately reported to the local SPD office.* 10/13/23 Charting note - "[Resident 4] was on the floor on [his/her] bottom with [his/her] back up against [room number]. [Resident 4] was complaining about [another resident] and wanted [him/her] to go away. Care staff stated [Resident 4] had punched the other resident in the chest and then [resident name] hit [ Resident 4] with a wheelchair and knocked [him/her] down on the ground."There was no documented evidence the altercation had been investigated in a timely manner. The facility reported the altercation to the local SPD office on 11/08/23, 26 days after the event.* 11/10/23 Charting note - "[Resident 4] ran over another resident with his wheelchair, and the situation got confrontational."There was no documented evidence the incident was immediately reported to the local SPD office.* 11/17/23 Charting note - "Another resident was being loud [resident room number],when [Resident 4] had gone up behind the resident. [Resident 4] grabbed the coat off the back of [the resident's chair] and had it around [the resident's] neck and was trying to choke [him/her] with it. Care staff rushed over to [resident name]. The resident had [his/her] hands on [his/her] neck saying [Resident 4] was trying to kill me."There was no documented evidence the altercation had been investigated in a timely manner. The facility reported the altercation to the local SPD office on 11/20/23, three days after the event.On 11/29/23, Staff 2 (Health Services Director/LPN) was asked to report the 9/16/23 and 11/10/23 altercations to the local SPD office. Verification the incidents had been reported was received on 11/30/23.The need to ensure all resident-to-resident altercations were reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 on 11/30/23. 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, provided clear direction for staff, and were consistently implemented by staff for 6 of 8 sampled residents (#s 1, 3, 4, 5, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 03/2023 with diagnoses including dementia and congestive heart failure.Observations of the resident, interviews with staff, and review of the resident's 10/31/23 service plan, 08/29/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.The resident required two staff assistance for all ADL care. The resident could answer simple questions, but was unable to fully direct his/her own care. The resident used a tilt-in-space wheelchair for mobility and had right-sided weakness.The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas:* Grooming;* Handroll/washcloth to right hand;* Call light placement and use;* Finger foods and health shakes;* Toileting, incontinence care, how and where to change;* Low bed and air mattress;* Non-skid footwear during transfers; and* Recliner vs. bed use.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/29/23. The staff acknowledged the findings.2. Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's 09/27/23 service plan, 09/05/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.The resident required one staff assistance for ADL and cueing. The resident spent most of his/her day wandering the halls throughout the unit or napping in different locations of the facility. The resident did not consistently initiate or direct his/her own care and needs were frequently anticipated by staff. The resident was able to ambulate and transfer on his/her own.The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not consistently implemented by staff in the following areas:* Shower assistance;* Resident romantic relationship;* Urinating in inappropriate areas;* Entering common areas/halls partially clothed;* Resident-to-resident altercations;* Shower and dressing assistance;* Toileting assistance and incontinence care;* Wandering and entrance into other apartments; and* Activities related to wandering.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/29/23. The staff acknowledged the findings.
3. Resident 3 was admitted to the facility in 08/2023 with diagnoses including central nervous system degenerative disease (dementia), asthenia (physical weakness), and history of pelvic, femur, and hip fractures. The resident was evaluated at admission to be a fall risk.Observations of the resident, interviews with staff, and review of the resident's 08/31/23 and 09/28/23 service plans, 08/31/23 through 11/27/23 temporary service plans, progress notes, and incident reports were completed.The resident had been admitted to hospice services on 11/17/23, following a significant decline which included a series of falls resulting in a hip fracture and other injuries, as well as testing positive for COVID-19. Since then, the resident was bedbound, had been sleeping most of the days or was only minimally responsive, and was declining most food and beverages offered by staff. Hospice ordered oxygen to be administered as needed at a rate of 2 liters per minute (LPM).a. The current service plan was not reflective of the resident's status or lacked a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas:* Instructions to provide food and beverages at every meal, and what to do if the resident was asleep to ensure adequate intake;* Specific instructions for how to provide meals including, but not limited to, the most current food texture order, providing a covered cup/glass, and use of a straw for beverages; and* Instructions for administering and monitoring the PRN oxygen.b. Resident 3's current service plan was not implemented in the following areas:* Two-hour checks for incontinence;* Repositioning the resident very two hours; and* Providing liquids and applying ointment to the resident's lips every one to two hours.The need to ensure Resident 3's service plan was reflective, included clear instructions for providing services, and was implemented was reviewed with Staff 1 (ED) and Staff 2 on 11/30/23. They acknowledged the findings.4. Resident 5 was admitted to the facility in 12/2021 with diagnoses including dementia, Type 2 diabetes mellitus, and chronic pain syndrome.Observations of the resident, interviews with staff, and review of the resident's 09/25/23 service plan, 08/29/23 through 11/27/23 temporary service plans, progress notes, physician communications, and outside provider notes were completed.The resident was admitted to hospice services on 11/06/23. The resident required two staff to transfer him/her into and out of his/her new Flex-Tilt wheelchair using a mechanical Hoyer lift. The resident was being treated for several recurring pressure ulcers on his/her bottom. The resident required staff to physically feed him/her.a. The current service plan was not reflective of the resident's care needs in the following areas:* Use of the Hoyer lift;* Hospice was now providing bathing; and* The resident needed physical feeding assistance.b. Resident 5's current service plan was not implemented in the following areas:* Observations on 11/28/23 and 11/29/23 indicated the facility was not repositioning and providing incontinence care every two hours as instructed in the service plan.The need to ensure Resident 5's service plan was reflective, included clear instructions for providing services, and was implemented was reviewed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.
5. Resident 1 was admitted to the MCC in 11/2023 with diagnoses including type 2 diabetes, obesity, and depression. The current service plan, dated 10/31/23 and Temporary Service Plans (TSPs) from 11/01/23 to 11/27/23 were reviewed, and observations and interviews with staff and Resident 1 were completed during the survey. The following was identified:The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:* Preferred to stay in their apartment during the day;* Episodes of tearfulness and anxiety;* Level of assistance required for ADLs and use of gait belt with transfers;* Decreased appetite;* Meal and hydration assistance; and* Nutritional shakes.The need to ensure service plans were reflective of residents' status and included clear directions to staff was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.6. Resident 4 was admitted to the MCC in 2/2020 with diagnoses including dementia without behavioral disturbances and major depressive disorder.Interviews with care staff and observations of Resident 4 during the survey revealed s/he was dependent on staff for ADL care and was unable to use the call light to request assistance.Resident 4's service plan, dated 10/26/23, was not reflective of the resident's needs and lacked clear direction to staff in the following areas:* Level of assistance required for hygiene, dressing, toileting/incontinence care, ambulation and transfers;* Recent falls and current interventions to minimize falls;* Resident-specific instructions for providing meal assistance; and* Ability to use call light.The need to ensure the service plan was reflective of Resident 4's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 03/2023 with diagnoses including dementia and congestive heart failure. Observations of the resident, interviews with staff, and review of the resident's 10/31/23 service plan, 08/29/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.The resident required two staff assistance for all ADL care. The resident could answer simple questions, but was unable to fully direct his/her own care. The resident used a tilt-in-space wheelchair for mobility and had right-sided weakness.a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or there was a lack of resident-specific directions to staff in the following areas:* Multiple medication changes;* Injury and non-injury falls;* Increased episodes of agitation with physical aggression;* Bruising to lower extremities and face; and* Extremity swelling/edema.b. The resident experienced ongoing severe weight loss between September 2023 and November 2023. The weight loss was not reported to the RN for completion of a significant change of condition assessment.The need to ensure documentation of short-term changes was noted at least weekly to resolution, clear, resident-specific instructions provided to staff, and significant changes were reported to the RN was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/30/23. The staff acknowledged the findings. 4. Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's 09/27/23 service plan, 09/05/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.The resident required one staff assistance for ADL and cueing. The resident spent most of his/her day wandering the halls throughout the unit or napping in different locations of the facility. The resident did not consistently initiate or direct his/her own care and needs were frequently anticipated by staff. The resident was able to ambulate and transfer on his/her own.The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or there was a lack of resident-specific directions to staff in the following areas:* Wandering into other apartments, partially clothed.The need to ensure documentation of short-term changes was noted at least weekly to resolution and clear, resident-specific instructions provided to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/29/23. The staff acknowledged the findings.
2. Resident 3 was admitted to the facility in 08/2023 with diagnoses including central nervous system degenerative disease (dementia), asthenia (physical weakness), and history of pelvic, femur, and hip fractures. The resident was evaluated at admission to be a fall risk.Between 09/22/23 and 11/27/23, the record indicated Resident 3 was found on the floor on six occasions.a. Following each of the falls, the facility failed to monitor the resident for changes in mobility to determine if the service plan needed to be updated to provide additional assistance with transfers or other fall prevention interventions.b. The facility documented the resident sustained the following injuries:* 11/16/23 - Bruising to the chest, back, and both hips; and* 11/17/23 - Swelling and discoloration to the left forehead/eyebrow area.The facility failed to document on the progress of these conditions at least weekly until the injuries resolved.The need to ensure the facility had a process for monitoring a resident following a fall or an injury was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition, communicate resident-specific instructions to staff on each shift, document weekly progress until the condition resolved, and/or refer significant changes of condition to the facility RN for 4 of 8 sampled residents (# 3, 4, 6, and 8) who had changes of condition. Findings include, but are not limited to:1. Resident 4 was admitted to the MCC in 02/2020 with diagnoses including dementia without behavioral disturbances and major depressive disorder.Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/26/23, and charting notes dated 09/01/23 through 11/27/23 were completed.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:* 09/16/23 - Resident-to-resident altercation;* 10/13/23 - Fall in bathroom with injury;* 10/24/23 - Return from ER;* 11/05/23 - Swelling to right leg; and* 11/10/23 - Resident-to-resident altercation.The need to ensure short-term changes of condition had actions or interventions determined and documented in the resident record and were communicated to staff on all shifts was discussed with Staff 1 (ED) and Staff 2 (Health Services Director) on 11/30/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 03/2023 with diagnoses including congestive heart failure, edema, and dementia.Progress notes, temporary service plans, and physician communications dated 08/29/23 through 11/27/23 indicated the resident was independent with meals. The resident required finger foods to encourage independence. The resident had experienced a change of condition in late September 2023 with a suspected stroke, multiple falls, and increased care needs. The resident was admitted to hospice on 09/29/23.Weight records, dated 08/01/23 through 11/29/23, indicated the resident experienced the following:* An 8.51 pound weight loss between 09/01/23 and 09/30/23, which constituted a 7.26% severe loss in a month;* A 4.5 pound weight gain between 09/30/23 and 10/01/23, which constituted a 4.14% gain in one day; and* An additional 13.5 pound weight loss occurred between 10/01/23 and 11/01/23, which constituted a 11.94% severe weight loss in one month.The resident continued to fluctuate between 100 pounds and 104 pounds between 11/03/23 and 11/27/23. The resident's weight on 11/29/23 was 103 pounds.Observations of the resident between 11/27/23 and 11/29/23 showed the resident up in a tilt-in-space wheelchair in common areas, as well as in his/her recliner in his/her bedroom. The resident was observed to eat 50-100% of the meals provided during six meal observations. The resident drank 100% of fluids provided during meals and snacks, as well as eating 50% of the snacks observed.The resident was not interviewable. Interviews with staff between 11/27/23 and 11/29/23 showed the following:Staff 14 (CG), Staff 13 (CG), Staff 9 (MT) and Staff 6 (CG) indicated the resident required two staff assistance for transfers and toileting. The resident could answer simple questions about his/her needs. The staff indicated the resident could eat independently with finger food, but had a more difficult time with silverware. Staff 9 indicated the resident was on daily weights due to his/her edema and had a medication in place to help with fluid retention.Staff 4 (RCC) indicated the resident did well at meals with the finger foods and was able to drink from a regular cup without issue. Staff 4 stated all residents were offered snacks twice a day and Resident 6 ate most of what was provided.Staff 2 (Health Services Director/LPN) and Staff 3 (RN) indicated the resident was weighed daily related to congestive heart failure and fluid retention. Staff 3 indicated the resident had ongoing weight fluctuations which were reported to the physician when weight change was greater than three pounds in a day or five pounds in a week. The staff indicated the resident required more assistance and had increased weakness since the falls and suspected stroke in September 2023 and being placed on hospice. The staff stated the resident typically ate very well with the finger foods. Staff 2 indicated the resident additionally received health shakes three times a day. Staff 3 (RN) stated she was unaware of the significant losses between September and November 2023 and had not completed a significant change assessment.The facility failed to ensure an RN assessment was completed for the weight loss from September 2023 to November 2023 which documented findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 11/29/23. The staff acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure the facility RN assessed all residents with a significant change of condition for 2 of 6 sampled residents (#s 5 and 6) with documented changes of condition requiring assessment. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 12/2021 with diagnoses including dementia, Type 2 diabetes mellitus, and chronic pain syndrome.The record indicated Resident 5 was receiving home health services to treat a wound on the back side of the leg. A home health visit note dated 09/26/23 read: "New wounds: [Right] upper buttocks: Stage 2 pressure injury...Sacrum Stage 2 pressure injury..." On 10/03/23, home health documented "New pressure injury @ buttocks" and identified an open wound to the "[left] medial buttocks."Documentation of a stage 2 or greater pressure wound represented a significant change of condition, for which an assessment was required by the facility RN. There was no documented evidence the facility RN completed an assessment of the resident which included findings, resident status, and interventions made as a result of the assessment.The need to ensure the facility RN completed and documented an assessment when a resident experienced a significant change of condition was reviewed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged no assessment had been completed. No additional documents were provided.

