Avamere at Chestnut Lane

The findings of the on-site investigation, conducted 08/19/24 through 08/20/24, 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 Nurse

Based on observation, interview, and record review, conducted during a site visit on 08/19/24 and 08/20/24, the facility's failure to carry out treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:Resident 1's physician orders, dated 05/23/24, indicated "[Resident 1] may use whirlpool bath as needed to treat chronic shoulder pain."During an interview on 08/19/24, Staff 1 (Executive Director) stated the whirlpool bath was broken, but was in the process of being fixed. During an interview on 08/19/24, Staff 4 (Director of Health Services) stated the whirlpool was not available right now, and Resident 1 had a physician order to use the whirlpool bath.During an interview on 08/20/24, Staff 6 (Resident Care Coordinator) stated the facility had not offered alternatives for the whirlpool bath that s/he was aware of. On 08/20/24, At approximately 11:50 am, Staff 5 (Maintenance Director) was observed turning on the whirlpool bath. The lights on the machine lit up, but the tub did not fill. Staff 5 examined the whirlpool bath controls further and said it was "locked out," and s/he was unable to operate the whirlpool.During an interview on 08/20/24, Resident 1 stated:-S/He had a physician order for the whirlpool; -Resident 1 had needed to use the whirlpool for shoulder pain, but hadn't had access; and-The facility had not offered an alternative or options.It was determined the facility failed to carry out treatment orders as prescribed for Resident 1.Findings were reviewed with Staff 1 (Executive Director) on 10/18/24.Verbal plan of correction: The facility had scheduled a technician to assess and repair the whirlpool on 08/22/24.

The findings of the kitchen inspection, conducted 05/28/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 05/28/24, conducted 08/07/24, 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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 05/28/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Flooring throughout the entire kitchen had significant build up of black matter including under, behind and/or in front of the following: - Convection oven; - Commercial mixer; - Shelving storing telephone; - Single sink in prep area; - Shelving storing cutting boards and food storage containers; - Entrance to walk in refrigeration; - Stove/grill/deep fat fryer; - Steamer; - Food service/steam table; - Ice machine; - Beverage service counter; and - Prep counter with commercial can opener.* Lower shelves under the steam table, both front and back with drips/spills/food debris; * Lids of food storage bins had food debris;* Commercial mixer had food splatter on the base and food debris on shelving;* Exterior and lids of the garbage cans near the service line had food drips/splatters;* Commercial can opener blade with black matter and food debris in the holder attached to prep counter;* Side of the steamer had food drips/splatter; * Exterior doors of refrigerator on the service line with drips/spills and interior bottom shelf with food debris; and * Fronts of the oven doors had food drips/splatter.Areas which required cleaning were observed and discussed with Staff 1 (Dietary Manager) and discussed with Staff 2 (Executive Director) on 05/28/24. The findings were acknowledged.

Based on interview and record review, conducted during a site visit on 02/12/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Finding include, but are not limited to: A review of the facility's posted staffing plan indicated:* Day shift: 6:00 am - 2:00 pm: five caregivers;* Day shift: 5:45 am - 2:15 pm: two health care coordinators;* Swing shift: 2:00 pm - 10:00 pm: five caregivers;* Swing shift: 1:45 am - 11:15 pm: two health care coordinators; * NOC shift: 10:00 pm - 6:00 am: three caregivers; and* NOC shift: 10:00 pm - 6:00 am: one health care coordinator.A review of staff schedules, dated 09/01/23 through 02/12/24 indicated 23 shifts in 09/2023, 11 shifts in 10/2023, 6 shifts in 11/2023, and 3 shifts in 12/2023 that were staffed below the posted staffing plan. There were 4 shifts in 09/2023 where only agency staff were scheduled. In an interview on 02/12/24, Staff 1 (Executive Director) indicated December 2023 was really short staffed and the facility hours for December was about 46% agency staff. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings of the investigation were reviewed with and acknowledged by Staff 1 on 02/12/24.Facility Plan of Correction: The facility has hired new staff and has been able to reduce the usage of agency staff to closer to 15% - 20% for the month of February and have been able to prioritize agency staff that are familiar with the residents and know a little American Sign Language.

