Wellsprings Assisted Living Facility

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The kitchen, food storage areas, and dining room were toured on 06/05/25 and the following was identified to be in need of cleaning and/or repair:

a. Kitchen:

* The handwashing sink had gray marks present;
* The cupboard under the handwashing sink had brown and green debris present inside and the left cupboard door hung off of one hinge;
* There was a triangle-shaped area in the floor by the reach in refrigerators that was in disrepair and not a cleanable surface;
* The plastic cutting boards had score marks throughout deeming them to be uncleanable;
* The white cupboards throughout the kitchen were observed to have chipping wood, chipped paint, and areas where the paint was peeling off;
* The red “Pyro-Chem” fire protection system container to the right of the stove was sticky to the touch;
* The areas where the baseboards met the flooring had black and brown build-up present throughout the kitchen;
* The kitchen entry and exit doors and door jambs had black and brown matter present as well as chipped paint and wood;
* There was a black stand-up fan that was not in use but had a thin layer of dust on the casing around the blades; and
* The shelf where the microwave was stored had holes in it and chipped paint which exposed bare wood.

b. Warewashing Area:

* The pan under the hot water heater had brown and gray debris inside, there was a soiled dried piece of paper in the pan, and a plastic bag with some water damaged paper in it;
* Small holes were observed in the wall behind the three-compartment sink;
* There was a stepping stool stored under the three-compartment sink with brown matter towards the ends of the legs;
* The wall behind the sink where the warewasher was had caulking that had turned black and brown; and
* The wall behind where the clean dishes came out of the warewasher had a ledge with built up dust and debris, with gouges in the wood and gray marks present.

c. Dry Food Storage Area:

* Freezer #3 had debris present in the shelving inside, a gouge inside on the bottom of the unit, and an accumulation of dust in the bottom vent.

d. Dining Room:

* The areas where the baseboards met the flooring had black and brown build-up present throughout the dining room;
* There were areas in the linoleum flooring where there were scrapes, scratches, and grooves deeming it an uncleanable surface;
* There was a stand-up refrigerator and freezer that had a layer of dust on the top of each unit;
* Both heating and cooling units had a layer of dust present;
* The bottom vent on the heating and cooling unit located farthest from the kitchen door was falling off;
* The flooring was raised with an accumulation of debris present by the heating and cooling unit located closest to the kitchen door;
* The wall where the heating and cooling units were had streaks of gray and black observed;
* The exit door between the heating and cooling units had black and brown streaking, chipped paint and wood in the door jambs, the glass where the tint was peeling off was sticky to the touch, and the threshold had an accumulation of debris present;
* The base underneath some of the dining room tables had dust and food debris observed; and
* The buffet where water and snacks were available to residents had dust and or debris inside of the cupboards, chipped or peeling paint throughout the buffet, areas with exposed wood on the countertop and one of the cupboard doors where the lock was located, the surface of the countertop was peeling away from the wood on the left side, and there were holes in the wall behind the buffet as well as black and brown marks observed on the wall.

The above areas were reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director) on 06/05/25. They acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement program that evaluated services, resident overcomes and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 09/17/24 through 09/19/24, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.
On 09/19/24, Staff 1 (Senior ED) was interviewed about the facility’s quality improvement program. She reported there was no quality improvement program in place.
Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:

Staff 1 (Senior Executive Director) was asked about the facility's quality improvement program on 01/14/25. During the interview, Staff 1 stated the facility did not have a Quality Improvement Program.

The need to ensure the facility had an effective method to evaluate services, resident outcomes and resident satisfaction was discussed. Staff 1 acknowledged the findings.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:

Staff 1 (Senior Executive Director) was asked about the facility's quality improvement program on 01/14/25. During the interview, Staff 1 stated the facility did not have a Quality Improvement Program.

The need to ensure the facility had an effective method to evaluate services, resident outcomes and resident satisfaction was discussed. Staff 1 acknowledged the findings.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#s 1 and 2) and one unsampled resident were treated with dignity and respect and failed to provide choice and opportunity to select or refuse service. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes and chronic pain.

On 09/18/24 at 10:35 am during an interview with Resident 1, it was observed the resident received a Styrofoam bowl and a plastic fork on the breakfast room tray. The resident reported residents who had meals in the dining room received regular plates and silverware, but those who had room trays received Styrofoam plates and plastic silverware.

On 09/19/24 at 11:10 am, the need to ensure the resident was treated with dignity and respect during the meal services was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director). They acknowledged the findings.

2. Resident 2 moved into the facility in 09/2018 with diagnoses including major depressive disorder, anxiety, and essential hypertension.

During an interview and observation with Resident 2 on 09/18/24 at 2:45 pm, Resident 2 reported s/he received a room tray with a Styrofoam container and shared a personal photograph that s/he had taken of the breakfast meal that was delivered to his/her room. The breakfast was in a Styrofoam container. Resident 2 stated, “we used to have regular plates and silverware. I guess they took them away because other residents were keeping the dishes, well I’m not sure why am I being punished?”

Review of Resident 2’s current service plan dated 06/07/24 indicated the facility would not use Styrofoam to deliver his/her meals.

A progress note dated 07/03/24 indicated the resident was delivered a meal in a Styrofoam container and the resident refused the meal.

On 09/19/24 at 8:30 am, the need to ensure the resident was treated with dignity and respect during meal services was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director). They acknowledged the findings.

3. During a general observation on 09/17/24 at 11:30 am and again at 12:55 pm, there was an audio device broadcasting a conversation at the nursing station which was located in a common area within the facility and an unsampled resident’s door was propped open throughout the day.

During an interview with Staff 9 (CG) on 09/17/24 at 1:00 pm it was reported the conversation was coming from [room number]. “We have the audio device because [s/he] falls a lot.” Staff 9 was asked how the device alerted staff to prevent a potential fall. Staff 9 stated “[S/he] has another device that alerts caregivers. This one, I don’t know.”

At 1:30 pm, the same unsampled resident's apartment door was propped open, and s/he had a visitor.

During an interview with the unsampled resident on 09/17/24 at 1:30 pm, the resident stated s/he was unaware of the audio device broadcasting his/her private conversation at the nursing station and that s/he preferred to have the apartment door closed, but “they always have it opened, I guess because they say I’ve had too many falls.”

At 1:32 pm, Staff 9 and Staff 16 (CG) were asked if there was direction in the resident’s service plan to have the device broadcasting the resident’s private conversations at the nursing station or direction to keep the resident’s door propped open. Staff 9 and 16 both stated they were not sure, but that they could close his/her apartment door if s/he wanted it closed. Staff 9 stated “we just keep it open so we can see [him/her].”

On 09/19/24 at 8:30 am, the need to ensure the resident was treated with dignity and respect and the facility provided choice and opportunity to select or refuse services was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director). They acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights and Protection

(1) The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of their rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (d) To receive information about the method for evaluating their service needs and assessing costs for the services provided.(e) To exercise individual rights that do not infringe upon the rights or safety of others.(f) To be free from neglect, financial exploitation, verbal, mental, physical or sexual abuse. (g) To receive services in a manner that protects privacy and dignity. (h) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday and holidays). (i) To have medical and other records kept confidential except as otherwise provided by law. (j) To associate and communicate privately with any person of choice, to send and receive personal mail unopened and to have reasonable access to the private use of a telephone.(k) To be free from physical restraints and inappropriate use of psychoactive medications. (l) To manage personal financial affairs unless legally restricted. (m) To have access to and participate in social activities. (n) To be encouraged and assisted to exercise rights as a citizen. (o) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (p) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (q) To be free of retaliation after they have exercised their rights provided by law or rule; (r) To have a safe and homelike environment. (s) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation or religion. (t) To have proper notification if requested to move out of the facility, and to be required to move out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to immediately investigate incidents and injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office if abuse could not immediately be ruled out, for 1 of 1 sampled resident1 (# 2) who had a fall and an injury of unknown cause. Findings include, but are not limited to:

Resident 2 moved into the facility in 09/2018 with diagnoses including major depressive disorder, anxiety, and essential hypertension.

Review of the resident's clinical record including progress notes from 06/07/24 through 09/17/24 and incident reports for the same time period were completed during the survey and identified the following:

• 06/11/24: Skin tear on the right ankle; and
• 07/19/24: Fall resulting in an emergency room visit.

The skin injury represented an injury of unknown cause and required an immediate investigation to rule out suspected abuse and reporting to the local SPD office if abuse could not be ruled out.

During an interview with Resident 2, s/he was unable to recall the details of what had happened to his/her ankle in June 2024 or what caused the fall in July 2024.

During an interview on 09/19/24 at 11:46 am, Staff1 (Senior ED) reported there were no investigations completed for either of the above incidents.

There was no documented evidence the facility immediately investigated the resident’s fall or skin tear to rule out suspected abuse and there was no documented evidence the facility reported the incidents to the local SPD office. Survey requested the facility report the above incidents to the local SPD office. Verification was received on 09/23/24 after survey exited.

The need to ensure all incidents and injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local SPD office if abuse could not be ruled out was discussed with Staff 1 and Staff 3 (Resident Care Director) on 09/19/24 at 8:30 am. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:

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) whose initial evaluation was reviewed. Findings include, but are not limited to:

Resident 3 moved into the facility in 08/2024 with diagnoses including type II diabetes and chronic obstructive pulmonary disease.

The initial evaluation was reviewed and failed to address the following required elements:

• Customary routines including sleeping, eating and bathing;
• Interests, hobbies, social, leisure activities;
• Spiritual, cultural preferences and traditions;
• Physical health status including list of current diagnoses, list of medications and PRN use, visits to health practitioner(s) ER, hospital or NF in the past year and vital signs if indicated by diagnosis, health problems or medications;
• Mental Health issues including, presence of depression, though disorders or behavioral or mood problems, history of treatment and effective non-drug interventions;
• Cognition, including memory, orientation, confusion and decision making abilities;
• Personality including how the person copes with change or challenging situations;
• Communication and sensory including hearing, vision, speech, assistive devices and ability to understand and be understood;
• Activities of daily living including dressing and grooming;
• Independent activity of daily living including ability to manage medications, ability to use call system, housekeeping and laundry and transportation;
• Pain including pharmaceutical and non-pharmaceutical interventions and how a person expressed pain or discomfort;
• Skin condition;
• Nutrition habits and fluid preference;
• List of treatments, type, frequency and level of assistance needed;
• Indicators of nursing needs including potential for delegated nursing tasks;
• Fall risk or history;
• Emergency evaluation ability;
• Complex medication regimen;
• History of dehydration or unexplained weight loss or gain;
• Recent loss;
• Unsuccessful prior placement;
• Alcohol and drug use; and
• Environmental factors that impact the resident’s behavior including, but not limited to noise, lighting and room temperature.