Based on observation and interview, it was determined the facility failed to ensure the indoor environment was kept clean and in good repair. Findings include, but are not limited to:During observations conducted 11/27/23 thru 11/29/23, the following areas were found to be in need of cleaning:* Main and small dining room floor, table bases, and chair legs/frames;* Main dining room kitchenette cabinet doors and sides, hardware, and cabinet laminate;* Main dining room kitchenette garbage receptacles;* Small dining room refrigerator had three uncovered, unlabeled, and undated beverages; * Small dining room refrigerator had two uncovered, unlabeled, and undated food products; * Main living room arm chairs;* Sections of baseboard throughout the facility corridors, dining rooms, common spaces, and common restrooms;* Walls throughout facility corridors, dining rooms, common spaces, and common restrooms; and* Multiple ambulatory assistive devices (wheelchairs, walkers, canes).During observations conducted 11/27/2023 and 11/28/2023, the following were observed to need repair:* Chair bases/frames throughout the facility were gouged, dinged, and scratched; * Sections of wooden handrails under hand sanitizer dispensers throughout the facility;* Transitions bordering Living Room (three separate transitions);* Unit 18 C/D shared restroom had a large section of wallpaper behind the toilet peeling off the wall;* Unit 18 C/D shared restroom had exposed nails in the wall;* Unit 17 and 18 C/D restrooms had no transition between shower and restroom floor;* Three communal shower rooms had no transition between shower stall and restroom floor;* Broken picture frame in TV Lounge located across the hallway from unit 18;* One of the industrial drying machines was not operable;* In the laundry room, six of six light fixtures had missing, broken, or cracked coverings, one cabinet door was missing, and one cabinet door had a missing hinge;* Unit 17's door handle had a broken key entry point; and * The caulking in the common area restroom, between the small dining room and kitchen, was in need of repair.Between 11/27/23 and 11/29/23, the interior of the facility was observed to have persistent/continuous unpleasant urine odor identified in the following areas:* Upon entry to the main residential common area;* At the entry of the corridor leading to the small dining room;* Common area restroom/shower room near the medication station; and* In unit 16, bed B had a heavy urine odor.On 11/27/23 and 11/29/23, the above noted findings were pointed out to and discussed with Staff 1 (ED) during tours of the facility.On 11/29/23 at 2:15 pm Staff 1 witnessed and acknowledged the heavy urine odor in unit 16 and determined a new mattress was needed.The need to ensure the facility was clean and in good repair was discussed with Staff 1 on 11/27/23, 11/29/23, and 11/30/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in resident units and common areas were maintained within a range of 110°F to 120°F. Findings include, but are not limited to: On 11/28/23 and 11/29/23 the following water temperatures were observed:* Apartment 18 A/B bathroom sink - 102°F;* Apartment 18 C/D bathroom sink - 101.6°F;* Apartment 18 D private sink - 101.6°F;* Apartment 17 - 103.7°F;* Apartment 16 - 107.6°F;* Apartment 8 - 103.5°F;* Community restroom across from kitchen - 108°F; and* Community restroom at entry of 20's hall - 108°F.On 11/28/23 at 12:45 pm and 11/29/23 at 12:05 pm, survey informed Staff 1 (ED) of the low water temperatures. Staff 1 stated she would contact a plumber.The need to ensure hot water temperatures were maintained between 110°F and 120°F was discussed with Staff 1 on 11/30/23. 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 C231, C513, and C545.

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 C260, C270, and C280.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of or inside their rooms at any time. Findings include but are not limited to: Observations were made between 11/27/23 and 11/29/23 of multiple sampled and unsampled residents being locked out of their apartments.* One resident attempted to open their apartment door; when the door would not open, the resident searched his/her purse, looked up and down the hallway, walked to the dining room and looked around, then returned to his/her apartment and attempted to open the door again.* On 11/27/23 and 11/28/23, the door of Unit 22 was observed to have two rolled up towels propping the door open. The resident stated s/he had been locked out of his/her apartment and using towels was how they knew they wouldn't get locked out. The resident also stated when they had been locked out in the past, they would sit at the end of the hall and wait for staff assistance.* On 11/29/23 multiple residents were observed attempting to open their apartment doors but were unable to because they were locked (apartments 9, 17, 23, and 26).The need to ensure residents were not locked out of or inside their rooms at any time was discussed with Staff 1 (ED) on 11/29/2023. She acknowledged the findings.

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 04/17/2023. 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

The findings of the re-licensure survey, conducted 03/14/22 through 03/16/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit survey to the re-licensure survey of 03/16/22, conducted 07/05/22 through 07/07/22, 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 Division 57 for Memory Care Communities.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second revisit to the re-licensure survey of 03/16/22, conducted on 09/19/22 through 09/20/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 03/14/22 through 03/16/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. This is a repeat citation. Findings include, but are not limited to: During the first re-visit survey conducted on 07/05/22 through 07/07/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 03/14/22 through 03/16/22, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.Staff 1 (ED) was interviewed on 03/15/22 at 2:30 pm. During the interview he confirmed the facility had failed to conduct ongoing quality improvement programs. Refer to deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. This is a repeat citation. Findings included, but are not limited to:During the survey, conducted 07/05/22 through 07/07/22, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.Staff 1 (ED) and Staff 4 (Regional Director) were interviewed on 07/07/22. During the interview Staff 1 confirmed the facility was in process of conducting some quality improvement audits related to environment, medication review and the kitchen; however, facility staff had not completed quality improvement audits in all areas, which included resident services.Refer to deficiencies in the report.

