Stoneybrook Assisted Living

Based on interview and record review, conducted during a site visit on 04/25/25, the facility's failure to obtain background checks on all subject individuals was substantiated. Findings include, but are not limited to:A review of Staff 2's (Caregiver) background check indicated the background check application was submitted on 09/07/23, with Staff 2 needing to have complied with fingerprinting by 10/18/23. There was a secondary request to comply on 10/23/23 and the background check was approved on 11/28/23. In an interview, Staff 1 (Executive Director) indicated Staff 2 did not get fingerprinting done before the required compliance date of 10/18/23. Therefore, his/her background check should have been closed, and no longer allowed to work. Staff 1 indicated Staff 2 had not been pulled off the floor and had worked after 10/18/23. Staff 2 had taken his/her fingerprints on 10/26/23 and had been approved to work on 11/28/23.The findings were reviewed with and acknowledged by Staff 1 on 04/25/25.The facility's failure to obtain background checks on all subject individuals was substantiated.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, were implemented, and were reviewed and updated following a significant change of condition for 2 of 6 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 11/2023 with diagnoses including type 2 diabetes and pancreatitis.

Resident 1's 03/11/25 service plan and progress notes dated 01/10/25 through 03/27/25 were reviewed, the resident was observed, and staff were interviewed.

The service plan had not been updated when the resident experienced a significant change of condition on 3/20/25, related to increased falls and subsequent hospitalizations. Additionally, the service plan was not reflective and did not provide clear caregiving instruction in the following areas:

* Nonadherence to treatment plans;
* Signs and symptoms of low and high blood sugar;
* Decreased food intake, including nutritional interventions;
* Episodes of severe pain, nausea and vomiting; and
* PRN pain medication, including non-pharmaceutical interventions.

On 04/03/25, the need to ensure service plans were updated after a significant change of condition was identified, were reflective of current care needs, and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 05/2023 with diagnoses including chronic back pain.

Observations of the resident, interviews with staff and review of the service plan, dated 01/28/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas:

* Air mattress, floating heels/elbows and low bed;
* Private caregiver and feeding assistance;
* Overbed table kept close to the resident, ensuring fluids within reach;
* ADL assistance of 1 staff vs 2 staff;
* Use of an incontinence wrap;
* Bed bath, outside of hospice services;
* Dentures and hearing aide;
* Side rail use; and
* Hallucinations.

The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings.

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.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(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 movein 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 observation, interview, and record review, it was determined the facility failed to ensure short term changes in condition had documented progress monitored at least weekly through resolution for 2 of 6 sampled residents (#s 2 and 4) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including chronic back pain.

The resident's 01/28/25 service plan, 12/03/24 through 03/31/25 observation notes, incident investigations and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Medication changes;
* Skin injuries/breakdown to multiple areas;
* Dark urine and urinary tract infection (UTI);
* Vomiting;
* Medication error; and
* Hallucinations.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia.

The resident's 02/11/25 service plan,12/02/24 through 03/31/25 observation notes, incident investigations and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Medication changes;
* Falls with and without injuries and ER visits;
* Bruising, rashes and/or skin breakdown to multiple areas of the body;
* Increased confusion; and
* Illness and UTI.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. 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 ensure a timely RN assessment was completed which included documented findings, resident status, and interventions made as a result of the assessment for 2 of 5 sampled residents (#s 2 and 4) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including chronic back pain.

Observations of the resident, interviews with staff, review of the service plan, dated 09/30/24 and 12/02/24 through 03/31/25 observation notes, physician communications and hospice visit notes were completed.

The resident required full assistance from staff for all ADL care. The resident required two staff for positioning, transfers, bed changes and incontinent care. The resident’s intake was poor to fair. S/he was inconsistently able to feed himself/herself and needed assistance for meal intake. A private caregiver had been hired to assist the resident with the lunch and dinner meals each day; the caregiver provided full feeding assistance to the resident.

Multiple observations of the resident between 03/31/25 and 04/02/25 showed the resident in bed. The resident was bedbound and spent most of his/her time sleeping. His/her intake was between 0% and 25% for all meals observed. The resident was fed by the private caregiver, the resident ate very minimal bites of food on his/her own.

The resident was discharged from hospice on 12/27/24. The resident was again admitted to hospice on 03/01/25 after further decline in condition and significant decrease in meal intake. The resident spent most of the time sleeping and/or groggy, fully bedbound and had little to no appetite. The resident had frequent pain with movement of his/her lower extremities, turning and positioning.

In an interview on 04/02/25, Staff 3 (RN) indicated she started with the facility as a consultant on 03/05/25. She was not made aware of the resident’s readmission to hospice until 03/20/25. When she became aware of the changes and hospice admission, she completed an assessment. Staff 3 acknowledged that the interventions she noted were not resident specific and should be more personalized to the individual resident needs.

The facility failed to ensure a timely RN assessment was completed for the resident’s decline in condition and lack of intake, which included resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and resident specific interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia.

The resident's 02/11/25 service plan,12/02/24 through 03/31/25 observation notes, incident investigations, hospital visit notes and physician communications were reviewed.

The resident required one person assistance with ADLs. The resident used a walker around his/her apartment and was assisted with a wheelchair for longer distances. The resident could eat and drink on his/her own and typically attended meals in the dining room. The resident had short term memory issues and could be forgetful. S/he was able to make some needs known.