The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/18/24 at 3:50 pm. Staff acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.(a) Resident evaluations must be:(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and(B) Performed at least quarterly, to correspond with the quarterly service plan updates.(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.(E) Documented, dated, and indicate who was involved in the evaluation process.(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location.(c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.(3) EVALUATION REQUIREMENTS AT MOVE-IN.(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.(c) The initial evaluation must contain the elements specified in section (5) of this rule, and address sufficient information to develop an initial service plan to meet the resident's needs.(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.(4) QUARTERLY EVALUATION REQUIREMENTS.(a) Resident evaluations must be performed quarterly after the resident moves into the facility.(b) The quarterly evaluation is the basis of the resident's quarterly service plan.(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.(5) The resident evaluation must address the following elements:(a) Resident routines and preferences including:(A) Customary routines, such as those related to sleeping, eating, and bathing;(B) Interests, hobbies, and social and leisure activities;(C) Spiritual and cultural preferences and traditions; and(D) Additional elements as listed in 411-054-0027(2).(b) Physical health status including:(A) List of current diagnoses;(B) List of medications and PRN use;(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and(D) Vital signs if indicated by diagnoses, health problems, or medications.(c) Mental health issues including:(A) Presence of depression, thought disorders, or behavioral or mood problems;(B) History of treatment; and(C) Effective non drug interventions.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) Activities of daily living including:(A) Toileting, bowel, and bladder management;(B) Dressing, grooming, bathing, and personal hygiene;(C) Mobility ambulation, transfers, and assistive devices; and(D) Eating, dental status, and assistive devices.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) Review of risk indicators including:(A) Fall risk or history;(B) Emergency evacuation ability;(C) Complex medication regimen;(D) History of dehydration or unexplained weight loss or gain;(E) Recent losses;(F) Unsuccessful prior placements;(G) Elopement risk or history;(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.(o) Environmental factors that impact the resident's behavior including, but not limited to:(A) Noise.(B) Lighting.(C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of service for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes and chronic pain.

Observations of the resident, interviews with staff and current service plan, updated 06/25/24, reviewed during the survey, from 09/17/24 thru 09/19/24, revealed Resident 1's service plan was not reflective of his/her status and did not provide clear directions regarding the delivery of services including what, when, how and how often the service should be provided in the following:

• Use of air mattress on the bed;
• Use of C-pap (a machine to use mild air pressure to keep breathing airways open while sleep);
• Bowel and bladder assistance status;
• Use of a side rail; and
• Insulin administration assistance status.

On 09/18/24 at 3:50 pm, the service plan was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director). They acknowledged the service plan was not reflective of the resident's status and lacked clear directions.

2. Resident 3 moved into the facility in 08/2024 with diagnoses including type II diabetes and chronic obstructive pulmonary disease.

Observations of the resident, interviews with staff and current service plan, updated 08/28/24, reviewed during the survey, from 09/17/24 thru 09/19/24, revealed Resident 3's service plan was not reflective of the resident's status and did not provide clear directions regarding the delivery of services including what, when, how and how often the service should be provided in the following:

• Customary routines including sleeping and eating;
• Interests, hobbies, social, leisure activities;
• Spiritual, cultural preferences and traditions;
• Cognition, including memory, orientation, confusion and decision making abilities;
• Communication and sensory including hearing, vision, speech, assistive devices use;
• Ability to use call system;
• Bathing/shower status;
• Skin condition;
• Nutrition habits and fluid preference;
• Emergency evaluation ability;
• Environmental factors that impact the resident’s behavior including, but not limited to noise, lighting and room temperature;
• Use of C-pap (a machine to use mild air pressure to keep breathing airways open while sleep);
• Use of ostomy and care instruction;
• Use of catheter and care instruction;
• Use of oxygen including setting and care instruction;
• Falls risk status;
• Eating and meal intake status;
• Personal hygiene status; and
• Mobility and use of wheelchair.

On 09/18/24 at 3:50 pm, the service plan was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director). They acknowledged the service plan was not reflective of the resident's status and lacked clear directions.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411-004-0030, the facility must incorporate all elements identified in the person-centered service plan into the resident's service plan.(2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.(a) The service plan must be completed:(A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and(B) Following quarterly evaluations.(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.(d) Changes and entries made to the service plan must be dated and initialed.(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.(g) The facility administrator is responsible for ensuring the implementation of services.(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.(b) The initial service plan must be reviewed within 30-days of move- in to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.(c) Staff must document and date adjustments or changes as applicable.(4) QUARTERLY SERVICE PLAN REQUIREMENTS.(a) Service plans must be completed quarterly after the resident moves into the facility.(b) The quarterly evaluation is the basis of the resident's quarterly service plan.(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2018 with diagnoses including major depressive disorder, anxiety, and essential hypertension.

Review of the resident's clinical record including progress notes from 06/07/24 through 09/17/24, service plan updated on 06/07/24 and interim service plans (ISP’s) were completed during the survey.

The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition:

• 06/11/24: Skin tear on the right ankle;
• 07/05/24: Swollen right foot/ankle;
• 07/19/24: Fall with emergency room visit;
• 07/19/24: Return to community with new diagnosis and medication; and
• 08/13/24: Fall in the transport van.

The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated resident-specific instructions and interventions to staff on each shift, and/or monitored the change of condition, at least weekly, until resolved was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 8:30 am. They acknowledged the findings.

2. Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes and chronic pain.

Resident 1's progress notes, dated 06/17/24 thru 09/01/24 and observations notes, dated 09/01/24 to 09/17/24 were reviewed during the survey and the following was identified:

• 06/18/24: “burn wound” on the right thigh;
• 07/13/24: A new medication for urinary tract infection;
• 07/29/24: Sores and redness in buttocks;
• 08/02/24: A small rash in the middle of the buttocks;
• 08/05/24: A small open area on the right thigh;
• 08/11/24: Received a new medication; and
• 09/07/24: Received anti-biotic treatment.

There was no documented evidence the resident's changes of condition were determined and documented what action or interventions was needed for the resident and communicated the determined action to staff on each shift. Additionally, there was no weekly monitoring completed through resolution.

During an interview on 09/18/24 at 2:40 pm, Staff 3 (Resident Care Director) confirmed there was no other skin tracking sheet to monitor the resident’s skin condition.

On 09/18/24 at 3:50 pm, the above information was discussed with Staff 1 (Senior ED) and Staff 3. They acknowledged the findings.


3. Resident 3 moved into the facility in 08/2024 with diagnoses including type II diabetes and chronic obstructive pulmonary disease.

Resident 3's progress notes, dated 08/29/24 through 09/03/24 and observations notes, dated 09/01/24 to 09/17/24 were reviewed during the survey and the following was noted:

• 09/03/24: New move-in and new environment; and
• 09/07/24: Received anti-biotic treatment.

There was no documented evidence the resident’s short-term changes of condition were monitored and documented at least weekly until the condition resolved.

On 09/18/24 at 3:50 pm, the above information was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director). They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 1 of 2 sampled residents (# 7) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 04/2024 with diagnoses including type 1 diabetes mellitus and cerebral infarction.

Clinical records, including the current service plan and progress notes from 12/02/24 through 12/29/24 were reviewed, and interviews with the resident and facility staff were conducted.

During the acuity interview on 01/13/25, it was reported the facility staff administered insulin to the resident multiple times daily. Observations of staff preparing and administering insulin injections were made on 01/14/25 and 01/15/25.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 12/18/24: underwent scheduled cardiac catheterization;

* 12/18/24: “…BG is elevated enough that his/her glucometer just reads “High”. (Machine specifications indicate “High” alert means BG is definitely higher than 400.”);

* 12/18/24: returned from ER with diagnosis of hyperglycemia;

* 12/19/24: “… his/her parents brought in insulin from home and gave him/her another 4 units.”;

* 12/20/24: BG 400 (outside normal parameters);

* 12/24/24: BG 398 (outside normal parameters);

* 12/2/24: “…[Resident] stopped his/her scooter said s/he had fallen asleep [while driving];

* 12/30/24: “residents foot is cracked open…”;

* 01/05/25: wrong dosage of insulin was administered by facility staff;

* 01/08/25: “Resident called…was sweating and confused. Checked blood was lower then 40.”; and

* 01/10/25: “when swing shift was leaving residents GL [glucose level] was 60 and going lower…”.

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Senior Executive Director), Staff 3 (Resident Care Director), and Staff 18 (RN). They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 1 of 2 sampled residents (# 7) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 04/2024 with diagnoses including type 1 diabetes mellitus and cerebral infarction.

Clinical records, including the current service plan and progress notes from 12/02/24 through 12/29/24 were reviewed, and interviews with the resident and facility staff were conducted.

During the acuity interview on 01/13/25, it was reported the facility staff administered insulin to the resident multiple times daily. Observations of staff preparing and administering insulin injections were made on 01/14/25 and 01/15/25.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 12/18/24: underwent scheduled cardiac catheterization;

* 12/18/24: “…BG is elevated enough that his/her glucometer just reads “High”. (Machine specifications indicate “High” alert means BG is definitely higher than 400.”);

* 12/18/24: returned from ER with diagnosis of hyperglycemia;

* 12/19/24: “… his/her parents brought in insulin from home and gave him/her another 4 units.”;

* 12/20/24: BG 400 (outside normal parameters);

* 12/24/24: BG 398 (outside normal parameters);

* 12/2/24: “…[Resident] stopped his/her scooter said s/he had fallen asleep [while driving];

* 12/30/24: “residents foot is cracked open…”;

* 01/05/25: wrong dosage of insulin was administered by facility staff;

* 01/08/25: “Resident called…was sweating and confused. Checked blood was lower then 40.”; and

* 01/10/25: “when swing shift was leaving residents GL [glucose level] was 60 and going lower…”.

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Senior Executive Director), Staff 3 (Resident Care Director), and Staff 18 (RN). They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to monitor each resident consistent with his or her evaluated needs and service plan; determine what actions or interventions were needed for changes of condition, communicate these instructions to staff on each shift, and document on the progress of the conditions at least weekly until resolved, for 2 of 2 sampled residents (#s 9 and 10) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 moved into the assisted living community with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, atrial fibrillation and heart failure. The resident was receiving hospice services.

a. The resident was evaluated for the use of oxygen. The oxygen order was transcribed on the MAR; however care staff including MT’s reported they were not monitoring the resident’s use of the oxygen or the resident’s oxygen saturation levels.