Based on observation, interview and record review, conducted during a site visit on 02/12/24, it was confirmed the facility failed to ensure staff 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. Findings include, but are not limited to: In an interview on 02/12/24, Resident 5 stated s/he had been unable to communicate with staff about his/her care needs. There are facility staff that do not know sign language and the facility uses staff from outside of the facility that do not know sign language.In an interview on 02/12/24, Staff 4 (Agency RA) stated s/he was on a contract with the facility through an agency for several months. S/He stated there is an app for staff to use to communicate to residents, but residents are not able to communicate needs to staff. S/He stated when s/he first came to the facility s/he was just thrown in and has since developed trust with the residents. The facility started American Sign Language (ASL) classes a few weeks ago, but they are for facility staff not for agency staff.On 02/12/24 at 11:25 am, CS observed Staff 4 entered Resident 1's room. Staff 4 was not able to communicate with Resident 1 about what service s/he was there to provide. Witness 1 and Witness 2 were used by Staff 4 to inform Resident 1 that Staff 4 wanted to take the trash out for Resident 1. In an interview on 02/12/24, Staff 1 (Executive Director) stated the facility does use agency staff and there is an app that staff can use to communicate with residents. The facility does request that agencies send staff that are comfortable working with deaf and hard of hearing residents, but there is no expectation for agency staff to know ASL.A review of staff schedules dated 09/01/23 through 02/12/24 indicated 4 instances in 09/2023 of only agency staff scheduled. The facility failed to ensure staff 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.The findings of the investigation were reviewed with and acknowledged by Staff 1 on 02/12/24.Facility Plan of Correction: The facility has hired new staff and has been able to reduce the usage of agency staff to closer to 15% - 20% for the month of February and have been able to prioritize agency staff that are familiar with the residents and know a little American Sign Language. The facility has mandated that 100% of staff know ASL within 3 months. Hiring Job Descriptions have been updated to reflect the requirement to be fluent in ASL.