Multiple daily observations between 03/31/25 and 04/02/25 showed the resident in common areas as well as in his/her apartment. The resident frequently was seated in the recliner in his/her room and watching television or napping. The resident attended all three meals each day in the dining room and multiple activities that occurred in the facility. The resident used the walker to move between the dining room and activity room with staff assistance. The resident ate more than 75% of meals and fluids provided.

a. Weight records, dated 11/06/24 through 03/31/25, indicated the resident experienced the following:

* The resident’s weight on 11/06/24 was 223.5 pounds. The resident’s next recorded weight was 211.8 pounds on 12/11/24. The resident experienced a severe weight loss of 11.7 pounds or 5.23% in a month.

* The resident gained 3.8 pounds between 12/11/24 and 01/02/25 which was not a significant gain. The resident’s weight continued to trend upwards from 215.8 pounds on 01/02/25 to 224 pounds on 02/04/25. This was an 8.4 pound increase or 3.89% gain in one month.

The resident’s weight currently remained around 220 pounds in March 2025 with no additional significant gains or losses.

In an interview on 04/02/25, Staff 2 (LPN) indicated she was unable to locate any RN assessment of the resident’s December 2024 weight loss. The resident’s intake was usually good. The resident was being treated for a UTI in mid to late December 2024 which may have affected the resident’s intake at the time. The resident did have some recurring edema to the lower extremities as well.

The facility failed to ensure a timely RN assessment was completed for the significant weight loss, which included resident status and interventions made as a result of the assessment.

b. Observation notes showed the resident experienced multiple falls between 01/01/25 and 02/01/25. The resident was evaluated at the ER for several of the falls because of pain complaints or concerns the resident had hit his/her head.

The After Visit Summary dated on 01/13/25 indicated the resident was seen for a fall which resulted in multiple rib fractures. The resident returned to the facility with an order for lidocaine for pain. The instructions included limits to movement based on pain concerns, rest and ice.

In interviews between 03/31/25 and 04/02/25 the following was noted:

Staff 13 (MT) and Staff 21 (CG) indicated the resident had some pain when the fracture occurred and did require some additional assistance from staff. The resident was not independent prior to the fracture, needed one person assistance for toileting and had more difficulty with certain positions or movements. The staff indicated the resident continued to require one staff for assistance, was able to make some needs known and pain seemed to be back to baseline. The resident’s cognition was about the same as previous with some forgetfulness and a bit of confusion.

Staff 2 (LPN) indicated at the time the resident experienced a fall and sustained the rib fractures s/he did not seem to be in a great deal of pain or limited in movement. The care staff were aware of the need to assist the resident with care due to the fractures. Staff 2 was unable to locate any RN assessment of the resident’s rib fracture.

Staff 3 (RN) indicated she was not with the facility at the time of the fracture, so she did not complete any significant change. The resident did not have any current issues that required a significant change of condition.

The resident indicated s/he received medications when needed, plenty of food and fluids and was not experiencing any current pain issues. The resident could not specifically remember the fall that led to the fractures or any issues around the injury during that time period. The resident indicated currently s/he was doing well.

The facility failed to ensure an RN assessment was completed timely for the resident’s rib fractures, which included resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and resident specific interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. 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 provide documentation that fire drills included all required components and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records for the prior six month were reviewed with Staff 4 (Maintenance Director) on 04/02/25.

a. Fire drills conducted lacked the following required components:

* Escape route used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and
* Number of occupants evacuated.

b. There was no documentation fire and life safety instruction for staff was being conducted on alternative months from fire drills.

The need to include required components in fire drills and provide fire and life safety instruction to staff on alternate months from fire drills, was discussed with Staff 4 on 04/02/25 and Staff 1 (ED) on 04/03/25. They 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 provide documentation of instruction to residents within 24 hours of admission in 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 and failed to reinstruct residents at least annually. Findings include, but are not limited to:

On 04/02/25, Staff 4 (Maintenance Director) reported that he provided residents with information regarding fire drills when they moved in, but that there was no documentation of this instruction.

In an interview on 04/03/25 Staff 1 (ED) reported there was currently not a system in place for reinstructing residents annually in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places in the event of an actual fire.

The need to ensure the required fire and life safety instruction was provided to residents within 24 hours of admission and at least annually thereafter, was discussed with Staff 4 on 04/02/25 and with Staff 1 on 04/03/25. They acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

(5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in 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. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

This Rule is not met as evidenced by:

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

The facility was toured on 04/01/25 and 04/02/25. The following were identified:

* The majority of dining room chairs and tables had areas of bare, splintered wood;
* Several dining room tables had dried food on the pedestal bases; and
* Resident rooms 138 and 218 had darks spots and stains on the carpet.

The above areas needing cleaning and repair were reviewed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 04/02/25. They 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:

The findings of the on-site investigation, conducted 08/30/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes on Abbreviations: "The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. "Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate."Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. "If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation, interview, and record review, conducted during a site visit on 08/30/23, it was confirmed the facility failed to keep the interior free from unpleasant odors. Findings include, but are not limited to: On 08/30/23, CS observed Resident 1's room to have a strong smell of dog urine. There were no prominent stains on the carpet and the room appeared clean. In an interview on 08/30/23, Resident 1 stated, "My dog is over 10 years old."In an interview on 08/30/23, staff stated the following:·Staff 4 (RCC) stated, "The residents' dog is incontinent."·Staff 2 (Housekeeper) stated, "The housekeeper who cleans that residents' room has not been here all week. Neither I nor the other housekeeper have completed that housekeepers' rooms, we have our own rooms to clean."·Staff 1 (Executive Director) stated, "We have three housekeepers, two work each day. The housekeeper who cleans that residents' room used to work five days a week, however, they came to me last week and told me [s/he] was going to two days a week. We have hired another person to work the remaining three days. The residents' room was not cleaned on 08/27/23 due to that housekeeper changing their schedule with no notice and the other person who was to cover for [him/her] called out sick. Neither of their rooms were cleaned that day." A review of the housekeeping schedule showed Resident 1's room had been cleaned on Sundays. The housekeeper's checklist showed the residents' room was cleaned on 08/13/23 and 08/20/23, but not on 08/27/23.It was confirmed the facility failed to keep the interior free from unpleasant odors.On 08/30/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Staff 1 will be responsible for getting someone to clean the carpet in Resident 1's room within the next week. Remind staff if they smell urine on the carpets to tell ED and maintenance so they can make arrangements to clean the carpets. Will speak with Resident 1's family about the urine smell to discuss possible further action with the incontinent dog.