On 04/02/25, surveyor observed the resident was wearing the nose canula and the oxygen was turned on. The resident stated s/he didn’t know how many liters s/he was taking and that s/he takes it on and off throughout the day.

b. “Care history” (tool used to monitor and chart on changes of condition) and “observation notes” (tool used by the facility to chart on a resident’s condition), dated 03/01/25 through 04/02/25 and the current service plan dated 03/06/25 were reviewed. The following changes of condition lacked determined actions or interventions needed, the action or intervention communicated to staff on each shift and/or weekly progress documented in the residents’ record until the condition resolved:

* 03/04/25 - New medication- PRN Tylenol for elevated body temperature for multiple days;

* 03/10/25 – Weight loss;

* 03/12/25 - Unwitnessed fall (intervention not communicated to staff);

* 03/14/25 – Unwitnessed fall (intervention not communicated to staff);

* 03/23/25 – Unwitnessed fall; and

* 03/24/25 – Permanent foley catheter.

The need to ensure the facility monitored each resident consistent with his or her evaluated needs and service plan; determine what actions or interventions were needed for changes of condition, communicate these instructions to staff on each shift, and document on the progress of the conditions at least weekly until resolved was discussed with Staff 3 (Residential Care Director) and Staff 18 (RN) on 04/02/25 at 1:35 pm.

2. Resident 9 was admitted to the facility in 02/2011, with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD), and dementia.

Review of Resident 9's progress notes, dated 03/01/25 through 04/02/25, revealed the resident experienced the following changes of condition:

* 03/03/25- A progress note documented the resident had “been in bed all day. [He/she] said it hurts too much to move”. ;

* 03/09/25- Two progress notes on this date noted Resident 9 was “confused and didn’t know where she needed to be”, and the resident stated “[he/she] must be hallucinating”.; and

* 03/27/25- Progress note reported the resident was having “increased SOB” [shortness of breath] and “received the inhaler more than prescribed”

The facility failed to determine if actions or interventions were needed, and there was no documented evidence the above noted changes were monitored at least weekly until resolution.

On 04/02/25 at 2:05, the need to ensure the facility evaluated changes of condition, determined necessary interventions, and monitored the changes of condition at least weekly until resolved, was reviewed with Staff 3 (Residential Care Director) and Staff 17 (RN). They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#s 1 and 2) who experienced significant changes of condition related to an ADL decline and weight gain. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2018 with diagnoses including major depressive disorder, anxiety, and essential hypertension. During the acuity interview on 09/17/24 it was reported the resident had a skilled nursing stay due to a foot fracture.

The resident's clinical records including progress notes, home health notes, service plan updated on 06/07/24 and interim service plans (ISP’s) were reviewed during the survey.

During an interview with Staff 3 (Resident Care Director) on 09/17/24 at 11:41 am it was reported the resident returned to the community on 06/07/24 and started home health physical therapy on 06/10/24.

A progress note dated on 06/07/24 indicated the resident was a Hoyer lift transfer and needed two, sometimes three people to transfer from recliner chair to bedside commode.

A progress note dated 06/13/24, from a previously employed LPN indicated “Resident with significant health decline. Resident now a two person Hoyer lift for all transfers and mobility needs.”

During an interview with the resident on 09/18/24 at 2:45 pm, s/he reported prior to fracturing his/her foot, “I was able to transfer with one person and didn’t need to use a Hoyer. I didn’t need to use a bedside commode. I was able to walk to the bathroom and would use my cane.”

This constituted a significant change of condition which required an RN assessment.

There was no documented evidence an RN assessed and documented Resident 2's condition, status or the findings made as a result of an RN assessment.

The need to ensure an RN assessment was completed for a significant change of condition was discussed with Staff 2 (RN) on 09/18/24 and Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 8:30 am. They acknowledged the findings.

2. Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes and chronic pain.

Resident 1's weight record was reviewed during the survey and the following was noted:

• 04/02/24: 209 pounds;
• 04/05/24 (re-weight): 218 pounds;
• 05/02/24: 230 pounds;
• 05/04/24: 230 pounds; and
• 09/02/24: 230 pounds.

The record showed from 04/05/24 to 05/04/24, the resident gained 12 pounds or 5.74 % of his/her body weight in 30 days, which represented a significant change of condition.

There was no documented evidence the facility evaluated the resident condition related to weight gain and an RN conducted an assessment of the resident’s weight gain which included findings, a description of resident status and a plan of care to address the weight gain.

On 09/19/24 at 11:10 am, the needs to ensure the facility RN completed assessments for significant change of condition was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director). They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment for 1 of 1 sampled resident (#10) who experienced significant changes of condition. Resident 10 had ongoing severe weight loss. Findings include, but are not limited to:

Resident 10 moved into the assisted living community in 03/2023 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, atrial fibrillation and heart failure. The resident was receiving hospice services.

During an interview with Staff 9 (CG) on 04/02/25 at 3:35 pm, it was reported approximately two to three weeks ago the resident started to decline, was less mobile, needing two people to transfer and his/her appetite started to decline.

a. Resident 10’s weight records were reviewed:

* 12/01/2024 – 183.4 pounds;

* 01/05/2025 – 185.4 pounds;

* 02/02/2025 – 170.4 pounds;

* 02/21/2025 – 166.8 pounds; and

* 03/10/2025 – 165.2 pounds.

From 01/05/2025 to 02/02/2025, Resident 10 had a weight loss of 15 pounds or 8.09% of his/her body weight in one month. This severe weight loss indicated a significant change of condition and required an RN assessment.

On 02/21/2025, another weight was taken, and the resident lost an additional 3.6 pounds.

On 03/10/2025, the resident’s weight continued to trend downward another 1.6 pounds, totaling 20.2 pound or 10.89% weight loss within three months.

There was no documented evidence the RN completed an assessment of the severe weight loss which documented findings, resident status, and interventions made as a result of the assessment and the resident continued to lose weight.

A current weight during survey was unable to be taken due to the resident’s condition.

During an interview on 04/02/25 at 3:30 pm, with Staff 24 (Cook), it was reported the kitchen had no instructions/interventions for weight loss for Resident 10.

During an interview on 04/02/25 at 3:45 pm, with Staff 5 (MT), it was reported there was no instructions to provide any fortified drinks or supplements for weight loss.

Review of ISP’s and the service plan dated 03/06/25 identified no history of weight loss or current weight loss interventions.

On 04/02/25 at 1:30 pm, an RN assessment for the resident's severe weight loss was requested. Staff 18 (RN) confirmed he was aware of the resident’s decline and weight loss and was coordinating with hospice.

There was no documented evidence a facility RN completed an assessment of Resident 10’s severe weight loss on 02/02/25, 03/10/25 or completed an RN assessment of the resident’s ADL decline.

b. During the acuity interview on 04/02/25 at 8:44 am, Resident 10 was identified to have experienced a decline in ADL ability and health status.

Interviews with staff and review of the current service plan and interim service plans reviewed from 03/01/25 through 04/02/25 identified the resident had a change in care needs and status in the following areas:

Two person transfers; and

Foley Catheter.

There was no documented evidence an RN completed an assessment for the ADL and health decline.

The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 3 (Residential Care Director) and Staff 18 on 04/02/25 at 1:35 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

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 (#1) 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 09/17/24, Resident 1 was identified to be administered insulin injections by non-licensed staff.

Resident 1's MARs, reviewed from 09/01/24 through 09/17/24, revealed the resident received Toujeo (insulin to treat diabetes) once daily and Novolog (insulin to treat diabetes) three times daily with meals as needed based on the blood sugar result. The insulin had been given by Staff 10 (MT), Staff 11 (MT), Staff 12 (MT) and Staff 15 (MT) on multiple occasions.

Review of delegation records and the MAR, showed the following:

• RN assessment, 05/30/24, indicated that Resident 1's diabetes condition was stable and predictable. However, there was no documented evidence as to how the RN determined the resident's condition was stable and predictable;
• There was no documentation of the rationale for the frequency for reassessing the resident's condition based on the resident's needs;
• The initial evaluation for Staff 10, 11, 12 and 15's skills and ability was completed on 07/16/24, 05/31/24, 06/19/24 and 07/17/24. However, there was no documentation of the rationale for deciding the task could be safely delegated to Staff 10, 11, 12 and 15;
• Additionally, Staff 10, 11, 12 and 15 lacked documentations of the rationale for the frequency for supervising and reevaluating the unlicensed person based on the unlicensed person's skills and abilities; and
• Staff 2 (RN) documented to schedule reevaluation for Staff 11 and Staff 12’s skill and ability in 60 days, or before 07/31/24 and before 08/19/24. However, there was no documented evidence of re-evaluation of the delegation task for the resident had been completed as of 09/19/24, including documented evidence of an individual observation/return demonstration of competence of the staff to determine if the staff remained capable and willing to perform the task safely.

During the survey on 09/18/24 at 3:10 pm, Staff 2 was directed to assess Resident 1’s diabetes condition and re-evaluate Staff 11 and 12 to determine their skills and ability to continue performing the task.

The requirements for delegation were reviewed with Staff 1 (Senior ED), Staff 2 and Staff 3 (Resident Care Director) during the survey. They acknowledged the findings.

On 09/18/24 at 3:50 pm and 09/19/24 at 11:10 am, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1, Staff 2 and Staff 3. They acknowledged the findings.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

(1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to coordinate on-site health services, ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted if necessary, and failed to ensure outside service providers left written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care for 1 of 1 sampled resident (# 2) who received home health services. Findings include, but are not limited to:

During the survey, Resident 2's clinical record including outside provider notes, service plan last updated on 06/07/24 and interim service plans (ISP’s) were reviewed during the survey. The following was identified:

Resident 2 received home health PT services beginning 06/10/24. The plan of care from the home health provider indicated the resident would have physical therapy one time per week.

Home health PT made the following recommendation:

* On 06/12/24, a provider note read “PT wants a rolling shower chair.”

There was no documented evidence the facility reviewed the recommendation, informed staff of new interventions, and adjusted the service plan if necessary.

There was a total of three outside provider notes from home health PT, which indicated the outside provider was potentially not leaving written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care, after each weekly visit.