Based on observation and interview, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to:Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.Upon entering the facility for the survey on 07/05/22 at 9:15 am, administrative staff and direct care staff were observed not wearing face masks. During the remainder of the survey, 07/05/22 through 07/07/22, administrative, kitchen and direct care staff were observed on several occasions having their masks pulled down so as not to cover their nose and, in some cases, not covering their mouth and nose. These staff were in offices or the medication room with the doors open, and residents were observed to be able to enter the rooms freely.The need to ensure staff fully and consistently complied with masking requirements was discussed with Staff 1 (ED) and Staff 18 (RN) during the exit meeting on 07/07/22. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#s 1 and 5) were treated with dignity and respect related to being provided treatment and insulin injection performance in a common area during lunch hours. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in August 2021 with diagnoses including dementia.During the acuity interview on 03/14/22, it was reported that Resident 5 received insulin injections from staff.During an observation on 03/14/22 at 12:08 pm, Resident 5 was having lunch, sitting at a table with three other residents in the dining room. Staff 5 (Personal Care Assistant (PCA)/MT) was observed to bring insulin and blood sugar check supplies into the dining room. Staff 5 collected a small amount of blood from the resident's finger, informed the resident of the blood sugar result, and administered insulin to the resident's left upper arm at the table in the dining room in front of other residents, and while those residents at the table were having lunch. The lack of privacy related to collecting blood from the resident and administering an insulin injection during lunch hours was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
2. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.During the acuity interview on 03/14/22, it was reported that Resident 1 had a wound to the forehead.During an observation on 03/14/22 at 12:45 pm, Resident 1 was sitting in the dining room at a table with three other residents with a loose, soiled bandage on his/her forehead. The dining room was full of residents waiting to be served lunch. Staff 5 (PCA/MT) was observed to bring wound care supplies into the dining room and changed the dressing to Resident 1's forehead, while in the dining room with multiple residents. The lack of privacy provided during wound care was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in December 2020 with diagnoses including dementia.An incident report and progress notes reviewed from 10/02/21 through 03/11/22 noted the following:*On 10/02/21, Resident 2 was placed on alert charting for grabbing another resident's breasts;*On 11/30/21, Resident 2 was noted to throw a resident out of his/her wheelchair;*On 12/03/21, the resident had placed his/her hands down another resident's shirt; and*An incident report dated 12/12/21 noted Resident 2 grabbed a resident and "threw" him/her to the ground.There was no documented evidence the facility reported the resident to resident altercations. Resident 2 was observed during the survey on 03/14/22 and 03/15/22 to be sitting in the common areas of the facility or engaged in an activity.The failure to report inappropriate touching and resident to resident altercations as abuse or suspected abuse was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22 at 2:07 pm. The incidents were reported to the local SPD office per request of the surveyor. Confirmation the incidents had been reported was received on 03/15/22.
Based on observation, interview and record review, it was determined the facility failed to ensure incidents including unwitnessed injury falls, resident to resident altercations and sexual behaviors were thoroughly investigated to rule out abuse or neglect and reported to the local SPD office as appropriate for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:1. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia. Review of incident reports and progress notes from 12/14/21 thru 03/14/22 showed the following: * An incident report dated 12/21/21 identified that Resident 1 had an unwitnessed fall and sustained a laceration under the left eye with swelling and bruising. * A progress note dated 03/09/22 identified the resident had an unwitnessed fall from the wheel chair and sustained a laceration to the left side of the forehead and a skin tear to the left wrist.There were no investigations completed to rule out abuse or neglect for the falls with injury. The incidents were not reported to the local SPD office.The need to ensure resident incidents were promptly investigated to rule out abuse or neglect was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff acknowledged the findings. The facility was asked to report the incidents from 12/21/21 and 03/09/22 to their local SPD office and a confirmation was provided prior to exit.

3. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain.A hospice visit note dated 06/13/22 was transcribed by a facility staff into the resident's progress notes on 06/14/22. It read in part, "I saw bruise on [his/her] back."On 06/14/22, Staff 18 (RN) documented in a progress note, "RN reviewed [hospice] note and observed area to back/side in which a bruise is reported."The bruise represented an injury of unknown cause for which the facility was required to report to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse/neglect.There was no documented evidence the facility immediately investigated the injury and concluded it was not the result of abuse, nor did the facility report the injury to the local office as suspected abuse.The need to ensure injuries of unknown cause were investigated immediately with documentation of how abuse was reasonably ruled out or, if abuse could not be ruled out, the injury was reported to the local office, was reviewed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 on 07/07/22. They acknowledged the findings.The surveyor requested the facility report the injury of unknown cause to the local Department office. Confirmation the incident was reported was received on 07/07/22 at 3:07 pm.

Based on interview and record review, it was determined the facility failed to ensure resident to resident altercations were immediately reported to the local SPD office for 2 of 2 sampled residents (#s 6 and 10), and failed to immediately investigate an injury of unknown cause, and document the injury was not the result of abuse or neglect, or report the injury to the local SPD office as suspected abuse for 1 of 1 sampled resident (#7). This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 02/2018 with diagnoses including Alzheimer's disease. During the acuity interview on 07/05/22 it was reported Resident 6 was involved in a resident-to-resident altercation. Progress notes and incident reports indicated between 04/30/22 and 07/05/22, Resident 6 had two documented incidents of resident-to-resident altercations on 05/13/22 and 05/21/22.The altercations represented incidents of abuse or suspected abuse that required reporting to local SPD office. There was no documented evidence the facility reported the incidents or took measures necessary to protect residents and prevent the reoccurrence of abuse. The need to immediately report altercations to the local SPD office was reviewed with Staff 1 (ED) and Staff 4 (Regional Director) on 07/06/22 and 07/07/22. The surveyor requested the facility self-report the resident altercations to local SPD office as suspected abuse. Verification was received prior to survey exit.2. Resident 10 was admitted to the facility in 02/2020 with diagnosis of dementia. During the acuity interview on 07/05/22 it was reported Resident 10 was involved in a resident-to-resident altercation. Progress notes and incident reports indicated between 04/30/22 and 07/05/22, Resident 10 had two documented incidents of resident-to-resident altercations on 04/28/22 and 05/13/22.The altercations represented incidents of abuse or suspected abuse that required reporting to local SPD office. There was no documented evidence the facility reported the incidents or took measures necessary to protect residents and prevent the reoccurrence of abuse. The need to immediately report resident altercations to the local SPD office was reviewed with Staff 1 (ED) and Staff 4 (Regional Director) on 07/06/22 and 07/07/22. The surveyor requested the facility self-report the resident altercations to local SPD office as suspected abuse. Verification was received prior to survey exit.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:The kitchen was toured on 03/14/22. The following areas were in need of cleaning and/or repair:* Rolling food cart inside the walk in refrigerator storing prepared food had dried food debris on the metal frame;* In the freezer, boxes of food were stored on the floor;* The dry storage area had bags with cooking utensils stored on the floor;* Shelving under the steam table that faced the oven had chipped laminate and exposed particle board in multiple areas;* The wall behind the warewasher had missing sheet rock and exposed wood framing;* Cupboards in the kitchenette area were chipped and gouged creating a non-cleanable surface;* Chemicals were observed under the kitchenette sink that were accessible to residents; * The shared wall between the warewasher and the dining room had a section of wall missing that exposed wood framing; and* The warewashing machine rinse temperature was greater than 180 degrees for sanitizing dishes, however, there was no data plate that provided instruction to staff ensuring dishes were washed and sanitized according to manufacturers recommendations. The areas in need of cleaning and/or repair were reviewed with Staff 7 (Dining Services Director) on 03/14/22 at 11:50 am. She acknowledged the findings.

3. Resident 4 was admitted to the facility in 2021 with diagnoses which included Alzheimer's dementia. Observations, staff interviews and review of the record during the survey revealed s/he was incontinent of bowel and bladder, needed staff assistance with ADL care needs, and did not advocate for him/herself or request assistance. The most recent quarterly evaluation, dated 01/10/22, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:* Personality: including how the person coped with change or challenging situations;* Mental Health: Effective non-drug interventions;* Ability to use call system;* Laundry; and * Alcohol use. On 03/15/22, the need to ensure Resident 4's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (ED). He acknowledged the findings. No other information was shared.
2. Resident 2 was admitted to the facility in 2020 with diagnoses including Alzheimer's Disease.a. Progress notes reviewed from 10/04/21 through 03/11/22 noted the resident was involved in resident to resident altercations, had an increase in sexual behaviors, was on alert charting for aggressiveness and agitation towards peers and staff, and was being monitored for changes in behavioral medications.The evaluation dated 10/25/21 noted the resident was "even tempered" and would become "upset and yell" at peers that were "too loud". During interviews on 03/14/22 with Staff 5 (Personal Care Assistant (PCA)/MT), Staff 10 (PCA) and Staff 11 (PCA) they stated the following:* Agitated easily;* Would grab and touch female residents' breasts; and* Pushed residents that were in his/her way.Resident 2's evaluation was not reflective of the resident's sexual behaviors, increased aggression or agitation, or resident to resident altercations. b. Resident 2's evaluation did not indicate who was involved in the evaluation process.Resident 2's evaluation was discussed with Staff 1 (ED) on 03/15/22 at 3:45 pm. Staff 1 acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and failed to ensure quarterly evaluations were reflective, signed, and addressed all changes based on the resident's status for 2 of 3 sampled residents (#s 2 and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to:1. Resident 3 moved into the facility in December 2021. The new move-in evaluation failed to address the following elements:* Physical health status including visits to health practitioner(s) ER, hospital or NF in the past year;* Mental health issues including effective non-drug interventions;* Ability to manage medications;* Ability to use call system;* Housework and laundry;* Transportation;* Fall risk or history;* Emergency evacuation ability;* Complex medication regimen;* Recent losses; and* Elopement risk or history.The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. The findings were acknowledged.