The findings of the on-site investigation conducted 08/30/2023 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 04/20/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, it was confirmed that the facility failed to administer medications and prescribed. Findings include:Review of Resident 1 (R1) medication administration records (MARs) and progress notes for March and April 2023. R1 did not receive a medication as prescribed on 03/28/2023. Review of Medication Management Policy, Incident Report dated 03/29/2023 revealed R1 medication not given as prescribed on 03/28/2023. Interviews on 04/20/2023, Staff 1 stated R1 did not receive medication as prescribed on 03/28/2023. Plan of Correction:Training provided.

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 12/07/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it was confirmed that the facility failed to provide assistance with bathing and washing hair. Findings include: During onsite interviews on 12/7/2022, Resident #1 (R1) stated that multiple times they did not receive their scheduled showers. Staff #4 (S4) stated there are days when residents' needs are missed, showers being one of those needs. A review of the Acuity Based Staffing Tool (ABST), R1 ' s service plan dated 10/7/2022, progress notes and the shower schedule communication log dated 10/23/2022-11/30/2022. These items demonstrated the shower schedule showed 10 times where staff stated a shower was not provided because they do not have time, 1 time stating they did not do shower due to short staffing and 2 times stating the call lights were high and were unable to provide shower. R1 missed their showers on 11/2/2022, 11/4/2022, and 11/18/2022. R1 ' s service plan, shower schedule, and ABST hours indicate they are to receive showers 3 times a week. On 12/7/2022, these findings were reviewed with and acknowledged by Staff #1 (S1). Plan of Correction: S1 stated the facility will be implementing new shower monitoring system per company policy once the new system is set up. The new system was being set up the day of the site visit.

Based on interview, observation, and record review it was confirmed that the facility failed to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include: During separate interviews on 12/7/2022, Resident #1 (R1) stated that the facility has been short staffed, and the biggest issues are swing shift and the weekends. R1 stated that multiple times they did not receive showers due to the facility not having enough staff to provide them with assistance. Staff #4 (S4) stated that there have been times the facility is understaffed, and needs are missed. During an unannounced site visit on 12/7/2022, Compliance Specialist (CS) observed 7 Caregivers (CG) and 2 Med Techs (MT) working for day shift. A review of the facility posted staffing plan, Acuity Based Staffing Tool (ABST), staff schedule for November and December 2022, the employee timecards for swing shift on 12/2/2022, R1's service plan, progress notes and the shower schedule communication log dated 10/23/2022-11/30/2022. The posted staffing plan and the ABST stated for day shift the facility needs 8 CG and 2 MT, swing shift 7 CG and 2MT, and NOC shift 3CG and 1MT. The timecards for swing shift indicated on 12/2/2022 there was 4CG and 3MT working. The shower schedule showed 10 times where staff stated a shower was not provided because they do not have time, 1 time stating they did not do shower due to short staffing and 2 times stating the call lights were high and were unable to provide shower. R1 missed their showers on 11/2/2022, 11/4/2022, and 11/18/2022. R1 service plan, shower schedule, and ABST indicate they are to receive showers 3 times a week. On 12/7/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 has obtained multiple Agency Contracts and is working with Corporate Recruiter to obtain adequate staff.

Based on interview and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate onsite interviews on 12/7/2022, Resident #1 (R1) stated that multiple times they did not receive showers due to the facility not having enough staff to provide them with assistance. Staff #4 (S4) stated that there have been times the facility is understaffed, and needs are missed. During an unannounced site visit on 12/7/2022, Compliance Specialist (CS) observed 7 Caregivers (CG) and 2 Med Techs (MT). A review of the facility posted staffing plan, Acuity Based Staffing Tool (ABST), Staff schedule for November and December 2022, the employee timecards for swing shift on 12/2/2022, R1 service plan, progress notes and the shower schedule communication log dated 10/23/2022-11/30/2022. The posted staffing plan and the ABST state for day shift the facility needs 8 CG and 2 MT, swing shift 7 CG and 2MT, and NOC shift 3CG and 1MT. The timecards for swing shift indicated on 12/2/2022 there was 4CG and 3MT working. The shower schedule shows 10 times where staff stated a shower was not provided because they do not have time, 1 time stating they did not do shower due to short staffing and 2 times stating the call lights were high and were unable to provide shower. R1 missed their showers on 11/2/2022, 11/4/2022, and 11/18/2022. R1 ' s service plan, shower schedule, and ABST hours indicate they are to receive showers 3 times a week. On 12/7/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 stated as of 12/8/2022 the ABST tool will be updated at time of every service plan change, new move in or discharge. Arranged staffing plan with policy analyst and will continue to obtain staff to meet the staffing levels. Implementing new shower monitoring system per company policy.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 9/8/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview, observation, and record review, it was confirmed the facility does not have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include: During onsite interviews on 9/8/2022 both Resident #1 and #2 (R1 and R2) stated that the facility is understaffed and that the call light can take up to 30 minutes to an hour to be answered. R2 stated that most staff respond to her, " I am busy since we are short staffed today." Compliance Specialist (CS) also interviewed Staff #3 who stated their concerns about the facility being understaffed. CS observed on unscheduled site visit on 9/8/2022 there to only 4 caregivers and 2 med techs working. Record review for site visit on 9/8/2022 of the staff schedule for August 2022, the posted staffing plan and call light logs from 7/18/2022-9/22/2022. Review of the call light logs revealed 65 times where the call lights exceed a 15-minute response time. Review of the staff schedule shows multiple days where the facility is understaffed based on their posted staffing plan. The posted staffing plan shows there should be 5 caregivers and 2 med techs working on day shift. Verbal POC: The facility is using agency for staffing and hiring more staff, staff will get more training on the proper procedure for answering call lights.

Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:During onsite interview on 9/8/2022 with Staff #1 and Staff #4 (S1) and (S4) both stated that the facilities current census was 91 residents and stated only 89 residents were entered into ABST. S4 stated that Resident #2 (R2) ABST needed to be updated because their hours for caregiving services do not reflect their actual needs.Compliance Specialist (CS) observed no posted staffing plan during onsite visit on 9/8/2022.Record review of the facilities ABST shows Resident #3 (R3) doesn ' t need any time with completing specific housekeeping or laundry services performed by staff, however, while CS was interviewing R3 there was a caregiver helping with laundry services.Verbal POC: Will add residents in before they move in S1 will reach out to policy analyst to get further clarification on how to use the tool properly when it comes to answering the 22 ADL questions adequately.

The findings of the re-licensure survey conducted 9/13/21 through 9/15/21 are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit survey to the re-licensure survey of 09/15/21, conducted 01/31/22 through 02/02/22, 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 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 09/15/21, conducted on 04/19/22 through 04/20/22, 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 observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare for 1 of 1 sampled resident (#6) reviewed for infection control and ADL incontinent care. Findings include, but are not limited to:Resident 6 was admitted to the facility in 2015 and admitted to Hospice in August 2021.Observations and interviews with staff and family members revealed Resident 6 was incontinent of bladder and relied on staff for all incontinence care needs. On 9/15/21 at 12:08 pm, the surveyor obtained permission to observe two person ADL incontinent care for Resident 6. During the observation, Staff 10 (Resident Assistant) failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 6's perineum. Staff 10 removed a soiled mattress cover from the resident's bed and handed it to Staff 12 (Resident Assistant). Staff 12 placed the soiled mattress cover and soiled blanket directly on the carpet flooring and failed to don clean gloves before assisting the resident to roll to the left side. Staff 10 proceeded to touch the resident's clean incontinent brief, closet door, the resident's clean mattress cover, clean bed linens, and fall mat while wearing the same soiled gloves. After care was completed, neither staff was observed performing hand hygiene after glove removal. Staff 12 donned clean gloves and proceeded to pick up the soiled linens off the floor and place them in a clear trash bag. Staff 10 proceeded to handle soiled incontinent products in a clear trash bag with bare hands.The above observations and the need to ensure staff consistently used universal precaution was discussed with Staff 1 (Administrator), Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all residents were treated with dignity and respect and failed to ensure residents received services in a manner that protected privacy for 1 of 1 sampled resident (#6) during ADL care. Findings include, but are not limited to: Resident 6 was admitted to the facility in 2015. During the acuity interview on 9/13/21, Staff 1 (Administrator) noted the resident was dependent on staff for all ADL care and was recently admitted to Hospice and was bedbound.The surveyor obtained permission to observe ADL incontinent care on 9/15/21 at 12:08 pm. Staff 10 (Resident Assistant) and Staff 12 (Resident Assistant) provided incontinent care and proceeded to change the resident's bedding. The residents preference was to not wear clothing and would often times only wear an incontinent brief and blanket covering his/her body. During incontinent care and while the bedding was changed, the two Resident Assistant's removed the blanket leaving the resident's upper body exposed. The above observations and the need to ensure residents were treated with dignity, respect and privacy when incontinent care was provided was discussed with Staff 1 (Administrator), Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a thorough investigation was completed, which documented abuse/neglect was ruled out or the incident was reported to the local SPD office if abuse could not reasonably be ruled out for 2 of 2 sampled residents (#s 2 and 6) who had documented unwitnessed falls and an injury of unknown cause. Findings include, but are limited to:1. Resident 2 was admitted to the facility October 2020, with diagnoses including unsteady gait, hypertension, diabetes, and endothelial corneal dystrophy (a disease of the eye).Clinical records were reviewed during survey and indicated the following:a. Resident 2's service plan dated 7/12/21, indicated the resident was alert and oriented to self, time and place but did display mild impairments and confusion when making decisions. The resident used a walker to assist with ambulation and was independent for transfers. The resident required staff assistance with dressing twice per day. The resident had a history of falls and staff were to provide risk monitoring checks once a shift.An incident report dated 7/30/21, stated staff responded to the resident's call light and found the resident on floor in his/her apartment. The resident stated s/he fell when reaching for his/her walker after getting up from a recliner chair. EMS (emergency medical services) were called and the EMTs (emergency medical tech) determined the resident did not need further evaluation at the hospital. The resident had complaints of immobility and pain on the morning of 8/1/21 but initially refused to go to the hospital. The resident's family took him/her to the hospital later in the afternoon and the resident returned to the facility that evening with a diagnosis of pelvic fracture.There was no documented evidence the incident was reported to the local SPD office and the post incident investigation dated 8/6/21, did not provide information related to how the facility ruled out abuse. Additionally, the report provided conflicting information related to the resident's diagnosis of hypertension, diabetes and vision loss. b. Resident 2's service plan dated 8/17/21, indicated the resident preferred to "remain in bed and not move around" related to pain from a pelvic fracture. Staff were to provide risk monitoring checks, incontinence care and repositioning four times per shift.An incident report dated 9/11/21, stated the resident's family member found the resident on the floor in his/her apartment. The family member called for staff assistance; no injury was noted. The resident stated s/he tripped when walking out of the bathroom. There was no documented evidence the incident was reported to the local SPD office and there no was no documented evidence the facility completed a thorough investigation to determine whether staff had provided repositioning, incontinence checks and monitoring checks as directed per the service plan prior to the incident to rule out potential neglect.The need to ensure a thorough investigation was completed for all incidents/accidents involving residents and/or report the incident to the local SPD office if abuse could not reasonably be ruled out was discussed with Staff 1 (Administrator) and Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings. The facility reported the incidents to the local SPD office per the survey team request. The facility provided documented confirmation of the report on 9/15/21.
2. Resident 6 was admitted to the facility in 2015. Clinical records were reviewed during survey and indicated the following:Charting notes dated 8/2/21 identified the Resident had extensive bruising to the back of his/her left hand and a skin tear just below the inner left elbow. A review of the service plan dated 5/27/21 indicated the resident had poor short-term memory and confusion related to time and place. The bruising and skin tear to left elbow constituted an injury of unknown cause.* On 8/5/21 the RN completed a skin assessment of the injury. * On 9/3/21 the RN wrote a chart note stating the left hand bruising and skin tear had healed. In an interview with Staff 1 (Administrator) on 9/14/21, she was unaware of the injury on 8/2/21 and confirmed the facility should have completed an investigation at the time the bruising and skin tear were identified. There was no documented evidence the facility completed an investigation of the incident to rule out suspected abuse or neglect and there was no evidence the facility reported the injury of unknown cause as suspected abuse or neglect to the local SPD office. The need to ensure injuries of unknown cause were immediately investigated and reported to the local SPD office if abuse could not reasonably be ruled out was discussed with Staff 1 and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