The need to coordinate on-site health services, ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted if necessary, and failed to ensure outside service providers left written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 8:30 am. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc

(2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (# 1) who received incontinence care and multiple unsampled residents who received room tray services. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes and chronic pain.

The surveyor observed on 09/19/24 at 8:18 am, Staff 6 (CG) provided incontinence care for Resident 1. During the observation, Staff 6 donned gloves without performing hand hygiene. Staff 6 then proceeded to remove the resident’s soiled brief, wipe and cleanse the resident’s perineum area and touched the resident’s body, clean incontinent product, clothing and bed linens while using the soiled gloves. Staff 6 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donned gloves.

The above observation was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 11:10 am. They acknowledged appropriate infection control practices were not implemented.

2. General observations were conducted from 09/17/24 through 09/19/24. The following was identified:

· Multiple care staff were observed entering and exiting unsampled residents' rooms touching their devices and other surfaces without preforming hand hygiene between each resident’s room.
· During meal service, delivering meal trays and providing hydration passes to multiple resident rooms, care staff failed to perform hand hygiene, don clean gloves, failed to wear a protective covering over potentially contaminated clothing, and failed to cover drinks and desserts during transport of food and beverages to multiple resident rooms.

The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 8:30 am. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system. Findings include, but are not limited to:

1.Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes.

During the acuity interview on 09/17/24, Resident 1 was identified to be administered insulin injections by non-licensed staff.

a. Review of the resident’s 08/01/24 – 09/17/24 MAR and delegation record showed the following:

• The resident was prescribed Toujeo (insulin to treat diabetes) once daily and Novolog (short-acting insulin) on a sliding scale (a method of adjusting the insulin dose based on blood sugar levels) three times daily with meals;
• The MAR showed on 14 occasions that there was no blood sugar result to determine the NovoLog dose before administering the insulin to the resident; and
• The delegation record indicated rotating the insulin injection site to prevent tissue damage and instructing staff to choose a different site. However, the injection site was not documented when staff administered insulin to the resident. Therefore, there was no documented evidence staff chose a different insulin injection site as directed.

b. Review of the resident’s 09/01/24 – 09/17/24 MAR and providers’ orders showed the following:

• Two separate providers prescribed Cipro (antibiotic) 250 mg two times daily for seven days on 09/06/24 and 09/09/24 for Resident 1. However, the resident’s MAR showed the resident received the antibiotic treatment for ten days, from 09/07/24 – 09/17/24, not seven days as prescribed.

During the survey on 09/18/24, Staff 3 (Resident Care Director) reported the facility received two sets of the same antibiotic from two separate providers, but the facility did not clarify the orders. Therefore, the resident received ten days of antibiotic treatment.

On 09/19/24 at 11:10 am, the above findings were reviewed with Staff 1 (Senior ED) and Staff 3. They acknowledged the findings.

2. Refer to C282, C303, C305, C310, C325 and C330.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

(1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes.

Review of the resident’s 08/01/24 – 09/17/24 MARs and providers orders showed Resident 1 had physician orders, dated 09/04/24, to notify for CBG (blood sugar levels) below 70 or above 400. The order was not transcribed to the MAR for staff to follow. Review of the resident’s MAR showed, there were multiple occasions the resident’s blood sugar levels were greater than 400 and there was no documented evidence the physician was notified for the CBG greater than 400.

On 09/18/24 at 3:50 pm and 09/19/24 at 11:10 am, the finding was reviewed with Staff 1 (Senior ED) and Staff 3 (Resident Care Manager). Staff 1 and 3 reported the facility changed their eMAR (electronic medication administration record) system to a new program as of 09/01/24 and would review these issues. They acknowledged the findings.

2. Resident 3 moved into the facility in 08/2024 with diagnoses including type II diabetes and chronic obstructive pulmonary disease.

During the acuity interview on 09/17/24, Staff 1 (Senior ED) and Staff 3 (Resident Care Manager) reported the resident used catheter and ostomy bags for bladder and bowel elimination.

Review of the resident’s 09/01/24 – 09/17/24 MAR and providers orders showed the following:

• The resident was prescribed catheter care instructions, C-pap (a machine to use mild air pressure to keep breathing airways open while asleep) at night with 4 LPM (liter per minute) setting and care instructions and oxygen at 1 LPM continuously for chronic respiratory failure with hypoxia (an absence of enough oxygen); and
• These orders were not transcribed to the MAR for staff to follow.

During the survey on 09/19/24 at 8:00 am, a C-pap machine and an oxygen concentrator was observed in the resident’s room.

In an interview on 09/19/24 at 8:02 am, Staff 15 (MT) reported she did not know the oxygen setting for Resident 3.

On 09/18/24 and 09/19/24, the above findings were reviewed with Staff 1 and Staff 3. They reported the facility changed its eMAR (electronic medication administration record) system to a new program as of 09/01/24 and would review these issues. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 1 of 1 sampled resident1 (# 1) who had documented medications refusals. Findings include, but are not limited to:

Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes, chronic pain and opioid dependence with opioid-induced disorder.

Review of the resident’s 08/01/24 – 09/17/24 MAR and practitioners orders showed the following:

• The resident was prescribed Buprenorphine-naloxone 2-0.5 mg twice daily and Novolog insulin three times daily; and
• Staff documented on the MAR that the resident refused buprenorphine-naloxone on 38 occasions and Novolog insulin on 44 occasions.

There was no documented evidence the facility notified the practitioners when the resident refused to consent to the orders.

On 09/19/24 at 11:10 am, the refusals were reviewed with Staff 1 (Senior ED) and Staff 3 (Resident Care Manager). They acknowledged the findings. No further information was provided.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure MARs were kept accurate, included reason for use, resident-specific parameters for PRN medications and medication-specific instruction to instruct non-licensed staff for 3 of 3 sampled residents (#s 1, 2 and 3) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2018 with diagnoses including major depressive disorder and anxiety.

a.Resident 2's 09/03/24 through 09/17/24 MARs were reviewed and identified the following as needed medications lacked resident specific parameters and clear instructions for unlicensed staff:

• Tramadol, every 12 hours as needed for pain; and
• Oxycodone-Tylenol twice daily as needed for pain.

There was not clear instructions or parameters for the sequence of use, if both medications could be administered at the same time, and/or if there was a time frame in which staff should wait before administering the other PRN pain medication.

b.The MAR lacked initials of the person administering medications on the following dates:
· 09/09/24, 09/10/24, and 09/12/24 for Atrovastatin for Hyperlipidemia, Oxcarbazepine for seizures, Seroquel an antipsychotic, Levetiracetam for seizures and phenytoin sodium for seizures.

c.The MAR lacked reason for use for the following medications:
· Bupropion, losartan potassium, prednisone, docusate sodium and cephalexin.

The need to ensure the MAR was kept accurate and included reason for use, initials of the person administering medications and had resident-specific parameters and clear instructions for unlicensed staff to follow was reviewed with Staff 1 (Senior ED) and Staff 3 (Care Coordinator Director) on 09/19/24 at 8:30 am. They acknowledged the findings.

2. Resident 1 moved into the facility in 06/2021 with diagnoses including type II diabetes and chronic pain.

Resident 1’s 09/01/24 - 09/17/24 MAR was reviewed during the survey and was found to be lacking accurate information and resident specific parameters to guide unlicensed staff in the following areas:

• Reason for the use of medication administrations in Buprenorphine-Naloxone, docusate, duloxetine, furosemide, hydroxyzine, belsomra, myrbetriq, Novolog, potassium, pramipexole dihydrochloride, toujeo, varenicline tartrate, cipro, ropinirole, gabapentin, Lantus and clearlax; and
• Multiple PRN ointment and powder for skin irritation lacked clear parameters for when to administer and where to apply.

On 09/19/24 at 11:10 am, the need to have a reason for the use of the medications and the resident specific parameters and clear instruction to unlicensed staff was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Manager). They acknowledged the findings.


3. Resident 3 moved into the facility in 08/2024 with diagnoses including type II diabetes and chronic obstructive pulmonary disease.

Resident 3’s 09/01/24 through 09/17/24 MAR was reviewed during the survey and were found to be lacking accurate information and resident specific parameters to guide unlicensed staff in the following area:

• Reason for the use of medication administrations in cefdinir, Metamucil and ipratropium-albuterol.

On 09/19/24 at 11:10 am, the need for resident specific parameters and clear instruction to unlicensed staff related to use of the medications was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Manager). They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to have a written policy that described how prescription drugs, not prepared as unit dose or blister packs, shall be dispensed to reduce errors in the tracking and administration of the drugs. Findings include, but are not limited to:

A copy of the facility's medication administration policy that addressed how prescription medications, that were not packaged as unit dose or blister packs (such as ointment, cream, liquids, etc.) were dispensed was requested on 09/17/24. Staff 1 (Senior ED) reported she would search the policy, however, she was not aware of the policy.

In an interview on 09/19/24 at 11:10 am, Staff 1 confirmed there was no facility policy which described the process of dispensing prescription drugs that were not in unit dose packaging. She further reported the facility had a medication administration policy, but there was no information that described what process the facility used to dispense medications that were not in blister packs or unit dose.

The need to develop and train staff on a facility policy to ensure accurate administration of prescription drugs that were not prepared as unit dose or blister packs was discussed with Staff 1 on 09/19/24 at 11:10 am. Staff acknowledged the findings.

OAR 411-054-0055 (4) Systems: Medication & Treatment-General

(4) MEDICATION AND TREATMENT - GENERAL. The facility must maintain legible signatures of staff that administer medications and treatments, either on the MAR or on a separate signature page, filed with the MAR.(a) If the facility administers or assists a resident with medication, all medication obtained through a pharmacy must be clearly labeled with the pharmacist's label, in the original container, in accordance with the facility's established medication delivery system.(b) The facility shall ensure that prescription drugs dispensed to residents are packaged in a manner that reduces errors in the tracking and administration of the drugs, including, but not limited to, the use of unit dose systems or blister packs.(A) The facility shall have as its primary goal dispensing prescription drugs in unit dose systems, blister packs or similar packaging.(B) When unit dose packaging cannot be reasonably achieved, the facility shall have a written policy describing how prescription drugs that are not prepared as unit dose or blister packs shall be dispensed. Written policies shall be in effect not later than October 1, 2018.(C) Subsection (b) of this rule does not apply to residents receiving pharmacy benefits through the United States Department of Veterans Affairs, if the pharmacy benefits do not reimburse cost of such packaging.(c) Over-the-counter medication or samples of medications must have the original manufacturer's labels if the facility administers or assists a resident with medication.(d) All medications administered by the facility must be stored in locked containers in a secured environment such as a medication room or medication cart.(e) Medications that have to be refrigerated must be stored at the appropriate temperature in a locked, secure location.(f) Order changes obtained by telephone must be documented in the resident's record and the MAR must be updated prior to administering the new medication stated on the order. Telephone orders must be followed-up with written, signed orders.(g) The facility must not require residents to purchase prescriptions from a pharmacy that contracts with the facility.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and were evaluated quarterly for 2 of 2 sampled residents (#s 2 and 4) who were reviewed for self-administration of medications. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2018 with diagnoses including major depressive disorder and anxiety.