2. Resident 2 was admitted to the facility in 2020 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the current service plan revealed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:* Lack of bed in the resident's apartment and preference to sleep in recliner chairs; and* Particular resident's that had been identified as involved in sexual behavior.The service plan was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22 at 2:07 pm. No additional information was provided.
3. Resident 3 was admitted to the facility in December 2021 with a diagnosis of Type II diabetes and dementia.Observations of the resident, interviews with staff, review of the service plan updated 02/14/22, Temporary Service Plans, and 01/01/22 thru 03/14/22 progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas: * Transfer assistance; * Incontinence and toileting needs and level of assistance required; * Right eye treatment status; * Right hip precaution; * Use of glasses; and * Falls and safety interventions.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. 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 needs and status and provided clear direction to staff for 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:1. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.The resident's service plan dated 12/02/21, progress notes from 12/14/21 through 03/14/22 and hospice notes were reviewed. Observations of the resident during survey and interviews with staff and family were completed. The service plan was not reflective and did not provide clear instruction to staff in the following areas:* Two person transfers;* Bed mobility;* Dressing, grooming, hygiene and toileting;* Ambulation and mobility;* Assistive devices;* History of falls;* Fall matt on the floor next to bed;* Perimeter mattress;* Non-skid footwear;* Meal assistance;* Evacuation ability;* Pain;* Skin conditions;* Pressure reducing cushion in wheel chair; and * Hospice Services. The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director). The staff acknowledged the findings.


Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of the resident's needs and provided clear direction regarding the delivery of services, for 2 of 4 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident service plans and Temporary Service Plans were reviewed, residents were observed, and residents and staff were interviewed to obtain information about the residents' current status and care that was needed and being provided by staff. The following deficiencies were identified:1. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services. The resident's record indicated a history of falls, and that s/he needed additional assistance with some ADLs following a fall on 07/06/22.The resident's current service plan was not reflective or followed in the following areas:* The resident now required full assistance with dressing rather than standby assistance as noted in the service plan;* The resident was no longer independent with transfers and ambulation and unable to safely ambulate using his/her 4-wheeled walker as noted in the service plan;* New interventions provided by hospice dated 06/07/22 were not added to the resident's service plan and implemented; and* The flow rate on the resident's oxygen concentrator was not set at the correct setting.The need to ensure service plans were reviewed and updated as necessary when a resident's care needs changed was reviewed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.

2. Resident 8 was admitted to the MCC in 02/2022 with diagnoses including vascular dementia. During the acuity interview on 07/05/22, Resident 8 was identified as having a hip fracture, weight loss, and received hospice care. Observations of the resident, interviews with staff on 07/05/22 through 07/07/22, and a review of the current service plan dated 04/19/22 indicated the service plan was not reflective of the resident's care needs and lacked clear instructions to staff in the following areas: * Hip fracture and postoperative hip precautions;* Recent hospital stay;* Puree diet and thickened liquids;* Full assist for food and fluid intake; * Full assistance with all ADLs;* Two-three person assist with repositioning and providing incontinence care while in bed;* Hospice services and schedule;* Pain areas and treatment;* Weight loss and interventions; and* Falls and current interventions.The need to ensure service plans were reflective, updated, and provided clear instructions to staff was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3 and 4's most recent service plans lacked documentation that 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 1 (ED) on 03/16/22. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed ensure changes of condition were evaluated, monitored through resolution, and actions or interventions were identified and implemented for 2 of 4 sampled residents (#s 1 and 3) reviewed for changes of condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in December 2021 with diagnoses including dementia. Review of the facility progress notes, dated 01/01/22 through 03/14/22, the resident's 02/14/22 service plan, temporary service plans and incident reports revealed Resident 3 had falls on 01/01/22 and 02/17/22.There was no documented evidence the facility thoroughly reviewed the incidents to determine the circumstances of the fall and there was no documented evidence the facility developed interventions to minimize further falls. The need to ensure short term changes were evaluated, and specific resident interventions determined and documented was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
2. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia. The resident's 12/02/21 service plan, 12/14/21 thru 3/14/22 progress notes, temporary service plans, incident reports and physician communications were reviewed. The resident experienced multiple short-term changes lacking evaluation, monitoring at least weekly to resolution, actions or interventions determined, documented and communicated to staff in the following areas:* 12/14/21-Non-injury fall;* 12/21/21-Fall with facial laceration, bruising and swelling;* 01/29/22-Hospice admission;* 02/22/22-Two non-injury falls; and* 03/09/22-Fall with skin injuries to the forehead and left arm.Staff 3 (Memory Care Director/LPN) reported on 03/15/22 that she had not monitored Resident 1's facial laceration, bruising and swelling from the 12/21/21 fall weekly to resolution. The need to ensure short term changes of condition were evaluated, monitored at least weekly to resolution, actions or interventions determined, documented and communicated to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff acknowledged the findings.
4. Resident 9 was admitted to the facility in 2021 with diagnoses including vascular dementia.On 07/06/22, the surveyor observed Resident 9 enter the medication room with a bloody right forearm. The resident appeared to have a five to six inch cut. Resident 9 stated "[dog] scratched me again." Staff 16 (MT) stated to the surveyor the blood came from a previous scratch that was scabbed over and reopened when the resident was playing with Staff 1's (ED) dog. During an end of day meeting on 07/06/22 at 4:40 pm, Staff 1 said the dog belonged to him and he brought the dog to the facility most days. The surveyor requested an incident report, progress notes and any updated service plans related to the resident's skin injury.Staff 1 provided the following documents:* A late entry progress note dated 06/30/22 that noted Resident 9 had a five to six inch long scratch on his/her forearm; and* An incident report completed on 07/06/22 that noted two injuries occurred, one on 06/30/22 and another on 07/05/22. The incident report noted the injuries were caused by the dog and that the dog's nails were trimmed on 07/05/22. During an interview on 07/07/22 at 9:18 am, Staff 5 (PCA/MT) was not aware of the resident's skin injury and verified there was no documented evidence on the TAR which indicated the resident had received treatment on 06/30/22.The surveyor and Staff 5 went to observe Resident 9 on 07/07/22 at 9:25 am. Resident 9 was observed to have three scratches on the right forearm approximately five to six inches in length. The scratches were scabbed and slightly reddened.During an interview on 07/07/22 at 10:30 am, Staff 14 (Activity Director) stated the dog came into the facility daily. Staff 14 stated the dog was rambunctious and at times would get wild and jump up on people especially during activities that involved a ball toss. Resident 9 experienced a change of condition on 06/30/22 related to a skin injury. At the time of the incident, there was no documented evidence the facility evaluated the resident to determine what actions or interventions were needed to help minimize future injuries, and implemented monitoring of the wound. The facility developed a temporary service plan on 07/06/22 with instructions for monitoring the resident's wound and instructions for staff for monitoring the dog. In addition, a plan of correction addressing ways to minimize the dog's "rambunctious" play was outlined and dispersed to staff. The facility's failure to respond to the change of condition was discussed with Staff 1 (ED) and Staff 4 (Regional Director). Staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services. The resident's record indicated a history of falls.The resident's record from 05/01/22 through 07/05/22 was reviewed including progress notes, hospice visit notes, the 06/2022 MAR/TAR, the current service plan dated 05/24/22, Temporary Service Plan (TSP) updates and incident reports. The facility failed to comply with rules related to changes of condition as follows:a. A facility staff transcribed a hospice visit note into the resident's progress notes on 05/17/22. The note read in part, "patient was complaining about a stomach ache and pain in [his/her] chest. [RN case manager] and facility staff notified." The facility failed to determine and document what action or intervention was needed for the resident and failed to monitor and document on the status of the resident's condition until resolved.b. On 05/27/22, a staff documented in a progress note that while assisting the resident with toileting, the staff observed blood in the stool. The facility failed to determine and document what action or intervention was needed for the resident and failed to monitor and document on the status of the resident's condition until resolved.c. The resident had a fall on 06/07/22 where s/he sustained a skin tear to the right wrist and complained of severe back pain, and a fall on 06/29/22 where s/he sustained pain and redness to the top of the head an a "tear" on the back. The TSPs that were written lacked resident-specific information about the falls and injuries, lacked clear instructions for monitoring the injuries, and lacked a review of the service-planned mobility needs and fall interventions for effectiveness. There was no documented monitoring of the injuries, and the facility failed to develop and implement any new interventions to try to prevent further falls. d. Between 06/13/22 and 06/16/22 (four days), the resident was not administered two medications prescribed for heart disease/congestive heart failure - amlodipine and furosemide. The facility failed to monitor the resident for any negative effects of not receiving the medications.The need for the facility to develop a system for identifying and communicating about changes of condition, reviewing existing interventions for effectiveness, and ensuring clear instructions regarding interventions and monitoring were documented and communicated to staff following a change of condition was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented, and communicated to staff, and the residents' conditions, including the effectiveness of interventions, were monitored weekly through resolution for 4 of 4 sampled residents (#s 6, 7, 8 and 9) who had documented changes of condition. Resident 8 had repeated injury and non-injury falls. Resident 6 had repeated resident to resident altercations. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the MCC in 02/2022 with diagnoses including vascular dementia. During the survey, s/he was identified with a history of falls, and a recent fall resulting in a right hip fracture.A review of Resident 8's 04/19/22 service plan provided the following interventions: * Staff to escort the resident to meals and activities;* Staff to remind the resident to ask for assistance with transfers; and* When the resident was in bed, the staff were to ensure the bed was at the lowest position.Observations of Resident 8 throughout the survey confirmed the resident was bed bound, was a two-three person assist for repositioning and incontinence care, and was dependent on staff for all ADLs. a. On 05/21/22, the resident had a fall and injured his/her nose. The resident was placed on alert charting for the injury, and the injury to the nose was documented as resolved on 05/31/22. However, the follow up investigation failed to document if service-planned interventions were being followed at the time of the fall, were effective, or if new interventions were needed following the fall. b. On 05/25/22, staff documented that the resident had an unwitnessed non-injury fall. There was no documented evidence the facility investigated the fall, determined if new interventions needed to be developed and communicated the information to staff, and documented monitoring of the resident's condition at least weekly until resolved. c. On 06/23/22, staff documented that the resident was found on the floor on his/her knees. The incident report completed on 06/23/22 noted an "apparent injury, small mark on [his/her] right ribs." The resident was placed on alert charting, and a Temporary Service Plan (TSP) noted the resident had a "small red mark on the right ribs" and instructed staff to report "any complaints of pain, any complaints of discomfort, and any observed discoloration." There was no documented evidence the facility determined if service-planned interventions were followed at the time of the fall, were effective, or if new interventions were needed following the fall. On 06/24/22, staff documented the resident had an x-ray in the facility which showed a subcapital fracture of the right hip. d. On 06/25/22, staff documented that the resident had a non-injury fall. The follow up investigation failed to document if service-planned interventions were being followed at the time of the fall, were effective, or if new interventions were needed following the fall.The resident was hospitalized on 06/25/22 for hip surgery. The facility's failure to evaluate Resident 8's fall risk, develop interventions to prevent falls, and monitor interventions for effectiveness resulted in a fall with a hip fracture. On 07/01/22, the resident returned to the facility. e. On 07/03/22, the resident was found wrapped in his/her blankets on the floor between the window and the bed. The incident report noted "frequent checks" as the follow-up action. The resident was put on alert charting, and a TSP instructed staff to monitor and report any complaints of pain, discomfort, observation of discoloration, and shortness of breath to the nurse. However, the facility failed to ensure the TSP instructed staff to provide frequent checks. f. On 07/04/22, the resident was found on the floor next to his/her bed, with the resident's head at the end of the bed and feet towards the head of the bed. The incident report documented "Frequent checks every thirty minutes/one hour" as the follow-up action. The resident was put on alert charting, and a TSP instructed staff to monitor and report any complaints of pain, discomfort, observed discoloration, and swelling or redness to the nurse. However, the facility failed to ensure the TSP instructed staff to provide frequent checks every thirty minutes/one hour.The failure of the facility to evaluate the resident, review previous fall interventions to ensure they were added to the service plan and were implemented, monitor fall interventions for effectiveness, or develop new interventions to try to prevent future falls or injuries placed the resident at risk for continued falls and/or injuries. The need to ensure the facility thoroughly investigated the circumstances for falls, determine if service planned interventions were implemented, were effective or if new interventions were needed, and failure to monitor and document on the resident's condition at least weekly until resolved was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 02/2018 with diagnoses including Alzheimer's disease. Review of the facility progress notes, dated 05/10/22 through 06/30/22, the current service plan, temporary service plans and incident reports identified Resident 6 had resident to resident altercations on 05/13/22 and 05/21/22.The current service plan lacked interventions to address resident to resident altercations and there were no other documents that communicated further interventions or monitoring instructions for staff following each altercation. The resident continued to be involved in physical altercations with other residents. The need to ensure incidents were evaluated, and specific resident interventions determined and documented was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings. Refer to Z 165, example 1.

Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN completed a significant change of condition assessment based on the condition of the resident, developed interventions and updated the service plan for 1 of 1 sampled resident (#1) who had a significant change of condition which included a decline in ADLs and mobility. Findings include, but are not limited to:Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.During the acuity interview on 03/14/22, it was revealed Resident 1 was a two person transfer, had experienced a decline in mobility and required an increase in ADL assistance. The service plan, dated 12/02/21, identified the resident as independent with transfers, ambulation and one person assist with toileting, dressing, grooming and showering.On 03/14/22 at 11:50 am, the resident was observed in a high back wheel chair in the dining room. Staff provided cues and some assist with intake of the meal. After the meal, staff provided full assist with mobility in the wheelchair. On 03/15/22 at 09:55 am Resident 1 was observed during a transfer from wheelchair to bed with a full two person assist. Staff 10 (Personal Care Assistant (PCA)) reported on 03/14/22 at 1:00 pm that the resident was independent with transfers and ambulation until approximately a month ago. She stated Resident 1 needed a two person total assist with transfers, mobility in a wheelchair and with all ADL cares. The resident's need for increased assistance with transfers, changes in mobility and ADL's in multiple areas, constituted a significant change of condition. There was no RN assessment completed.The need for an RN assessment which included development of interventions, documentation of findings and updating of the service plan was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed and documented for 1 of 1 sampled resident (#8) who experienced a significant change of condition related to weight loss. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the MCC in 02/2022 with diagnoses including a history of stroke and vascular dementia. The resident's 04/19/22 current service plan, 05/01/22 through 07/04/22 charting notes, and weight documentation were reviewed during the survey and identified the following weights:* 05/01/22; 160 pounds; and* 06/01/22; 151 pounds. Between 05/01/22 and 06/01/22, Resident 8 lost nine pounds or 5.62% total body weight in one month. This weight loss represented a significant change of condition for Resident 8, which required an RN assessment. There was no documented evidence an RN assessment was completed for Resident 8's significant weight loss. In an interview on 07/06/22, Staff 18 (RN) confirmed there was no RN assessment. During the survey the resident was observed to receive nutritional supplements, specially prepared meals and was assisted with eating. The resident was unable to be weighed during the survey. The need to ensure an RN assessment was completed related to significant changes in condition and included the required components of documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 on 07/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.During the acuity interview on 03/14/22, Resident 5 was identified to be administered insulin injections by non-licensed staff.Resident 5's MARs, reviewed from 02/01/22 through 03/16/22, revealed insulin had been given by Staff 5 (Personal Care Assistant (PCA)/MT) on multiple occasions.The initial delegation for Staff 5, completed 12/24/21, lacked documentation in the following areas:* The skills and ability of the unlicensed person;* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; and* How frequently the unlicensed person should be supervised and re-evaluated, including rationale for the frequency based on the competency of the caregiver.Additionally, there was no documentation that Staff 2 (RN) re-evaluated Staff 5 within 60 days of the initial delegation. The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 03/16/22. He acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 4 of 4 sampled residents (#s 9, 11, 12 and 13) reviewed for the delegation of insulin injections by unlicensed staff. This is a repeat citation. Findings include, but are not limited to:Residents 9, 11, 12 and 13 were identified as having insulin-dependent diabetes and were administered insulin injections by non-licensed staff. On 07/06/22, the facility's RN delegation records were reviewed and revealed the following:The previous facility delegating RN transferred delegation of the residents to Staff 18 (RN) on 06/14/22. The transferred delegations were accepted missing the following required documentation:* Rational for frequency of reassessment of the resident;* Rational that task could be safely delegated to unlicensed staff; and* Rational for the frequency at which staff would be reevaluated.Staff 18 completed initial delegations for Residents 9, 11, 12 and 13 with five care staff. The delegations were missing the following required documentation: * Nursing assessment and condition of the client to determine the client's condition was stable and predictable;* Rational for frequency of reassessment of the resident;* Rational that task could be safely delegated to unlicensed staff; and* Rational for the frequency at which staff would be reevaluated.The new delegations also included the staff would be reevaluated in 90-days instead of the required 60-days for initial delegations.On 07/07/22, the need to ensure RN delegation was completed and maintained as required by OSBN Division 47 Administrative rule was discussed with Staff 1 (Executive Director) and Staff 18. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 3 sampled resident (#3) who received outside provider services. Findings include, but are not limited to: Resident 3 was admitted to the facility 12/2021 after right hip surgery. During the acuity interview on 03/14/22, Resident 3 was identified to receive HH services.The resident's progress notes dated 01/01/22 through 03/14/22, 02/14/22 service plan, Temporary Service Plans and HH visit notes dated 01/15/22 through 03/01/22 were reviewed and revealed the following:* 01/25/22 HH OT recommendation - "Please check in with [the resident] about hip pain...seems to have increased pain with ambulation and transfers." Resident could "benefit from ice pack application to hip."; and* 02/03/22 HH PT recommendation - "Will notify surgeon of ongoing pain...Please remember [his/her] hip precautions: no bending more than 90 [degrees], no crossing legs, no rotating... keep foot pointed out".There was no documented evidence these recommendations were communicated to staff nor implemented. On 03/14/22, Staff 2 (RN) confirmed the Home Health recommendations were not passed on to the staff or implemented for the provision of care for Resident 3's right hip care instruction and pain.The need to ensure ongoing coordination of care with outside providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. 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 service providers to ensure staff were informed of new interventions, and that the service plan was adjusted, if necessary, for 1 of 1 sampled resident (#7) for whom hospice left instructions for the facility. This is a repeat citation. Findings include, but are not limited to:Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident's record indicated a history of falls. The resident was receiving hospice services.a. The record indicated Resident 7 had a fall on 06/07/22 in his/her room and sustained a skin tear to the right wrist and complained of back pain. A hospice nurse visited later on 06/07/22, evaluated the resident and left the following written instructions for the facility:* Increase morphine orders to be faxed;* Keep bed at lowest position;* Keep wheelchair and walker out of reach when resident was in bed;* Encourage use of call light;* Every-hour checks; and* Toileting every four hours. A facility staff transcribed the hospice visit note into the resident's progress notes on 06/08/22. However, there was no documented evidence the facility added the interventions to Resident 7's service plan and informed staff of the new interventions. b. A facility staff transcribed a hospice visit note into the resident's progress notes on 05/17/22. The note read in part, "patient was complaining about a stomach ache and pain in [his/her] chest. [RN case manager] and facility staff notified."There was no documented evidence the facility coordinated care with the outside provider which included an evaluation of the resident to determine if the service plan needed to be adjusted and staff informed of any new interventions.The need to ensure the facility had a system to ensure outside provider notes were reviewed and new instructions were added to the resident's service plan and implemented, was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, for 2 of 4 sampled residents (#s 7 and 8) whose physician orders were reviewed. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services.Resident 7's most recent signed physician orders were reviewed and compared to the 06/2022 MAR/TAR. The following orders were not followed:* Amlodipine qd (for heart disease) and furosemide qd (for congestive heart failure) were not administered for four days (06/13/22 through 06/16/22) because the facility failed to obtain refills through hospice. * Ibuprofen BID (for pain) was not administered on 06/20/22 and potassium chloride qd (for congestive heart failure) was not administered on 06/23/22 because the facility failed to obtain refills through hospice. * On 06/11/22 and 06/16/22, PRN lorazepam was given for shortness of breath without having first administered PRN morphine with ineffective results per the physician orders dated 06/06/22. * On 06/07/22, 06/08/22 and 06/17/22, PRN morphine was given for pain without having first administered PRN ibuprofen with ineffective results per the administration instructions. * During the survey, Resident 7's oxygen concentrator flow rate was observed to be set at 1.75 liters per minute, not three liters per minute as prescribed.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
2. Resident 8 was admitted to the MCC on 02/2022 with diagnoses including vascular dementia, stroke, high blood pressure and constipation. Resident 8 had the following PRN bowel medications:* Senna two tablets (17.2 mg) give first if no bowel movement in three days;* Bisacodyl suppository (10 mg) give second if no bowel movement in three days and the Senna was ineffective. The resident's 06/01/22 through 07/05/22 bowel monitoring records showed the following:* Bowel monitoring on the 06/2022 TAR indicated Resident 8 did not have a bowel movement from 06/12/22 through 06/17/22, when the facility administered PRN Senna. The PRN Senna was not administered to the resident on the third day of not having a bowel movement, as prescribed;* The TAR indicated the resident did not have a bowel movement until 06/19/22, two days after PRN Senna was administered; and * There was no documented evidence the resident was administered the PRN Bisacodyl suppository when the Senna was ineffective. The need to ensure medication and treatment orders the facility was responsible to administer were carried out as prescribed was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 1 of 3 sampled residents (# 14) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 14 was admitted to the facility in 04/2021 with diagnoses including dementia.Resident 14's MARs and current physician orders, dated 09/01/22 through 09/19/22, were reviewed and revealed the following:* Memantine 5 mg was ordered on 08/31/22 to be administered once a day for seven days, then was to increase to twice daily for dementia. The Memantine was administered once a day as ordered for seven days and then discontinued on 09/07/22. There was no order to discontinue the medication. The resident did not receive the Memantine as ordered on 23 occasions.Resident 14's MARs and orders were reviewed with Staff 18 (RN) on 09/19/22, and Staff 25 (Executive Director) on 09/20/22. They acknowledged staff failed to ensure the order was carried out as prescribed. Administration of the medication was resumed on 09/19/22 at 8:00 pm.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented medication and treatment refusals. Findings include, but are not limited to:Resident 4's MARs were reviewed for the time period of 02/01/22 through 03/15/22. Staff documented Resident 4 refused:* Tylenol (for pain) on six occasions;* Docusate sodium (stool softener) on four occasions;* Risperidone (for mood) on four occasions;* Morphine (for pain) on one occasion; and * Sertraline (antidepressant) on three occasionsThere was no documented evidence the facility notified Resident 4's physician/practitioner of the refusals.Staff 16 (MT) was interviewed on 03/15/22 at 1:10 pm. During the interview, she confirmed the lack of documentation that staff had notified Resident 4's physician/practitioner of medication refusals. The need to inform Resident 4's physician/practitioner of medication refusals was discussed with Staff 1 (ED) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications, for 3 of 4 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 2021 with diagnoses which included Alzheimer's and edema. Resident 4 had an order for compression stockings for edema. Staff were instructed to "apply compression stockings to lower extremities in the morning before resident gets out of bed ..."Review of the MAR, from 03/01/22 - 03/15/22 revealed that on 03/15/22 at 8:00 am, Staff 16 (MT) initialed that the resident's compression stockings had been applied. Multiple observations of the resident on 03/15/22 revealed s/he was not wearing compression stockings. In an interview with Staff 5 (Personal Care Assistant (PCA)/MT) on 03/15/22, she said PCAs applied the stockings, not the MTs. She added that the stockings had not been donned that morning because the family was washing them. Staff 16 was interviewed on 03/15/22 at 1:10 pm. She was unaware that the resident was not wearing the stockings. She reviewed the MAR and confirmed she initialed that the stockings had been applied without verifying it. The need to ensure an accurate MAR was discussed with Staff 1 (ED) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.
2. Resident 3 was admitted to the facility in 2021 with diagnoses including type II diabetes.Resident 3 had a physician order to administer Trulicity (a medication to treat type II diabetes) injection weekly.Resident 3's 03/01/22 through 03/14/22 MAR revealed the following:* 03/04/22 - there was no staff signature noting administration of the injection as scheduled; and* 03/11/22 - Staff 17 (PCA/MT) signed on the MAR that she administered the Trulicity injection when Staff 3 (Memory Care Director/LPN) administered the injection.The need to ensure an accurate MAR was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
3. Resident 1 was admitted to the facility in February 2021 with a diagnosis of dementia.Resident 1's 02/01/22 thru 03/14/22 MAR was reviewed and identified the following PRN pain medications ordered: * Acetaminophen oral every six hours as needed for pain and for fever; and* Morphine Sulfate oral every two hours as needed for pain or shortness of breath. The MAR gave no direction to staff on which medication to use first for the resident's pain.The need to ensure MARs included clear direction to staff for medication administration was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident-specific parameters, staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications, direct care staff administering the medications had knowledge of common side effects and when to contact a health professional regarding side effects, and all direct care staff had knowledge of non-pharmacological interventions for 2 of 2 sampled residents (#s 1 and 4) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:1. Resident 4 moved into the facility in 2021 and had diagnoses which included Alzheimer's dementia. Review of the resident's service plan, physician orders, and 02/01/22 through 03/15/22 MAR revealed the following: Resident 4 was prescribed lorazepam 0.5 mg (anti-anxiety medication) one tablet every two hours PRN for anxiety. The facility failed to ensure the resident's MAR and clinical record included the following required information:* Resident-specific parameters regarding how Resident 4 expressed anxiety;* Common side effects; * When to contact a health professional regarding side effects; and * Staff administered the PRN lorazepam on 11 occasions without documentation that non-pharmacological interventions were attempted prior to administration of the medication. Additionally, the record lacked documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 4. During an interview with Staff 16 (MT) on 03/15/22 at 1:10 pm, she reviewed the resident's record and confirmed staff had not documented that non-pharmacological interventions had been attempted prior to administering the medication. The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (ED) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.
2. Resident 1 moved into the facility in February 2021 and had diagnoses which included dementia. Review of the resident's physician orders, and 02/01/22 thru 03/10/22 MAR revealed the following: Resident 1 was prescribed the following PRN psychotropic medications: Lorazepam 0.5 mg (anti-anxiety medication) every two hours PRN for anxiety/shortness of breath; andHaloperidol 0.5 mg (anti-psychotic medication) 0.5 mg every hour PRN for agitation/delirium.The facility failed to ensure the MAR included the following required information:* Resident-specific parameters regarding how Resident 1 expressed anxiety, agitation or delirium;* Non-pharmacological interventions to be attempted prior to considering the administration of the medication; * Common side effects; and * When to contact a health professional regarding side effects.The need to ensure the required information for PRN psychotropic medications was documented in the MAR was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff 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 including a thorough review by an RN, PT or OT prior to use and documentation of less restrictive alternatives prior to use for 1 of 1 sampled resident (#1) who had a perimeter mattress on the bed. Findings include, but are not limited to:Resident 1 was admitted to the facility in February 2021.On 03/14/22 at 1:00 pm, Resident 1's bed was observed to have a perimeter mattress (a mattress with raised edges). Staff 10 (Personal Care Assistant (PCA)) stated the perimeter mattress was to prevent Resident 1 from getting up because s/he had a history of falls from the bed.There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use.The lack of assessment for use of a perimeter mattress was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired direct care staff (#10) completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 03/15/22 with Staff 8 (Business Office Manager). There was no documented evidence Staff 10 (Personal Care Assistant (PCA)), hired 02/04/22, had completed the required training in abdominal thrust and First Aid.The need to ensure staff have completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 8 and Staff 1 (ED) on 03/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months and failed to ensure fire drills included all required documentation components. Findings include, but are not limited to:Fire and life safety records for 10/2021 through 03/2022 were reviewed on 03/15/22 and revealed the following:* The lack of fire and life safety training provided to staff on alternating months on different topics;* The facility was not consistently relocating or evacuating residents during fire drills; and* Fire drill documentation lacked the following required information; - Escape route used; - Evacuation time-period needed; - Resident evacuation problems encountered; and - Number of occupants evacuated.The need to ensure staff received required fire and life safety training and fire drills included required components according to the Oregon Fire Code was reviewed with with Staff 1 (ED) and Staff 6 (Maintenance Director) on 03/16/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation that fire and life safety training was provided to residents within 24 hours of move-in; and* Alternate exit routes were used during fire drills.The need to ensure residents received fire and life safety training and that alternate exit routes were used during fire drills was discussed with Staff 1 (ED) and Staff 6 (Maintenance Director) on 03/16/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C303 and C513.