3. Resident 1 was admitted to the facility August 2021 with a diagnosis including back strain.The resident's move-in evaluation dated 7/30/21, did not include the following required information:* Use of assistive devices (bed side rails and trapeze bar for mobility); and* Interests, hobbies, and social/leisure activities.The need to ensure the move-in evaluation included all required information was discussed with Staff 1 (Administrator) and Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an initial new move-in evaluations included information on all required elements for 2 of 2 residents (#s 1 and 5) and failed to ensure quarterly evaluations were completed timely and were reflective of the residents' current status for 1 of 6 sampled resident (#6) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in July 2021 with diagnoses including chronic lower back pain and sciatica. During the acuity interview on 9/13/21, Resident 5 was identified as a fall risk.Resident 5's initial move-in evaluation completed 7/1/21, lacked the following required elements:* Pain including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort; and* Risk indicators including fall risk and history. The need to ensure new move in evaluations addressed all required elements to develop an initial service plan was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings. 2. Resident 6's clinical records were reviewed during survey and identified the following deficiencies: a. Resident 6's quarterly evaluation was due in August 2021. A copy of the most current evaluation was completed on 9/9/2021. In an interview, 9/13/21, Staff 3 (Health Services Assistant) confirmed the evaluation should have been completed in August 2021. b. Resident 6's quarterly evaluation, completed 9/9/21, was not reflective of the resident's current status in the following areas:* How a person copes with change and challenging situations;* PRN psychotropic medications;* Use of hearing aids;* Scheduled incontinent care;* Edema; * Sleep habits;* Side rails;* Meal assistance; and* Environmental factors including room temperature. The need to ensure quarterly evaluations were completed timely, were accurate and included documented changes of condition was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 3 of 3 sampled residents (#s 9, 10 and 11). This is a repeat citation. Findings include, but are not limited to:Resident 9, 10, and 11's quarterly evaluations were reviewed during survey. There was no documented evidence the evaluations had been updated quarterly. The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