During the acuity interview on 09/17/24, Resident 2 was not identified as self-administering any of his/her prescribed medications.

Review of Resident 2's signed physician orders dated 09/04/24 and MAR dated 09/03/24 through 09/17/24 indicated the following:

• The resident was prescribed calcium 500-vitamin D3 500 mg-15 mcg, take one tablet by mouth daily;
• The signed order did not indicate the resident was able to self-administer the medication; and
• The medication was not transcribed on the 09/2024 MAR for staff to administer.

During an interview with Resident 2 on 09/18/24 at 2:45 pm, the resident confirmed s/he had the supplement in his/her apartment and was taking one tablet by mouth twice per day. Based on the resident’s statement s/he was not self-administering the correct dose as prescribed by the physician.

During an interview on 09/17/24 at 3:10 pm, with Staff 3 (Resident Care Director), an evaluation of the resident to safely administer the medication and a signed physician order of approval for the resident to self-administer the prescribed calcium 500-vitamin D3 500 mg-15 mcg was requested.

There was no documented evidence the facility obtained a physician's or other legally recognized practitioner's written order of approval for self-administration of the calcium 500-vitamin D3 500 mg-15 mcg and the facility failed to evaluate the resident’s ability to safely self-administer the medication.

The need to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and ensure a quarterly evaluation was completed was discussed with Staff 1 (Senior ED) and Staff 3 on 09/19/24 at 8:30 am. They acknowledged the findings.

2. Resident 4 moved into the facility in 08/2021 with diagnoses including end stage renal disease, coronary artery disease and chronic obstructive pulmonary disease. During the acuity interview on 09/17/24, staff reported Resident 4 only self-administered his/her as needed oxycodone and docusate sodium.

Resident 4’s signed physician orders dated 04/15/24, and 09/03/24 through 09/17/24 MAR were reviewed during the survey and interviews with the resident and staff were conducted.

During an interview on 09/17/24 at 10:54 am, Staff 3 (Resident Care Director), confirmed the resident was self-administering oxycodone, as needed and docusate sodium. Survey requested the most recent quarterly evaluation to self-administer medication and treatments. Staff 3 reported “I don’t think [facility RN] would have done an evaluation, we have the signed orders.”

During an interview with Resident 4 on 09/19/24 at 9:03 am and observations within the resident’s apartment identified s/he had oxycodone, docusate sodium, a c-pap machine (a machine to use mild air pressure to keep breathing airways open while sleep), oxygen concentrator and an inhaler. Resident 4 confirmed s/he was self-administering all of the above medications by him/herself.

There was no documented evidence the facility had obtained signed written orders of approval for the resident to self-administer the c-pap machine, oxygen or the inhaler nor did the facility evaluate the resident’s ability to safely self-administer prescribed medications and treatments.

The need to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and to ensure the facility evaluated the resident’s ability to safely self-administer medications at least quarterly was discussed with Staff 1 (Senior ED) and Staff 3 on 09/19/24 at 8:30 am. They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

(5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure psychotropic medications used to treat a resident's behavior had written common side effects, instructions on when to call a health care professional, resident-specific parameters, and non-drug interventions for staff to attempt and document with ineffective results prior to administering an as needed psychotropic medication for 1 of 1 sampled resident (# 2), who was prescribed a PRN psychotropic medication. Findings include, but are not limited to:

Resident 2 moved into the facility in 09/2018 with diagnoses including major depressive disorder and anxiety. During the acuity interview on 09/17/24, Resident 2 was identified as being prescribed an as needed psychotropic medication.

Resident 2’s 09/03/24 through 09/17/24 MAR and signed physician orders dated 09/04/24 were reviewed and identified the following PRN psychotropic medication was prescribed and administered:

· Alprazolam 0.25 mg, give one tablet by mouth daily, as needed;
· The PRN medication was administered on nine occasions;
· The MAR lacked written instruction of common side effects, when to call the prescriber, and clear parameters of how the resident exhibited anxiety; and
· There was no documented evidence unlicensed staff documented non-pharmacological interventions were attempted with ineffective results prior to administering the PRN psychotropic medication.

The above findings were discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 8:30 am. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure medications that were administered p.r.n. that were given to treat a resident's behavior had written, resident-specific parameters and PRN psychotropic medications were administered only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#6) who had orders for PRN psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 05/2024 with diagnoses including chronic kidney disease and hypertensive heart disease with heart failure.

The resident's service plan, 12/19/24 to 01/13/25 progress notes, 01/01/25 to 01/13/25 MARs and current physician orders were reviewed. The following was identified:

The resident had an order for lorazepam, administer one tablet by mouth every two hours as needed for anxiety or restlessness. The MARs indicated staff administered the PRN medication on seven occasions from 01/01/25 to 01/13/25.

The resident had an order for haloperidol lactate, administer one mL by mouth/under tongue every two hours as needed for anxiety/nausea. The MARs indicated staff administered the PRN medication on three occasions from 01/01/25 to 01/13/25.

The resident had an order for lorazepam cream, apply one mL to wrist or abdomen every two hours as needed for anxiety. The MARs indicated staff did not administer the PRN medication from 01/01/25 to 01/13/25.

There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the PRN psychotropic medications.

During interviews on 01/14/25 at 1:45 pm Staff 8 and Staff 15 acknowledged they did not know the order in which they were to administer the PRN psychotropic medications.

The need to ensure PRN psychotropic medications have written, resident-specific parameters and documentation staff administered PRN psychotropic medications only after attempting non-pharmacological interventions with ineffective results was discussed with Staff 1 (Senior Executive Director) and Staff 3 (Resident Care Director) on 01/15/24. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure medications that were administered p.r.n. that were given to treat a resident's behavior had written, resident-specific parameters and PRN psychotropic medications were administered only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#6) who had orders for PRN psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 05/2024 with diagnoses including chronic kidney disease and hypertensive heart disease with heart failure.

The resident's service plan, 12/19/24 to 01/13/25 progress notes, 01/01/25 to 01/13/25 MARs and current physician orders were reviewed. The following was identified:

The resident had an order for lorazepam, administer one tablet by mouth every two hours as needed for anxiety or restlessness. The MARs indicated staff administered the PRN medication on seven occasions from 01/01/25 to 01/13/25.

The resident had an order for haloperidol lactate, administer one mL by mouth/under tongue every two hours as needed for anxiety/nausea. The MARs indicated staff administered the PRN medication on three occasions from 01/01/25 to 01/13/25.

The resident had an order for lorazepam cream, apply one mL to wrist or abdomen every two hours as needed for anxiety. The MARs indicated staff did not administer the PRN medication from 01/01/25 to 01/13/25.

There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the PRN psychotropic medications.

During interviews on 01/14/25 at 1:45 pm Staff 8 and Staff 15 acknowledged they did not know the order in which they were to administer the PRN psychotropic medications.

The need to ensure PRN psychotropic medications have written, resident-specific parameters and documentation staff administered PRN psychotropic medications only after attempting non-pharmacological interventions with ineffective results was discussed with Staff 1 (Senior Executive Director) and Staff 3 (Resident Care Director) on 01/15/24. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed thoroughly by an RN, PT or OT prior to use, provided instruction to the caregivers on the correct use and precautions, and failed to evaluate the use of the device on a quarterly basis for 1 of 1 sampled resident (# 1) who had a half-length side rail on the bed. Findings include, but are not limited to:

Resident 1 was observed on 09/18/24 at 10:35 am, to have a half-length side rail on the bed, in the up position which were identified to be devices with potentially restraining qualities.

Review of the resident's clinical record showed the following:

• No documented evidence of an assessment completed by a RN, Physical Therapist or Occupational Therapist for the use of the side rail. Therefore, there was no documented evidence that other less restrictive alternatives had been attempted prior to their use; and
• No instruction on the service plan to caregivers related to use and precaution of the side rail.

On 09/19/24 at 11:10 am, the lack of documented assessment and care instructions for the use of the side rail was reviewed with Staff 1 (Senior ED) and Staff 3 (Resident Care Manager). They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training completed by each employee. Findings include, but are not limited to:

During a review of staff training records on 09/17/24 at 12:40 pm the following was identified:

· Staff 4 (CG), Staff 5 (CG), Staff 7 (Kitchen Manager), Staff 8 (MT), Staff 9 (CG), Staff 10 (MT), Staff 13 (Housekeeper) and Staff 15 (MT) training records were reviewed; and
· Staff failed to complete and provide documented evidence that sampled staff administering medications and providing personal care had completed pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned before working independently with residents, and that sampled long term staff had completed a total of 12 hours of annual in-service training including annual infection control training.

The requirement to maintain written documentation of training completed by each employee was discussed with Staff 1 (Senior ED) and Staff 3 on 09/18/24 at 9:55 am. They acknowledged the findings.

Refer to C 370, C 372, and C 374.

OAR 411-054-0070 (2) Staffing Rqmt and Training: Training Rqmts

(2) REQUIREMENTS APPLICABLE TO ALL TRAINING. The facility shall:(a) Have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Facility shall also maintain documentation regarding each direct care staff ' s demonstrated competency.(b) Maintain written documentation of all trainings completed by each employees.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation, pre-service dementia care training, home and community-based services (HCBS) and infectious disease prevention training had been completed prior to staff providing direct care to residents for 3 of 3 new hired direct care staff (#s 5, 10 and 15). Findings include, but are not limited to:

Review of the facility's training records on 09/17/24 indicated the following:

Staff 5 (CG), hired 06/13/24, Staff 10 (MT), hired 06/13/24, and Staff 15 (MT), hired 06/04/24, lacked documented evidence they had completed pre-service orientation, pre-service dementia training, and infectious disease prevention training prior to providing direct care to residents. Staff 5 also lacked documented evidence of completing HCBS training.