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse. Findings include, but are not limited to:On 03/14/22 a tour of the facility identified the following deficiencies:* Six mattresses were stacked next to the dumpster, along with wood and metal debris; and* Approximately two dozen sand bags, some broken open, were strewn near the tool shed, along with plastic tarps, pieces of wood, and tomato cages.The exterior areas were reviewed with Staff 1 (ED) during a tour on 03/15/22. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was free from unpleasant odors, and was maintained clean and in good repair. Findings include, but are not limited to:The facility was observed on 03/14/22 through 03/16/22. The following deficiencies were identified:* Urine and stool odors in the hallways, laundry room, and bathrooms;* Multiple urine-soaked briefs overflowing top of trash can in bathroom nearest private dining room;* Open soiled laundry bag in laundry room, showing clothing soiled with brown matter;* Scrapes and gouges in walls, doors, and door jambs in laundry room, rendering the surfaces uncleanable;* Yellow, white and brown splatters in and around utility sink in laundry room;* Dark brown matter smeared on the electrical outlet to the right of the television, and splatters and spills on the chairs and tables in the private dining room; and* Food debris on the floor, and in cabinets and drawers of the kitchenette at the end of hallway, opposite Resident Room 18.Those findings were shown to or reviewed with Staff 1 (ED) on 03/15/22 and 03/16/22. He acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the environment was in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 07/06/22 and 07/07/22 revealed the following:* An approximate six by six inch area behind the warewashing machine in the kitchen had crumbling sheet rock and was not a cleanable surface;* The tile flooring in the bathroom across from the nurses office had multiple chipped and broken areas that created a non-cleanable surface;* An approximate three foot by three foot area in the flooring of the laundry room laminate was pealed off requiring repair; and* An approximate two by two inch hole in the sheet rock behind a dryer in the laundry room created a non-cleanable surface.The environmental areas were discussed and observed with Staff 1 (ED) and Staff 6 (Maintenance Director) during the survey. Staff acknowledged the findings.