3. Resident 1 was admitted to the facility August 2021.Review of the resident's current service plan and temporary service plans revealed the service plans were not reflective of the residents use of bed side rails and trapeze bar to aid in mobility.The mobility devices were observed in place on the resident's bed on 9/14/21 and the resident stated the devices were used to help him/her get out of or move around in bed.The need to ensure the service plan was reflective of the resident current status and care needs was discussed with Staff 1 (Administrator) and Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, updated during changes of condition and provided clear caregiving instructions for 3 of 6 sampled residents (#s 1, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in July 2021 with diagnoses of chronic lower back pain and sciatica. Observations of resident ADL care, on 9/13/21 through 9/15/21, interviews with staff, and review of the resident's current service plan and temporary service plans were conducted during the survey. The service plan dated 7/2/21 was not reflective of the resident's status and failed to provide clear caregiving instructions to staff in the following areas: * Pain management; and* Activities, social and leisure.2. Resident 6 was admitted to the facility in August 2015. During the acuity interview on 9/13/21 the Resident was identified as needing full ADL assistance and had recently been admitted to hospice. Observations of resident ADL care, 9/13/21 through 9/15/21, interviews with staff and review of the resident's current service plan dated 9/14/21 and temporary service plans were conducted during the survey. The service plan was not reflective of the resident's current care needs and/or failed to provide clear instructions for the delivery of care and services in the following areas:* Frequency and responsibilities of hospice services, including Chaplain services;* Need for repositioning and assistance with bed mobility;* Two-person incontinence care;* Instructions for staff to provide incontinent care in bed;* Use of hearing aids;* PRN oxygen;* Need for PRN laundry services due to incontinent care; and* Environmental factors including room temperature. The need to ensure service plans were reflective of the residents' current status and care needs and provided clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed quarterly for 3 of 3 sampled residents (#s 9, 10 and 11). This is a repeat citation. Findings include, but are not limited to:Resident 9, 10 and 11's quarterly service plans were reviewed during survey. There was no documented evidence the service plans had been updated quarterly.The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution for 2 of 5 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility August 2021 with a diagnosis including hypertension.Clinical records reviewed during survey (including progress notes dated 8/24/21 - 9/13/21, current service plan, temporary service plans, hospital records, and resident evaluations and assessments) indicated the following:Resident 1's service plan indicated s/he was alert and oriented to self, place and time, was able to make to make decisions, communicate needs and was independent for managing his/her own medications.On 9/2/21, progress notes sated the RN evaluated the resident related to complaints of blurry vision. The resident verbalized concerns related to a history of stroke. On 9/6/21, the resident requested to be sent to the hospital because s/he was concerned s/he was having a stroke because of blurry vision. The resident was admitted to the hospital for observation of possible TIA (transient ischemic attack). The resident returned to the facility on 9/10/21 with a cardiac event monitor and instructions to follow up with cardiology in six weeks.There was no documented evidence the facility developed interventions and monitored the residents status when s/he complained of blurry vision on 9/2/21.The facility's change of condition policy was reviewed on 9/15/21. The policy stated when residents experienced short term changes of condition staff would provide appropriate care and initiate alert charting and a temporary service plan. During an interview on 9/14/21, Staff 2 (Director of Health Services/RN) stated she did evaluate the resident's immediate health status and provided appropriate care on 9/2/21, but she was not aware of the procedure for developing temporary service plans and monitoring.The need to ensure short-term changes of condition were evaluated and interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.2. Resident 2 was admitted to the facility October 2020 with diagnoses including unsteady gait, hypertension, and diabetes.Clinical records were reviewed during survey and indicated the following.a. Resident 2 was admitted to hospice services 8/16/21.In a progress note, dated 8/25/21, staff documented "no hunger and very poor intake". Review of the resident's weight records dated 7/2/21 - 9/14/21, indicated the resident lost 5.8 pounds (4.6% loss in total body weight) from 7/2/21 to 9/7/21. The resident declined to be weighed at the time of survey.There was no documented evidence the resident's poor appetite and weight loss was evaluated and interventions were determined, documented, communicated to staff, and monitored weekly. b. Resident 2's current service plan dated 8/17/21 and temporary service plans stated the resident "preferred to stay in bed and not move around" related to pain from a recent pelvic fracture. Staff were to provide incontinence checks and position changes in bed four times per shift.Progress notes dated 8/23/21 - 9/11/21 stated the resident was able to transfer out of the bed and go to the bathroom with staff assistance.There was no documented evidence the resident's change in transfer and positioning preferences was evaluated and interventions were determined, documented, communicated to staff, and monitored weekly. The need to ensure ensure short-term changes of condition were evaluated and interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution was discussed with Staff 1 (Administrator), Staff 2 (Director of Health Services/RN), Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure resident changes of condition were monitored at least weekly through resolution for 1 of 3 sampled residents (#9) who experienced changes of condition. Resident 9 had a wound that was not monitored weekly, which then worsened over time. This is a repeat citation. Findings include but are not limited to:Resident 9 was admitted to the facility in 06/2021, with diagnoses including diabetes.Interviews with staff and review of Resident 9's records, including progress notes dated 11/15/21 through 01/31/22, the current service plan, and current evaluations, indicated the following:During the acuity interview on 01/31/22, Staff 3 (Health Services Assistant) stated Resident 9's spouse lived in the facility and administered all medications and provided all treatments for Resident 9. On 02/02/22, Staff 6 (MT) stated Resident 9's spouse was usually able to administer all medications and provide all treatments for Resident 9, but may have temporarily had difficulty with those tasks when s/he experienced an illness in the first weeks of 01/2022. Staff 6 stated the spouse was now back to baseline and there were no current concerns related to him/her completing those tasks for the resident.Progress notes, dated 11/15/21 through 01/31/22, indicated the facility was monitoring a wound on Resident 9's right heel. An RN note dated 12/28/21 noted the wound measured 2 cm by 6 cm and "the open skin is getting slowly smaller." There was no documented evidence the facility monitored the wound after 12/28/21. Staff 19 (Resident Services Coordinator/LPN) evaluated the wound on 02/01/22 per the survey team's request and noted the wound was open, with red and yellow drainage and measured 6 cm by 8 cm.Resident 9 had a wound on the right heel that was not monitored between 12/28/22 and 02/01/22, the wound progressed and increased in size.The need to ensure resident changes of condition were monitored weekly through condition resolution was discussed with Staff 1 (Administrator), Staff 18 (Assistant Administrator), and Staff 19 on 02/02/22. Staff acknowledged the findings. They consulted with the facility RN and developed a new treatment plan for Resident 9.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for 1 of 1 sampled resident (#6). Findings include, but are not limited to:During the acuity interview on 9/13/21, Staff 1 (Administrator) noted Resident 6 required assistance with medication administration and was recently admitted to hospice. A review of Resident 6's clinical record identified the following deficiencies: A hospice physician order for PRN oxygen was prescribed on 8/15/21. The order was not transcribed on the September 2021 MAR. On 9/14/21, observation of the resident's apartment identified there was no oxygen readily available for the resident to use. In an interview on 9/14/21, Staff 2 (Director of Health Services/RN) was unaware of the order for oxygen and reported the resident doesn't use oxygen. Staff 2 stated they don't have oxygen available for the resident and that she would need to call hospice to clarify the order.The need to ensure adequate professional oversight of the medication system was discussed with Staff 1 and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were documented in resident records and carried out as prescribed for 2 of 6 sampled residents (#s 3 and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 2014 with diagnoses including quadriplegia. Review of Resident 3's physician orders and MAR, dated 9/1/21 to 9/13/21 identified the following deficiencies:* The record lacked physician orders for administration of PRN oxycodone 5 mg and wound care to buttocks; * Resident 3 was prescribed PRN Norco (for pain) with instructions the facility first offer the resident Tylenol or ibuprofen and document refusals of these, prior to Norco administration. The MAR indicated the resident was administered PRN Norco on 9/1/21, 9/2/21, 9/4/21 and 9/6/21 with no documented evidence that Tylenol or ibuprofen were offered and refused first;* Records showed cephalexin 250 mg (antibiotic) was not administered as ordered from 9/5/21 to 9/13/21; and* There was no documented evidence the physician was notified as ordered, following a monthly blood pressure reading outside the ordered parameters on 9/2/21. 2. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes and hypertension. Review of Resident 4's MAR, dated 9/1/21 to 9/13/21 and physician orders identified the following deficiencies:* There was no documented evidence the physician was notified as ordered, following a monthly blood pressure reading outside the ordered parameters on 9/1/21.On 9/15/21 the need to ensure all written, signed orders from a legally recognized practitioner were documented in resident records and carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to orders, for 1 of 1 sampled resident (#3) who had documented medication or treatment refusals. Findings include, but are not limited to:Resident 3 was admitted to the facility in 2014 with diagnoses including quadriplegia. Review of Resident 3's MAR, dated 9/1/21 to 9/13/21 identified the following refusals, as documented by staff:* Fiber Nat powder (for bowel care) was refused on 9/3/21, 9/4/21, 9/5/21 and 9/12/21; and * Ketoconazole 2% shampoo was refused on 9/3/21 and 9/10/21. There was no documented evidence the facility notified the physician when the resident refused consent to the orders.On 9/15/21 the need to notify the physician following a resident's refusal to consent to orders was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings. No further information was provided.