The training program and requirements were discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/18/24 at 9:55 am. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES.(a) Prior to beginning their job responsibilities, all employees must complete an orientation that includes training regarding:(A) Residents' rights and the values of community-based care.(B) Abuse and reporting requirements.(C) Standard precautions for infection control.(D) Fire safety and emergency procedures.(b) If the staff member's duties include preparing food, they must have a food handler's certificate.(c) All staff must receive a written description of their job responsibilities.(d) PRE-SERVICE INFECTIOUS DISEASE PREVENTION TRAINING. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-monthperiod prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:(A) Transmission of communicable disease and infections, including:(i) Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Respiratory hygiene and coughing etiquette.(B) Standard precautions.(C) Hand hygiene.(D) Use of personal protective equipment.(E) Cleaning of physical environment, including, but not limited to:(i) Disinfecting high-touch surfaces and equipment.(ii) Handling, storing, processing and transporting linens to prevent the spread of infection.(F) Isolating and cohorting of residents during a disease outbreak.(G) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (H) Facilities will be required t have all staff trained, as described in this rule, by July 1, 2022.(e) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.(A) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.(B) Online training will be made available by the Department by January 1, 2022.(C) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.(D) The Department will review training from facilities or other entities with the goal of making training available to facilities by January 1, 2022.(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete theDepartment-approved HCBS training, as provided below:(A) Effective March 31, 2024, all staff must have completed the required training.(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning jobresponsibilities.(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.(a) Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.(b) Pre-service dementia care training requirements for:(A) 2018 - Direct care staff hired on or before December 31, 2018 shall complete pre-service dementia care training outlined in OAR 411-054-0070 by December 31, 2018, regardless of when they first provide direct care to residents.(B) 2019 and beyond - Direct care staff hired on or after January 1, 2019 shall complete required pre-service dementia training prior to providing direct care to residents.(c) Documentation of dementia training:(A) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.(B) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.(d) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility ' s pre-service dementia training.(e) A certificate of completion must be made available to the Department upon request.(f) Pre-service dementia care training must include the following subject areas:(A) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.(B) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.(C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.(D) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:(i) Identify and address pain.(ii) Provide food and fluids.(iii) Prevent wandering and elopement.(iv) Use a person-centered approach.(g) Pre-service orientation to resident:(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident's service plan.(B) Staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 caregiving staff (#s 5, 8, 10 and 15) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records was completed on 09/17/24.

Staff 5 (CG), hired 06/13/24, Staff 8 (MT) hired 08/16/24, Staff 10 (MT), hired 06/13/24, and Staff 15 (MT), hired 06/04/24, lacked documented evidence they had demonstrated competency in all areas within 30 days of hire, including but not limited to:

· The role of service plans in providing individualized resident care;
· Providing assistance with the activities of daily living;
· Changes associated with normal aging;
· Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;
· Conditions that require assessment, treatment, observation and reporting;
· General food safety, serving and sanitation;
· If the direct care staff person’s duties include the administration of medication or treatments, the facility must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised; and
· Staff 8 (MT), 10 (MT), and 15 (MT), lacked documented medication administration competency.

On 09/18/24 at 9:55 am, survey requested Staff 8, 10 and 15 be removed from administering medications until medication competency could be verified and documented for the sampled staff. On 09/18/24 at 3:45 pm Staff 3 (Resident Care Director) provided survey a new staffing schedule that included MT’s with documented MT training records through the end of the month. Staff 3 reported that she would be observing and documenting MT competency for the above sampled MT’s throughout the week and they would not independently pass medications until competency was completed.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 (Senior ED) and Staff 3 on 09/18/24 at 9:55 am. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

"Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (6) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:(A) The role of service plans in providing individualized resident care.(B) Providing assistance with the activities of daily living.(C) Changes associated with normal aging.(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.(E) Conditions that require assessment, treatment, observation and reporting.(F) General food safety, serving and sanitation.(G) If the direct care staff person ' s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.(9) ADDITIONAL REQUIREMENTS. Staff:(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed."

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term direct care staff (#s 4 and 9) completed 12 hours of annual in-service training, including at least six hours of dementia care topics and annual infectious disease training based on their anniversary date of hire, and failed to ensure 2 of 3 long-term non-direct care staff (#s 7 and 13) completed annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 09/17/24 at 12:40 pm and the following was identified:

a. There was no documented evidence Staff 4 (CG) hired 06/14/21 and Staff 9 (CG) hired 05/13/22 completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including annual infectious disease prevention training and a minimum of six hours of training on dementia care topics.

b. There was no documented evidence Staff 7 (Kitchen Manager) hired 04/01/09, and Staff 13 (Housekeeper) hired 08/22/22, completed annual training on infectious disease outbreak and control.

The need to ensure long-term direct care staff completed and documented the required number of hours of annual in-service training and that long-term non-direct care staff completed annual infectious disease training was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/18/24 at 9:55 am. They acknowledged the findings.

OAR 411-054-0070 (2-5)(5-8) Annual Training and Other Requirements

(2) An administrator of a facility and the employees of the facility, as specified by the Department of Human Services by rule, must receive training in recognizing disease outbreaks and infection control at the time of hiring, unless the administrator or the employee has received the training at another facility within the 24-month period prior to the time of hiring, and annually as part of, and not in addition to, the administrator or employee's continuing education requirements.(3) The department, in consultation with the Oregon Health Authority, shall prescribe by rule the requirements for the training, which must include at least the following: (a) How to properly prevent and contain disease outbreaks based on the current best evidence in the field of infection and disease outbreak identification, prevention and control;And (b) The responsibility of staff members to report disease outbreaks under ORS 433.004.(4) The training may be provided in person, in writing, by webinar or by other electronic means. The department shall make online trainings available.(5)(a) A facility must establish and maintain infection prevention and control protocols designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases.(5) ANNUAL INSERVICE FOR ALL STAFF. Annual infectious disease training requires the following:(a) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.(b) Annual in-service training must be documented in the employee record.(c) These annual training requirements will be required as of July 1, 2023.(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Annual in-service training hours are based on the anniversary date of hire.(b) Requirements for annual in-service dementia training:(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee ' s assessed competency.(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct and record fire drills every other month consistently and document all required components of fire drills. Findings include, but are not limited to:

1. There was no documented evidence the facility conducted fire drills every other month consistently as required. The facility had fire drills in 04/2024 and 05/2024 for the last six months.

2. Review of fire drill records between 03/2024 and 08/2024, showed the facility failed to document the following required components:

• Escape route used;
• Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
• Number of occupants evacuated; and
• Evidence alternate routes were used during the fire drills.

On 09/19/24 at 11:10 am, the need to conduct and document fire drills every other month with all required components was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Manager). Staff acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

This Rule is not met as evidenced by:

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

Refer to C156, C270 and C330.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:
Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C 270.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain all interior surfaces in good repair. Findings include, but are not limited to:

The interior of the building was toured on 09/17/24 and 09/18/24. The following areas needed repair:

• The carpet throughout the facility was worn out and had multiple spots and stains;
• Rooms 12, 16 and 27’s doors were chipped, dinged, gouged and scratched;
• Exit doors near Room 9 and back kitchen door were chipped, dinged, gouged and scratched;
• Door frame in Rooms 3 and 9 were chipped, dinged, gouged and scratched;
• Baseboard near Room 4 and near janitor’s closet had missing part of the baseboard;
• Wall near Rooms 5 and 9 was chipped, dinged, gouged and scratched;
• Water damage on the wall, window frame and shelves in the laundry room;
• Wall and baseboard in the laundry storage room were chipped, dinged, gouged and scratched;
• The eye station in the laundry storage room was stained;
• Hopper sink and the floor behind the hopper sink were stained and had a layer of accumulated black matter;
• The laminate floor throughout the laundry storage room had multiple brown spots and stains;
• A ceiling vent in the whirlpool room had a layer of dust; and
• The laminate floor behind the whirlpool had multiple brown spots and stains.

On 09/18/24 at 8:20 am and 09/19/24 at 11:10 am, the areas in need of repair were reviewed with Staff 1 (Senior ED). She acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to have a setting that ensured individual rights of privacy, dignity and respect. Findings include, but are not limited to:

During survey, 09/17/24 – 09/19/24, the followings was observed:

• An audio device was observed in the nursing station where people in the common area were able to hear the resident personal and private conversation;
• Meal services; and
• Preferences and privacy related to keeping open the apartment door.

The need for an individual setting with rights of privacy, dignity and respect was reviewed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 11:10 am. They acknowledged the findings.

Refer to C 200.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities:
(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to have the setting that was physically accessible to an individual. Findings include, but are not limited to:

During the survey, multiple residents reported the following:

• Several thresholds to access the inner courtyard and the entrance to the facility were high and inaccessible by a walker or wheelchair;
• “I get high centered and feel like I’m going to fall”;
• “You betcha they are heavy, those things are a death trap”; and
• “I agree, I don’t go out there anymore.”

During the tour of the environment 09/19/24, noted wooden, well-defined, thresholds approximately one inch high at the main entrance and two doors entering the inner courtyard.

During the tour, a unsampled resident who was in a wheelchair in the inner courtyard reported that they used the rug to smooth the threshold and the doors leading to the courtyard were heavy and would swing shut too quickly causing residents to struggle with exiting the doors.

The need to have the setting physically accessible to an individual was reviewed with Staff 1 (Senior ED) and Staff 3 (Resident Care Manager) on 09/19/24 at 11:10 am. They acknowledged the findings.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(b) The setting is physically accessible to an individual.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure each individual had visitors of his or her choosing at any time for 1 of 2 sampled residents (#1) and one unsampled resident whose Home and Community-Based Services (HCBS) were reviewed. Findings include, but are not limited to:

1.During an interview on 09/18/24, Resident 1 reported that the facility did not allow his/her friends to visit during the night or early in the morning. The resident further stated his/her friends visited him/her between 3:00 and 4:00 am, but the facility did not allow them to visit.

Review of the resident’s clinical record, staff documented the resident’s progress note, which showed the facility allowed the friend to come to the door to get the phone, but the friend was not allowed to enter the facility.

On 09/19/24 at 11:10 am, Staff 1 (Senior ED) and Staff 3 (Resident Care Manager) reported that the resident’s friends visited late at night under the influence. The Individual Based Limitation (IBL) process was discussed with them. They acknowledged the findings.