Due to the facility requesting an extension, the plan of correction date was extended to 09/30/22 for facility environmental areas. The facility remains out of compliance.

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 150, C 156, C 200, C 231, C 240, C 372, C 420, C 422, C 510 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 150, C 156, C 160, C 231 and C 513.


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

Based on interview and record review, it was determined the facility failed to ensure 7 of 8 sampled direct care staff (#s 5, 10, 11, 13, 17, 18, and 19) completed all required orientation, pre-service and competency training within the required timelines. Findings include, but are not limited to:Training records were reviewed on 03/15/22 with Staff 8 (Business Office Manager). The following deficiencies were identified:1. There was no documented evidence that Staff 10 (Personal Care Assistant (PCA)), hired 02/04/22, and Staff 11 (PCA), hired 02/24/22, completed pre-service orientation in the following areas:* Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control; and* Fire safety and emergency procedures.2. Staff 5 (PCA/MT) was hired 01/06/21. There was no documented evidence that Staff 5, Staff 10, and Staff 11 completed the following pre-service training requirements within 30 days of hire:* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being;* Family support and the role the family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that required on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.3 a. There was no documented evidence that Staff 5, Staff 10, and Staff 11 demonstrated competency in their 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.b. Staff 10 and Staff 11 did not have documented evidence of competency in the following area:* General food safety, serving and sanitation. c. Staff 5 did not have documented evidence of competency in the following area:* Medication and treatment administration. 4. In addition, 4 of 5 remaining MTs (#s 13, 17, 18, and 19) did not have documented evidence of competency in medication and treatment administration. Staff 1 (ED) was requested to ensure training of MTs prior to scheduled shifts.The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 and Staff 8 on 03/15/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 19, 22 and 24) completed all required orientation, pre-service dementia training and demonstrated competency in job duties within 30-days of hire and 3 of 3 direct care staff (#s 5, 13 and 24) completed training and demonstrated satisfactory performance in any duty assigned. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 07/06/22 and 07/07/22.1. Staff 24 Personal Care Associate/Medication Technician (PCA/MT) was hired on 04/28/22.a. Staff 24 lacked documented evidence of completing orientation training, prior to beginning job responsibilities, in the following areas:* Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures; and* Written job description.b. Staff 24 lacked documented evidence of competency demonstration within 30 days of hire related to the following training topics: * 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;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* Medication administration training. The surveyor requested documentation of training competencies for Staff 24 prior to her next scheduled shift. A plan to provide training for Staff 24 was received and accepted by the survey team on 07/07/22.2. Staff 22 (PCA) was hired on 04/21/22.a. Staff 22 lacked documented evidence of completing orientation training prior to beginning job responsibilities in the following areas:* Resident rights and values of CBC care; * Standard precautions for infection control; and* Abuse reporting requirements. b. Staff 22 lacked documented evidence of pre-service dementia training in the following areas: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;* Techniques for understanding, communication and responses to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach;* Environmental Factors that are important to a resident's well-being;* Family support an the role the family may have in the care of the resident; and* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities. c. Staff 22 lacked documented evidence of competency demonstration within 30 days of hire related to the following training topics: * Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.3. Staff 19 (PCA/MT) was hired 02/01/22. During an interview on 07/06/22 at 4:40 pm, Staff 1 (ED) verified Staff 19 worked as a Resident Care Coordinator, caregiver and medication aide dependent on the needs of the facility. Staff 19's training records lacked documented evidence of completing orientation training, pre-service dementia training and competency demonstrated within 30 days of hire. The surveyor requested documentation of training competencies for Staff 19 prior to her next scheduled shift. A plan to provide training for Staff 19 was received and accepted by the survey team on 07/07/22.The facilities training program was reviewed and discussed with Staff 1 (ED), Staff 8 (Business Office Manager) and Staff 4 (Regional Director) during the survey. Staff verified the lack of documented training for Staff 19, 22 and 24.
4. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services.The resident had signed physician orders dated 06/16/22 for continuous oxygen to be administered at a rate three liters per minute via nasal cannula. The resident used an oxygen concentrator when in his/her room and a portable oxygen machine when in common areas of the building.On 07/05/22, 07/06/22 and 07/07/22, the oxygen flow rate on Resident 7's concentrator was observed to be set at 1.75 liters per minute. In separate interviews on 07/07/22, Staff 5 (Personal Care Assistant/MT), Staff 13 (Personal Care Assistant/MT) and Staff 24 (Personal Care Assistant/MT) were each asked if they knew how to read and set the flow rate on Resident 7's concentrator. All three staff stated they did not know how to read and set the flow rate and they had not been taught as part of their training.The need to ensure staff were properly trained to perform their required job duties was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. Staff 18 acknowledged the findings and suggested arranging for a hospice provider to provide training for the staff.

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 260, C 262, C 270, C 280, C 282, C 290, C 305, C 310, C 330 and C 340.