2. Resident 2 was admitted to the facility October 2020 with a diagnosis including Type II diabetes. Review of Resident 2's MAR, dated 9/1/21 to 9/13/21 identified the following inaccuracies:* The MAR lacked parameters for daily CBG (capillary blood glucose) checks related to when staff should notify the RN or physician; and* The MAR did not include a reason for use for the medication glimepiride 1 mg.On 9/15/21, the need to ensure the facility maintained an accurate MAR was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications that were ordered by a legally recognized prescriber and administered by the facility for 3 of 5 sampled residents (#s 2, 3 and 5) whose records were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2014. Review of Resident 3's MAR, dated 9/1/21 to 9/13/21 identified the following inaccuracies:* The MAR lacked parameters for use for the following PRN bowel medications: docusate sodium 100 mg, lactulose 10 gm/15mL, and Milk of Magnesia 473 mL;* The MAR lacked parameters for use for the following PRN cough medications: guaifenesin 100 mg/5mL and benzonatate 100 mg; and* The MAR listed the reason for use of Mucinex ER 600 mg as "constipation". The correct reason for use was congestion.On 9/15/21 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings.
3. Resident 5 was admitted to the facility in July 2021 with diagnoses of chronic lower back pain and sciatica.Review of Resident 5's MAR dated 9/1/21 through 9/13/21 identified the following inaccuracies:The MAR lacked parameters for use for the following PRN pain medications: * Acetaminophen (Tylenol) 650 mg;* Acetaminophen 325 mg given every four hours; and* Tramadol.On 9/15/21 the need to ensure multiple PRN medications prescribed for the same reason had parameters instructing staff on which medication to administer first was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings.

2. Resident 1 was admitted to the facility August 2021 with a physician order stating the resident was able to self-administer medications.During an interview with Resident 1 on 9/14/21, s/he reported s/he did self-administer all of his/her medications.There was no documented evidence the facility evaluated the resident's ability to safely self -administer medications upon move-in. The need to ensure residents who self-administer medications were evaluated upon move-in was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to obtain a written physician's order of approval for self-administration of prescribed medications or failed to ensure residents who chose to self-administer their medications were evaluated at move-in and at least quarterly for ability to safely administer their own medications, for 2 of 2 sampled residents (#s 1 and 4) who administered their own medications. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes and chronic back pain. Review of the resident's MAR, dated 9/1/21 to 9/13/21 and Self-Administration of Medication Evaluation, dated 6/30/21 identified the following deficiencies:Records showed the facility failed to evaluate Resident 4's ability to safely administer the following five medications that were self-administered by Resident 4: docusate sodium(for bowel care), GNP Calcium tab (supplement), Vitamin B 6 (health maintenance), melatonin (promotes sleep) and mometasone (for itching/skin irritation). On 9/15/21 the need to evaluate resident's ability to safely administer their own medications, and to ensure all self-administered medications were included in the physician's order of approval was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents who self-administered medications, and had more than one resident in a unit, were evaluated for safety on a quarterly basis and had physician's orders to self-administer medications, for 2 of 2 sampled residents (#s 8 and 9) who were reviewed for self-administration. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 06/2021 with a diagnosis of osteoporosis.During the acuity interview on 01/31/22, Staff 3 (Health Services Assistant) reported Resident 8 administered his/her own medications.Review of Resident 8's records revealed there was no physician order for the resident to self-administer medications. There was no documented evidence the resident was re-evaluated for his/her ability to safely self-administer medications on a quarterly basis.2. Resident 9 was admitted to the facility in 06/2021 with a diagnosis of diabetes.During the acuity interview on 01/31/22, Staff 3 (Health Services Assistant) reported Resident 9 and Resident 8 shared an apartment, and Resident 8 administered Resident 9's medications.Review of Resident 8's and Resident 9's clinical records revealed Resident 8 had not been evaluated to determine if s/he was able to safely administer medication to Resident 9. There was no documented evidence of a physician order for Resident 8 to administer medications to Resident 9.The need to ensure residents who self-administer medications, and had more than one resident in a unit, were evaluated for safety on a quarterly basis and had physician's orders to self-administer medications was discussed with Staff 1 (Administrator) and Staff 19 (Resident Services Coordinator/LPN) on 02/02/22. They acknowledged the findings. Resident 8 and 9 were evaluated for safety, and the facility requested orders form the residents' physicians.