2. During a group interview on 09/18/24 multiple residents reported an unsampled resident had limitations on a specific visitor.

During the HCBS facility interview with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 10:00 am they confirmed the information reported from the group interview. Staff 1 also reported the resident wanted the limitation for the visitor because the visitor was causing problems and had the police called. Staff 1 reported the facility had not completed the approved form to implement the limitation and had not documented the resident’s consent to the limitation or include the HCBS limitation in the person-centered service plan.

The need to ensure HCBS right to have visitors at any time was discussed with Staff 1 and Staff 3 on 09/19/24 at 10:30 am. They acknowledged the findings.

OAR411-004-0020(2)(h) Individual Visitors: Any Time

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(h) Each individual may have visitors of his or her choosing at any time.

This Rule is not met as evidenced by:

Based on interview and record review it was determined the facility failed to ensure an Individually-Based Limitation (IBL) was based on specific assessed needs by completing and signing a program approved form documenting the consent to limiting 1 of 1 sampled resident (#1) and one unsampled
resident’s right to visitors' at any time, was only implemented with the informed consent of the individual or, as applicable, the legal representative of the individual and was documented in the resident’s person-centered service plan. Findings include, but are not limited to:

1. Review of Resident 1’s clinical record including current service plan and previous 90 days of progress notes and observation notes identified the following:

• Resident 1’s HCBS right to have visitors at any time was being limited.

2. During a group interview on 09/18/24 multiple residents reported an unsampled resident had limitations on a specific visitor.

During an interview with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 10:00 am they confirmed the information reported from the group interview and stated the facility had not completed the approved form to implement the limitation and had not documented the resident’s consent to the limitation.

There was no documented evidence the facility completed a program approved form that justified and documented at minimum all the following requirements:

• The specific and individualized assessed need justifying the IBL;
• The positive interventions and supports used prior to any IBL;
• Less intrusive methods that have been tried but did not work;
• A clear description of the limitation that is directly proportionate to the specific assessed need;
• Regular collection and review of data to measure the ongoing effectiveness of the IBL;
• Established time limits for periodic reviews of the IBL to determine if the limitation should be terminated or remains necessary;
• The informed consent of the individual or, as applicable, the legal representative of the individual, including any discrepancy between the wishes of the individual and the consent of the legal representative; and
• An assurance that the interventions and support do not cause harm to the individual.

The need to ensure the facility completed and maintained a signed program approved form which documented the consent to limit visitors for specific residents’ and ensured the form was signed by the individual, or, if applicable, the legal representative of the individual and the IBL was documented in the person centered service plan was discussed with Staff 1 (Senior ED) and Staff 3 (Resident Care Director) on 09/19/24 at 10:30 am. They acknowledged the findings.

OAR411-004-0040(1) Limitations: Threats To Health And Safety

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 12/18/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 12/18/23, conducted 06/11/24, are documented in this report. The facility was found to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 12/18/23, the facility's kitchen was observed to need cleaning and/or repair in the following areas:* Shelving throughout the kitchen, dishwashing area and dry storage had food spills, white/gray accumulation, dust, and/or debris. Untreated wood shelving was noted throughout the dry storage area and kitchen;* Debris and spills were noted in storage cupboards which held clean dishes, pots, and pans. Shelves were peeling, chipped or gouged with exposed particle board/wood;* Drawers and cupboards throughout the kitchen had peeling surfaces, exposed particle board, spills and/or debris;* Patched area on the floor, near the corner cupboard, was separating and had black accumulation at the edges;* A black speckled substance was noted along the wall/ceiling joint above the spice rack;* Wall to the left of the stove was peeling with large pieces loose near the floor;* Refrigerator and freezer units in the dining room had dust, debris and dead insects on the tops of the units, spills or debris in the interior, and one refrigerator had a torn seal on the left side of the unit;* Sprinkler heads in the main kitchen area had a thick layer of dust and cobwebs;* Light covers throughout the kitchen had dust, debris, webs and/or cracked or missing covers;* A top corner of the island was cracked with a missing piece of plastic;* Corner cupboard doors on the lower cupboard near the ice machine were broken;* Freezer #2 had cracked and broken plastic with missing pieces on the lower shelf; and* Freezer #3 had debris on the bottom shelf as well as broken plastic near the front lowest panel, and the back panel was pushed in and bowed.The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (Administrator) and Staff 2 (Director of Culinary Services) on 12/18/23. The staff 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 10/6/2022. 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 observations, interviews and record review it was confirmed the facility failed to visually observe resident take their medications. Findings include:Review of facility service plan for Resident # 1 revealed that the resident is unable to administer their own medications and the facility is to assist resident with the administration of all medications. During tour of facility on 10/06/2022 at 2:25 pm Compliance Specialist observed a paper cup with 4 medications in it on a table in Resident # 1 room. Review of Resident # 1 Medication Administration Record for the Month of October 2022 revealed that the medications in the paper cup in Resident # 1's room should have been administered at 12:00 pm. Interview with Staff # 1 and Staff # 2 on 10/06/2022 with both acknowledging that the facility should have visually observed Resident # 1 take their medications. Facility Correction Plan: Facility will assess resident's ability to self-administer medications, review resident's service plan to accurately reflect resident's ability to self-administer medications, and facility will provide training to med-tech staff to visually observe residents take their medications.

Based on interviews and record review it was confirmed the facility failed to carry out medications as prescribed. Findings include:Review of facility Incident Self-report form dated 03/02/2022, Facility Medication Incident Report dated 03/02/2022, and Medication Passing Detail form for medications administered 12/10/2021 through 12/17/2021 reveal that the facility failed to administer resident # 1's medication for 3 days after it was ordered. Interview with Staff # 1 and Staff # 2 on 10/06/2022 with both acknowledging that the facility failed to administer Resident # 1 their medication for 3 days after it was ordered.

Based on interview and record review it was confirmed that the facility failed to consistently staff to the levels, intensity and qualifications indicated by the tool and failed to address all of the ABST elements. Findings include the following:During an unannounced site visit on 10/06/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities current posted staffing plan and found that the faciltiy is not staffing to the levels indicated by the ABST. The facility ABST also failed to address repositioning in bed or chair and responding to call lights. In an interview with Staff #1 (S1) on 10/06/2022 who acknowledged that the posted staffing plan did not meet the staffing levels indicated by the ABST.

The findings of the kitchen inspection, conducted 08/18/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 08/18/22, conducted 10/24/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 08/18/22 at 4:00 pm, the facility kitchen was observed to need cleaning and repair in the following areas:a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:* Multiple air vents near the ceiling and the walls surrounding them;* Ceiling lights; * A floor fan;* Flooring in dish machine area; and* Wall behind and underneath the dish machine.b. The following areas needed repair:* Ice build-up in several freezers;* Peeling paint on the wall behind the dish machine;* Scraped paint on wall corners near the dish machine area;* Entry doors and jambs had scraped paint;* A cabinet door had peeling laminate; and* The low temperature chemical dish machine was observed to operate multiple times and inconsistently registered the required temperatures for sanitation. The repair company was immediately contacted.The areas which required cleaning and repair were observed and discussed with Staff 1 (Administrator) on 08/18/22. The findings were acknowledged.

The findings of the re-licensure survey conducted 7/26/21 through 7/28/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugarCG: caregivercm: centimeterED: Executive DirectorF: Fahrenheit HH: Home Health LPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration Record MCC: Memory Care Community mg: 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 to the re-licensure survey of 07/28/21, conducted 02/16/22 through 02/17/22, 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 OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second revisit to the re-licensure survey of 07/28/2021, conducted on 05/25/2022, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home, and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:1. A review of Resident Council minutes dated 4/2021 through 6/2021, identified the following resident concerns:* "Residents would like dessert served with meal not after they have left (noted 4/2021 and 5/2021)";* Resident stated "toilet tank is wobbly/breaking" (noted 4/2021 and 5/2021);* "Resident's would like more outdoor activities" (noted 4/2021 and 5/2021);* Resident stated staff "shouldn't be allowed to throw his/her cups away that are on his/her desk and piano";* Resident "is missing some clothes";* Resident asked, "if you could put the dates and times that you will be at which building so they know when you will be available";* Resident asked, "if you could please get his/her carpets shampoo";* Multiple residents asked if their windows can be cleaned;* Multiple residents asked for light bulbs in their apartments to be replaced";* Resident stated, "call light and shower handle are not working";* Resident asked, "why the time difference with all the medications? Could s/he take them sooner together?";* Resident stated, "when s/he asks for a pain pill s/he always gets told s/he has to wait and wants to know why"; and* Resident stated, "s/he not getting her/his pills at the right time."There was no documented evidence the above concerns identified during the meetings had been addressed, responded to or resolved.2. From 7/26/21 through 7/28/21, the survey team conducted resident interviews with multiple alert and oriented facility residents. They expressed complaints about the facility including, food quality and service, areas of disrepair, dissatisfaction with care giving, medication orders were late, limitations on time allowed for care planning, lack of resolution from resident council meetings, and fear of retaliation from administration if concerns were brought forward. 3. Observations on 7/28/21, revealed carpets in non-sampled resident room still needed cleaning and repair. In an interview on 7/27/21, Staff 1 (ED) reported residents were conducting Resident Council meetings, however the residents were not holding council positions and the meetings were conducted by facility staff. Staff 1 acknowledged the Resident Council should be resident driven unless it was determined there were no residents willing or cognitively able to hold the meetings without staff involvement. Staff 1 acknowledged she was not documenting follow up actions or responding timely to the above resident concerns. Staff 1 reported there was no "Resident Complaint/Grievance Forms" or other system in place for residents to bring concerns forward. Staff 1 acknowledged the need to improve the facility's method for responding to and resolving resident complaints.