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 270, C 280, C 282, C 290 and C 303.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C303.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans for each resident was developed and included in service plans for 3 of 4 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 2, 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) on 03/16/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose records were reviewed. Findings include, but are not limited to:Resident 1, 2, 3 and 4's service plans were reviewed during survey. Each of the service plans lacked an individualized activity plan that included the following:* Past and current interests;* 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 to participate in group activities or assist with providing more individualized activities.The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to develop individualized activity plans for 3 of 4 sampled residents (#s 6, 7 and 9) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6, 7 and 9's records were reviewed during the survey. There was no documented evidence the facility developed individualized activity plans based on activity evaluations which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.On 07/07/22, the lack of an individualized activity plan was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the community, and include information and instructions for staff on the service plan for 2 of 2 sampled residents (#s 6 and 10) who had a documented history of challenging behaviors. Resident 6 and 10 continued to have resident to resident altercations with multiple peers. Findings include, but are not limited to:1. Resident 6 resided in a MCC and was diagnosed with Alzheimer's disease. The resident's current service plan indicated s/he had a history of thinking items were stolen. The service plan instructed staff to assist with looking for the item and if not found, fill out an incident report to validate his/her concern. There was no further information regarding altercations or other behaviors noted.Progress notes and incident reports indicated between 04/30/22 and 07/05/22, Resident 6 had two documented incidents of resident to resident altercations on 05/13/22 and 05/21/22. Both behaviors included intrusion into a common area bathroom when another resident was in the bathroom and intrusion into another resident room. Both incidents resulted in physical injury to Resident 6. In an interview on 07/06/22, Staff 16 (Personal Care Assistant/MT) reported Resident 6 had a history of the following behaviors: * Intrusive into other resident rooms or personal space;* Paranoia that other residents or staff were stealing his/her belongings;* Yelling at staff and residents;* Cussing at staff and other residents (mostly staff);* S/he could also become physical with staff and other residents;* Resistive to care; and * Hoarding things in his/her room and would become physical with staff if they tried to clean his/her room. Family members would intervene and assist by taking the resident out of the facility so staff could deep clean his/her room. Interventions noted by Staff 16 included the following: * Supervise when s/he was walking the hallways;* Ensure other resident rooms were locked;* Change caregivers and re-approach; and * Call family if s/he refused care. Staff 16 further acknowledged, "We just try to deal with [him/her], [s/he] is a real hand full, a real challenge."In an interview with Staff 14 (Activity Director) on 07/05/22, the following behaviors were noted:* Hoarding; and* Noise and large groups were triggers for behavior.Staff 14 added, "I wrote in [his/her] activity evaluation that daily 1:1 activities were preferred to ensure [s/he] doesn't become escalated near other residents."The facility failed to evaluate Resident 6's behavior, add information about the behavior and resident to resident altercations to the service plan, and develop interventions for staff to protect themselves and residents from future altercations. The resident continued to engage in physical altercations with other residents. The surveyor requested an individualized behavior plan on 07/07/22 that addressed Resident 6's behaviors. Survey received and accepted a behavior care plan on 07/12/22.The need to evaluate Resident 6's behaviors, update the service plan and provide interventions for staff to attempt when the behavior occurred was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.2. Resident 10 was admitted to the MCC facility in 02/2020 with a diagnosis of dementia. Progress notes and incident reports reviewed from 04/28/22 through 07/05/22 indicated Resident 10 had three physical altercations on 04/28/22, 05/13/22 and 05/15/22. The resident's current service plan dated 04/19/22 indicated staff were to report any behavior or out of baseline behaviors to the MT/licensed nurse, provide 1 on 1 engagement and redirect. There was no further information regarding altercations, other behaviors, potential triggers for the behaviors, or further interventions noted.During an interview with Staff 16 (Personal Care Assistant/MT) on 07/06/22, it was reported Resident 10 would become agitated and escalate if s/he heard another resident saying something disrespectful to female staff. "[His/her] response was usually yelling, getting out of [his/her] wheelchair and physically punching or hitting the other resident." If staff were unable to intervene it usually resulted in physical aggression towards others. Staff 16 also reported Resident 10 was able to walk independently and only preferred to use the wheelchair. "[S/he] is actually pretty strong and when [s/he] becomes agitated [s/he] will get out of the wheelchair and approach the resident that is bothering [him/her] which usually resulted in a punch or swinging [to hit another resident]."The facility failed to evaluate Resident 10's behavior, add information about the behavior and resident to resident altercations to the service plan, and develop interventions for staff to protect themselves and residents from future altercations. The resident continued to engage in physical altercations with other residents. The surveyor requested an individualized behavior plan that addressed Resident 10's behaviors on 07/07/22. Survey received and accepted a behavior care plan on 07/07/22.The need to evaluate Resident 10's behaviors, update the service plan and provide interventions for staff to attempt when the behavior occurred was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:The MCC was toured on 03/15/22. Twenty-seven out of 40 residents lacked individual identification of their rooms that would assist in room recognition.The need to ensure each resident room was individually identified for the resident was reviewed with Staff 1 (ED) on 03/15/22 during a walk-through of the facility. He acknowledged the findings.

Based on interview, observation and record review it was confirmed the facility failed to ensure there were enough staff to meet the scheduled and unscheduled needs of residents. Findings include, but not limited to: During onsite visit on 01/20/2022, the Memory Care Unit had 42 high acuity residents requiring care. Compliance Specialist (CS) observed the following areas: *Residents soiled clothing piled up in laundry room. *Resident #1 soiled him/herself after lunch, related to no staff available to provide toileting assistance; and*Only 1 MT and 1 CG arrived for the swing shift. Posted staffing plan indicates facility should have 3 CGs and 1 MT on for swing shift. CS asked Staff #1 (S1-med tech) about the residents ' acuity and there was no documentation that contained information regarding the resident ' s individual care needs. During separate interviews with Staff #1-4 (S1-S4) the following was stated: *We do not have an acuity tool; *Not all Service Plans are accurate or up to date; *We are very short staffed. We only have 3 CGs who are not out sick. Our Executive Director, RCC and LPN have been covering night shift; *We can ' t complete residents showers or laundry sometimes. The laundry room is a mess and full of clean and dirty laundry; *We don ' t use agency staff and I don ' t know why; *Swing shift should have 3 CGs and 1 MT and most of the time it is only staffed with 1 MT and 1 CG, like today; and The facility was unable to tell the CS how they get their staffing based on resident acuity. The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.

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 01/20/2022. 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

Based on interview, observation and record review it was confirmed the facility failed to ensure there were enough staff to meet the scheduled and unscheduled needs of residents. Findings include, but not limited to: During onsite visit on 01/20/2022, the Memory Care Unit had 42 high acuity residents requiring care. Compliance Specialist (CS) observed the following areas: *Residents soiled clothing piled up in laundry room. *Resident #1 soiled him/herself after lunch, related to no staff available to provide toileting assistance; and*Only 1 MT and 1 CG arrived for the swing shift. Posted staffing plan indicates facility should have 3 CGs and 1 MT on for swing shift. CS asked Staff #1 (S1-med tech) about the residents ' acuity and there was no documentation that contained information regarding the resident ' s individual care needs. During separate interviews with Staff #1-4 (S1-S4) the following was stated: *We do not have an acuity tool; *Not all Service Plans are accurate or up to date; *We are very short staffed. We only have 3 CGs who are not out sick. Our Executive Director, RCC and LPN have been covering night shift; *We can ' t complete residents showers or laundry sometimes. The laundry room is a mess and full of clean and dirty laundry; *We don ' t use agency staff and I don ' t know why; *Swing shift should have 3 CGs and 1 MT and most of the time it is only staffed with 1 MT and 1 CG, like today; and The facility was unable to tell the CS how they get their staffing based on resident acuity. The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.

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 01/20/2022. 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

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. During the onsite visit on 01/20/2022, 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. Deficiencies that were identified included, but were not limited to:Compliance Specialist (CS) was not screened in at any time during onsite visit. Witness #1 (Infection Control Specialist) was also not observed to be screened prior to or at any time during their time in the facility. Multiple staff members (Staff #1-4 [S1-4]) were observed not wearing eye protection.Staff were observed not hand washing or using alcohol-based hand sanitizer before or after assisting covid positive residents. There was no disinfection station or face shields outside of the COVID positive Resident Rooms. CS observed S1 and S4 doff gowns and gloves after leaving a covid positive residents' apartment and dispose of them down the hallway into a common area trash can with no lid. The trash can was overflowing with used Personal Protective Equipment (PPE). During separate interview with Staff #1-4 (S1-4), the CS was given different answers when asked questions regarding PPE, screening, and sanitation and disinfectant usage/practices. The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation, which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.

Based on interview, observation and record review it was confirmed the facility failed to ensure there were enough staff to meet the scheduled and unscheduled needs of residents. Findings include, but not limited to: During onsite visit on 01/20/2022, the Memory Care Unit had 42 high acuity residents requiring care. Compliance Specialist (CS) observed the following areas: *Residents soiled clothing piled up in laundry room. *Resident #1 soiled him/herself after lunch, related to no staff available to provide toileting assistance; and*Only 1 MT and 1 CG arrived for the swing shift. Posted staffing plan indicates facility should have 3 CGs and 1 MT on for swing shift. CS asked Staff #1 (S1-med tech) about the residents ' acuity and there was no documentation that contained information regarding the resident ' s individual care needs. During separate interviews with Staff #1-4 (S1-S4) the following was stated: *We do not have an acuity tool; *Not all Service Plans are accurate or up to date; *We are very short staffed. We only have 3 CGs who are not out sick. Our Executive Director, RCC and LPN have been covering night shift; *We can ' t complete residents showers or laundry sometimes. The laundry room is a mess and full of clean and dirty laundry; *We don ' t use agency staff and I don ' t know why; *Swing shift should have 3 CGs and 1 MT and most of the time it is only staffed with 1 MT and 1 CG, like today; and The facility was unable to tell the CS how they get their staffing based on resident acuity. The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.

Based on interview, observation and record review it was confirmed the facility failed to ensure there were enough staff to meet the scheduled and unscheduled needs of residents. Findings include, but not limited to: During onsite visit on 01/20/2022, the Memory Care Unit had 42 high acuity residents requiring care. Compliance Specialist (CS) observed the following areas: *Residents soiled clothing piled up in laundry room; *Resident #1 soiled him/herself after lunch, related to no staff available to provide toileting assistance; and*Only 1 MT and 1 CG arrived for the swing shift. Posted staffing plan indicates facility should have 3 CGs and 1 MT on for swing shift. CS asked Staff #1 (S1 MT) about the residents' acuity and there was no documentation that contained information regarding the resident's individual care needs. During separate interviews with Staff #1-4 (S1-S4) the following was stated: *We do not have an acuity tool; *Not all Service Plans are accurate or up to date; *We are very short staffed. We only have 3 CGs who are not out sick. Our Executive Director, RCC and LPN have been covering night shift; *We can't complete residents showers or laundry sometimes. The laundry room is a mess and full of clean and dirty laundry; *We don't use agency staff and I don't know why; *Swing shift should have 3 CGs and 1 MT and most of the time it is only staffed with 1 MT and 1 CG, like today; and The facility was unable to tell the CS how they get their staffing based on resident acuity. The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.