Based on interview and record review, it was determined the facility failed to ensure documentation that 3 of 4 sampled newly-hired employees (#s 13, 14 and 15) completed pre-service orientation or dementia care training prior to assuming their job duties. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (Administrator) on 9/14/21. The following deficiencies were identified:1. Staff 13 (Kitchen Aide) was hired 7/7/21. There was no documented evidence Staff 13 completed the following training requirements:* Resident rights and values of CBC care;* Abuse reporting requirements;* Oregon Food Handler's training; and* That Staff 13 was provided a written job description.2. Staff 14 and Staff 15, both Resident Assistants who provided direct care to residents, lacked documented evidence they completed approved pre-service dementia training prior to providing care to residents.The need to ensure documentation of completed pre-service training was reviewed with Staff 1 on 9/15/21. She acknowledged the lack of training documentation.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 20, 21 and 22) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 01/31/22 and revealed the following:a. There was no documented evidence Staff 20 (RA), Staff 21 (RA), and Staff 22 (RA), hired 10/19/21, 11/23/21, and 10/29/21 respectively, had completed one or more of the following required topics prior to beginning their job responsibilities:* Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures; and* Written job description.b. There was no documented evidence Staff 20 and Staff 22 completed all pre-service dementia training prior to providing care to residents.The need for staff to complete all required pre-service orientation and dementia training prior to starting their job duties and providing care to residents was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 14, 15 and 16) completed all required training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 9/15/21 with Staff 1 (Administrator). The following deficiencies were identified:1. Staff 14, a Resident Assistant who provided direct care to residents, lacked documented evidence of demonstrated competency in all required areas within 30 days of hire.2. Staff 14, 15 and 16, Resident Assistants who provided direct care to residents, lacked documented evidence of having completed First Aid and abdominal thrust training within 30 days of hire.The need to ensure documentation of completed competency and Fist Aid training within 30 days of hire was reviewed with Staff 1 on 9/15/21. She acknowledged the lack of training documentation.
Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 20 and 22) demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 01/31/22 and the following was identified:There was no documented evidence Staff 20 (RA), hired 10/19/21, and Staff 22 (RA), hired 10/29/21, had completed one or more of the following required competencies within 30 days of hire:* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* First aid/abdominal thrust.The need to ensure there was documented evidence staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drill records included all required information and components. Findings include, but are not limited to:Fire and life safety records for April - August 2021 were reviewed on 9/15/21. Fire drill records lacked consistent documentation of the following required information:* Escape route used;* Evacuation time needed;* Resident evacuation problems encountered; and* Number of occupants evacuated.The need to ensure fire drill records included all required information was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C252, C260, C270, C325, C370 and C372.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways in good repair. Findings include, but are not limited to:The exterior of the building was toured on 9/13/21. There were multiple sections of the concrete path that encircled the building that had drop-offs from the surface of the path to the planting bed of up to two inches. This represented a fall risk for residents.The drop-offs were reviewed with Staff 1 (Administrator), Staff 17 (Maintenance Coordinator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the drop-offs.

Based on observation and interview, it was determined the facility failed to keep all interior surfaces in good repair. Findings include, but are not limited to:The interior of the building was toured on 9/13/21. The following areas needed repair:* Door frames or doors of rooms 103 and 243, the staff laundry room and the exit door near room 130 were scuffed or gouged.* Sections of the hallway handrails across from or near rooms 111, 119, 127, 128, 137 and the intersection of the hallway with room 206 where gouged and missing paint, leaving a rough surface.The condition of the doors, doorframes and handrails were reviewed with Staff 1 (Administrator), Staff 17 (Maintenance Coordinator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the areas needing repair.

Based on observation and interview, it was determined the facility failed to ensure covers of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that are subject to incidental contact by individuals. Findings include, but are not limited to:The interior of the building was toured on 9/13/21. Room 220, a one-bedroom unit, had a baseboard heater under the window in the bedroom. When the heater was turned on and allowed to heat up, the metal surface of the heater reached 139 degrees F. The heater was located where a resident could come into incidental contact with the hot surface of the heater. The facility provided information that indicated there were a total of 48 one-bedroom rooms that had similar baseboard heaters.The risk posed by the hot surface of the baseboard heaters was discussed with Staff 1 (Administrator) on 9/13/21, and with Staff 17 (Maintenance Coordinator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the surface of the heaters exceeded 120 degrees F.