The findings of the re-licensure survey conducted 07/17/23 through 07/21/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 first re-visit to the re-licensure survey of 07/21/23, conducted 02/20/24 through 02/21/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood 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 second revisit to the re-licensure survey of 07/21/23, conducted on 04/18/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required components for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. Findings include, but are not limited to:Resident 4 moved into the facility in 04/2023. A record review of the new move-in evaluation failed to address the following areas: * Customary routines, including bathing;* Cognition, including memory and confusion;* History of treatment of mental health issues;* Personality, including how the person copes with change or challenging situations;* Ability to understand and be understood; and* Non-pharmaceutical interventions for pain.The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2023 with diagnoses including chronic venous hypertension with ulcers of bilateral lower extremities and lymphedema.Resident 4's current service plan, dated 06/15/23, was reviewed, observations were made, and interviews were conducted between 07/17/23 and 07/21/23. Resident 4's service plan was not reflective and did not provide clear instruction to staff in the following areas:* Cat description and care, including strategies to keep the cat in the apartment;* Outside provider information, including contact information and frequency of visits;* Front-wheeled walker vs four-wheeled walker;* Communication needs;* Preferences regarding bathroom privacy; * Falls and fall interventions;* Pain; and* Wound care, including management of soiled bandages between home health visits.The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs or provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 04/2021 with diagnoses including bipolar disorder, hearing loss, and obesity.Observations of the resident apartment, interviews with the resident and staff from 07/17/23 to 07/20/23, and review of the service plan, dated 07/10/23, indicated the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Transfers;* Toileting;* Side rails; and* Communication interventions for verbal behaviors.The need for service plans to be reflective of the resident's current care needs and provide clear instruction to staff was discussed with Staff 1 (ED), and Staff 2 (RN) on 07/21/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident specific instructions or interventions were developed for short-term changes of condition, the interventions were communicated to the staff and the condition was monitored, at least weekly, through resolution for 1 of 3 sampled residents (#4) who experienced changes of condition. Findings include, but are not limited to:Resident 4 was admitted to the facility in 04/2023 with diagnoses including lymphedema and chronic venous hypertension with ulcers of bilateral lower extremities.The resident's current service plan dated 06/15/23, progress notes dated 04/25/23 through 07/16/23, and corresponding incident reports were reviewed. The resident had multiple documented short-term changes of condition between 04/28/23 and 07/16/23.a. The following changes of condition lacked documented evidence determined actions or interventions were communicated to staff on all shifts:* 04/28/23 - New admission to the facility;* 05/06/23 - New antibiotic for leg infection;* 05/11/23 - New medication (miconazole);* 05/15/23 - Fall;* 05/31/23 - Gabapentin dosing change; * 06/06/23 - Fall with hip bruising;* 07/12/23 - Fall;* 07/12/23 - ED visit; and* 07/13/23 - Fall with bruising.On 07/21/23 at approximately 9:15 am, Staff 1 (ED) confirmed the facility used interim service plans (ISPs) which were retained in the facility's computer documentation system; however, caregiving staff were unable to access the computer system. The facility printed ISPs for the caregiving staff on all shifts to read and sign; but the facility shredded the ISPs after two or three weeks and retained no copy to demonstrate the communication of interventions to all staff.b. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:* 04/28/23 - New admission to the facility;* 04/28/23 - Chronic bilateral leg wounds;* 05/03/23 - Two bruises on right arm;* 05/06/23 - New antibiotic for leg infection;* 05/11/23 - New medication (miconazole);* 05/31/23 - Gabapentin dosing change; * 06/02/23 - Fall;* 06/06/23 - Behaviors; and* 06/06/23 - Fall with hip bruising.The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the change of condition was monitored through resolution was discussed with Staff 1 and Staff 2 (RN) on 07/21/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to carry out medication orders as prescribed for 1 of 4 sampled residents (#4) whose orders were reviewed. Resident 4 was not administered antidepressants as prescribed which put the resident at risk of potential harm. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 04/2023 with diagnoses including generalized anxiety disorder and lymphedema. Resident 4's signed physician orders, MAR/TAR dated 07/01/23 through 07/16/23, and progress notes dated 04/25/23 through 07/16/23 were reviewed during the survey and revealed the following:a. Resident 4 admitted to the facility with a signed physician order, dated 04/24/23, to administer sertraline 50 mg - two tablets twice daily for depression and anxiety. The resident was to receive 100 mg twice daily for a total of 200 mg per day.On 07/06/23, the facility received an order from Resident 4's primary care provider to change the resident's sertraline administration time. The resident was to receive sertraline 100 mg - two tablets by mouth daily. This totaled 200 mg once daily.Resident 4's MAR indicated s/he received sertraline 50 mg - four tablets by mouth two times a day for major depressive episodes. This totaled 200 mg twice daily for a total of 400 mg per day, or two times the amount prescribed by the resident's physician. The facility documented the resident received a total of 400 mg of sertraline daily for nine consecutive days between 07/08/23 and 07/16/23.On 07/18/23 at 9:42 am, Staff 1 (ED) was alerted to the medication error, acknowledged the finding, created an incident