Based on observation, interview and record review, it was determined the facility failed to ensure the dish machine was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The surveyor toured the kitchen including the dish washing station on 7/27/21 at 8:30 am. Staff 8 (Cook) ran the dish machine at the request of the surveyor. The dish machine wash/rinse cycle was observed two times. It did not reach manufacturer required temperature of 120 degrees F. the first time and only reached temperature during the rinse cycle the second time. July 2021 temperature logs for the dish machine were observed posted on the wall. Not all days had temperatures documented and the temperatures that were written on the log were all lower than the required temperature. The findings were shared with Staff 1 (ED) on 7/27/21 at 9:05 am. Staff 1 stated she would call and have the dish machine looked at.On 7/28/21 at approximately 3:00 pm, the dish machine was observed running two more times and confirmed the wash cycle was not at the required manufacturer's suggested temperature. Staff 1 stated a new hot water heater was needed and had been ordered. Soon after, Staff 1 provided a written plan to the survey team for the use of paper and plastic products until the repair could be completed.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements and addressed sufficient information to develop an initial service plan, for 1 of 1 sampled resident (# 3) who was recently admitted to the facility. Findings include, but are not limited to:Resident 3 was admitted to the facility in 6/2021. Review of the new move in evaluation identified the following required elements were not documented as being addressed:* List of medication and PRN use; * Visits to health practitioners, ER, hospital or nursing facility in the past year;* Vital signs if indicated by diagnosis, health problems or medications;* Presence of depression, thought disorders, behavioral and mood problems;* History of treatment;* Effective non-drug interventions;* Decision making abilities;* Transfers assistance;* Eating assistance;* Ability to manage medications;* Pharmaceutical and non pharmaceutical interventions for pain;* List of treatments: type, frequency and level of assistance needed;* Indicators of nursing needs including potential for delegated nursing tasks;* History of dehydration or unexplained weight loss or gain;* Recent losses; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, and room temperature. The initial evaluation form was reviewed with Staff 1 (ED) on 7/28/21. She acknowledged all of the required elements were not addressed on the evaluation form.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction to staff for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:Review of Resident 2's current service plan dated 7/14/21 identified it was not reflective of the resident's care needs and lacked clear direction to staff in the following areas:* Monitoring meal intake; * Use of knee high socks or Ted hose; * Morning care routine; * Med Techs administering insulin;* Skin condition monitoring;* Transfer assistance;* Monitoring oxygen saturation levels and administration; * Pain management and applying ice packs; and* Frequency of safety checks.The need to ensure service plans were accurate, reflective and provided clear direction to staff was discussed with Staff 1 (ED) on 7/28/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction to staff for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 09/2012. The resident's service plan dated 11/15/21 and facility document entitled, "Service Checkoff List" dated 02/2022 were reviewed. The Service Checkoff List was printed monthly and was used by caregiving staff as a condensed form of the resident's service plan. Per an interview with Staff 11 (Med Aide) on 2/17/22 at 11:31 am, the following elements were identified as not accurate or failed to provide clear caregiving instruction: * Hospice services received; * Frequency of safety checks; * Behaviors and interventions for yelling out and wandering; * Ability to use the pull cord in the bathroom; * Wake up assist; * Breakfast routine; * Lunch routine; * Set up assistance for face washing and teeth brushing; * Full assistance for hair brushing; and * Fall interventions. The need to ensure service plans were accurate, reflective and provided clear direction to staff was discussed with Staff 12 (Senior ED), Staff 5 (ED) and Staff 2 (RN/Health and Wellness Director) on 02/17/22. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 05/2021. A review of the resident's 11/03/21 through 02/16/22 progress notes and 12/26/21 service plan were reviewed and revealed Resident 5 was receiving PT through an outside agency for strengthening, The service plan dated 12/06/21 was not reflective regarding PT services provided to the resident. The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 2 (Health and Wellness Director) and Staff 5 (Executive Director) on 02/16/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 10/2011 with diagnoses including major depressive disorder. Resident 1's record was reviewed during the survey and the following was revealed:* The resident had a dose reduction of clonazepam (sedative) on 4/12/21 from 1 tablet 0.25 mg nightly to; one-half a 0.25 mg tablet nightly;* On 5/6/21, the health care provider ordered the clonazepam to be discontinued; and *A chart note was written on 5/10/21 (four days later) that the clonazepam was discontinued.There was no documented evidence the facility evaluated, and/or monitored the above short-term change of condition. The need to ensure short-term changes of condition were evaluated, and monitored at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 7/28/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to determine and document what action or interventions were required for short term changes of condition, communicate the changes to staff and the facility failed to monitor residents consistent with evaluated and service planned needs for 2 of 2 sampled residents (#s 1 and 2) who were reviewed with short term changes of condition and monitoring care needs. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2019 with diagnoses including Dementia.a. Review of Resident 2's July 2021 MAR, July 2021 service check-off list, service plan dated 7/14/21 and progress notes from 5/6/21 through 7/20/21 identified the resident was evaluated to need monitoring for aspiration precautions, cardiac risk, diabetic risk, fall risk, urinary tract infection, skin condition, and oxygen monitoring and oxygen administration. On the following dates, there was no documented evidence the facility monitored the above care needs:* 7/3/21 and 7/4/21 eve shift;* 7/5/21 day shift;* 7/10/21 day shift;* 7/11/21 day and eve shifts;* 7/12/21 day shift;* 7/15/21 eve shift;* 7/17/21 day shift; and* 7/19/21 day shift.b. Progress note on 5/6/21 identified a medication change to reduce scheduled Dicolfenac Sodium gel for pain management to PRN. There was no documented evidence the facility monitored the residents pain levels, adverse effects, communicated the changes to staff, put other pain management interventions in place or resolved the medication change.The need to ensure staff were documenting on evaluated care needs and changes of condition was discussed with Staff 1 (ED) and Staff 3 (Resident Care Director) on 7/28/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what action or interventions were required for short term changes of condition, communicate the changes to staff and monitor through resolution for 1 of 2 sampled residents (# 4) who were reviewed with short term changes. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted to the facility in 09/2021. The resident's 02/01/22 through 02/16/22 MAR, progress notes dated 11/06/21 through 02/10/22 and Interim Service Plans dated 11/04/21 through 02/10/22 were reviewed. The following changes of condition were identified: * 11/06/21 - staff identified the resident's left arm was "hard and swollen" in the same location as where a COVID booster injection was administered; * 01/07/22 - unwitnessed fall; and * 02/02/22 - tested positive for COVID. There was no documented evidence the facility determined and documented what action or interventions were required for the short term changes of condition and no documented evidence the changes were monitored through resolution. Resident 4's short term changes of condition were discussed with Staff 12 (Senior ED), Staff 5 (ED) and Staff 2 (Health and Wellness Director) on 02/17/22. No additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#1) who experienced a significant change of condition related to falls with injury. Findings include, but are not limited to: Resident 1 was admitted to the facility 10/2011 with diagnoses including neuropathy and hypertension. The resident's clinical records including progress notes, evaluation, service plan and temporary plans of care were reviewed during the survey. A progress note dated 07/02/21 reported the resident had been sent to the ER for a fall resulting in a fractured arm.An evaluation of the resident was done and temporary service plans were developed and provided to staff on all shifts. Monitoring of Resident 1 was documented in the progress notes by staff. There was no documented significant change of condition assessment completed by the RN for the fall with fracture. The need to ensure an RN assessment was completed for Resident 1's significant change of condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/28/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to assess 1 of 1 sampled resident (#5) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in 5/2021 and has a history of urinary tract infections. Review of the resident's 11/03/21 through 02/16/22 progress notes revealed the resident expressed the following concerns to facility staff:* 12/03/21 - Difficulty using hands, shakiness;* 12/04/21 - Difficulty moving arms, shakiness.* 12/05/21 - Pain in arms and shoulders.* 12/13/21 - Shakiness;* 12/26/21 - Fall;* 12/29/21 - Shakiness; and * 01/02/22 - Shakiness, mumbling when speaking.On 01/05/22 facility staff noted the resident would often request transportation to the facility dining room for meals as s/he continued to experience difficulty with ambulation. In a 02/17/22 interview with Staff 9 (Med Aide), she confirmed the resident previously ambulated to the facility dining room independently. On 01/09/22 the resident was admitted to the hospital with a diagnosis of a urinary tract infection. There was no documented evidence the facility RN had completed an assessment regarding the resident's significant change in condition, documented findings, resident status and interventions made as a result of the assessment.The lack of an RN assessment with documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 2 (RN/Director of Health and Wellness) and Staff 5 (ED) on 02/16/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications for 1 of 2 sampled residents (# 1) whose MARs were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 10/2011 with diagnoses that included spinal pain and gastritis.Resident 1's 7/1/21 through 7/26/21 MARs were reviewed and revealed the resident had multiple PRN medications. The following medications did not include clear parameters for unlicensed staff to follow:* PRN Norco (narcotic pain medication); and* PRN Miralax (for constipation).The need to ensure residents' MARs had resident-specific parameters for medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 7/27/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a resident who chose to self-administer medication had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#3). Findings include, but are not limited to:Resident 3 was admitted to the facility in June 2021 with a diagnosis of diabetes.There was no documented physician's order for the resident to self-administer insulin. In an interview on 7/27/21, Staff 2 (RN) reported she was aware the resident was administering insulin and taking CBG's with staff assistance. Staff 2 stated "we were fortunate the PCP was here the day s/he moved in. She said it was ok for her/him to do this and would follow up with an order. I don't have the order and will need to call her."The need to have a signed physician order for all residents who chose to self-administer medications was discussed with Staff 1 (ED) on 7/28/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 6 and 7) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 7/27/21 indicated the following:Staff 6 (MT), hired 4/20/21, and Staff 7 (CG), hired 6/16/21, lacked documented competency within the first 30 days of hire for topics including: * The role of service plans in providing individualized resident care;* Providing assistance with the activities of daily living;* 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; * Staff 6 lacked medication and treatment administration; and* Staff 7 lacked documented evidence First Aid/abdominal thrust training was completed.The need to document demonstrated competency in job duties and ensure direct care staff received first aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) and Staff 3 (Business office Manager) on 7/2721. 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, reviewed between 12/2020 and 5/2021, revealed the facility lacked documented evidence of the following:* Evidence alternate routes were being used during fire drills;* Residents instructed on fire and life safety procedures within 24 hours of admission;* Documenting annual resident fire safety training in the areas of safety procedures, evacuation methods, responsibilities during a fire drill, and designated meeting place outside of the building; and* Documenting problems encountered with residents who resisted participation in the fire drill and what changes were made to ensure the evacuation standard is met. The need to ensure all required components of fire and life safety were implemented and documented was discussed with Staff 1 (ED) on 7/27/21 at 11:30 am. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. This is a repeat citation. Findings include, but are not limited to:During the entrance conference on 02/16/22 the surveyor requested the facility's fire and life safety training records. The following was identified:There was no documented evidence residents were re-instructed at least annually on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.The need to ensure all fire and life safety requirements were met was discussed with Staff 12 (Senior ED) and Staff 5 (ED) on 02/17/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 260, C 270, C 280 and C 422.