report and then self-reported the incident to the local Seniors and People with Disabilities (SPD) office. Confirmation of this reporting was received at 11:54 am on 07/18/23.During an interview with Resident 4 on 07/18/23 at 12:38 pm, s/he reported the facility had brought him/her four tablets of sertraline recently. The resident questioned the number of pills provided because s/he previously took two tablets of sertraline at a time. The resident was assured the medication change was accurate and directed by the physician. With the increased dosing, the resident complained of stomach upset and increased sleepiness with a recent incident where s/he fell asleep in the restroom. Resident 4 was observed to be sleeping during the day on three separate occasions during the relicensure survey. The resident's statement was corroborated through a progress note dated 07/07/23 at 10:45 pm which stated the following:"[Resident 4] was asking why there are 4 pills of Sertraline. HCC (Health Care Coordinator) told that it was [his/her] [doctor] who prescribed the increase. [Resident 4] said yes I saw my [doctor] and he didn't tell me about increase [sic] doses. [Resident 4] said I am worried that it would make me more sleeping [sic] before I ask for Xanax later. So [s/he] took two out and gave it to HCC."The failure to follow physician orders as prescribed for the resident's sertraline put Resident 4 at serious risk of potential harm.b. Resident 4 had an order to receive Lasix 40 mg (for swelling) one tablet by mouth two times a day. The medication was not administered as prescribed on nine occasions because the facility was awaiting delivery by the pharmacy, or the MAR was blank.On 07/20/23 at 11:13 am, the surveyor and Staff 12 (MT) observed and checked the MAR and medication supply. Staff 12 confirmed the medication had not been administered as prescribed.The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings, and no additional information was provided.
2. Resident 8 was admitted to the facility in 08/2018 with diagnoses including atrial fibrillation and sleep apnea.Review of the resident's most recent 90-day physician order summary, signed by the prescriber on 12/02/23, included an order to "Put on in the morning then take off Compression Stocking at night and wash by hand with a bit of soap then hang up until dry for the next day DAILY." The order summary was stamped and initialed as reviewed by two MTs and a facility nurse using the facility's three-check system.In an interview on 02/21/24, Staff 25 (Regional Nurse Consultant) confirmed the order had not been added to the resident's MAR or TAR until that day.In interviews on 02/21/24, Staff 22 (MT) and Staff 24 (CG) both stated they were not putting compression stockings on the resident. In an interview also on 02/21/24, Resident 8 confirmed the facility was not putting compression stockings on him/her.The need to ensure orders are reviewed and carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (LPN) and Staff 25 on 02/21/24. They acknowledged the order for the compression stockings had not been carried out as prescribed.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 7 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 12/2012 with diagnoses including Type II diabetes with diabetic retinopathy and superficial keratitis of both eyes (inflammation of the cornea).The resident's MAR and TAR dated 02/01/24 through 02/19/24, current physician orders dated 12/06/23, and updated physician orders following medical appointments on 02/06/24 and 02/16/24 were reviewed. The following was revealed:* Resident 7 had a physician order, dated 12/06/23, to receive one drop of artificial tears in each eye four times daily for eye health. Following an appointment on 02/06/24, the resident's dosing was increased to every two hours while awake. The dosage was changed back to four times daily on 02/16/24. Both updated physician orders were stamped and initialed as reviewed by two medication technicians using the facility's three-check system.The resident's TAR indicated artificial tears were administered four times daily from 02/01/24 through 02/19/24. There was no documented evidence the eye drops were administered every two hours between 02/06/24 and 02/16/24 as prescribed. * The resident also had an order, dated 02/06/24, to receive one drop of Refresh Celluvisc in each eye four times daily for corneal epitheliopathy (staining of the corneal epithelial layer). At the resident's follow-up appointment on 02/16/24, the physician ordered the medication to continue to be administered four times daily. Both physician orders were stamped and initialed as reviewed by two medication technicians using the facility's three-check system.The resident's TAR indicated the Refresh Celluvisc was not administered as ordered between 02/06/24 and 02/19/24. On 02/21/24 at 11:46 am, this surveyor and Staff 3 (LPN) reviewed the resident's TAR and physician orders. Staff 3 and Staff 25 (Regional Nurse Consultant) confirmed the resident was not administered the accurate dosing of the artificial tears or the Refresh Celluvisc. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) on 02/21/24. She acknowledged the findings.

3. Resident 5 was admitted to the facility in 04/2021 with diagnoses including bipolar disorder and obesity.Resident 5's 07/01/23 through 07/17/23 MAR was reviewed and identified the following:a. Resident 5 was prescribed PRN Dulcolax (for constipation) and PRN Miralax (for constipation). The MAR lacked parameters instructing staff on which medication to use first. b. Resident 5 was prescribed PRN Nystatin (for rash). The MAR lacked medication specific instructions including where and when to administer.The need to ensure MARs included resident specific parameters and instructions was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 07/21/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications and clear instructions to staff for 3 of 5 sampled residents (#s 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 11/2011 with diagnoses including diabetes.Resident 3's 07/01/23 through 07/17/23 MAR was reviewed and identified the following:a. Resident 3 was out of the facility 06/22/23 through 07/14/23. During that time the following medications were documented as given:*Atorvastatin - 07/03/23 and 07/07/23;*Gabapentin - 07/03/23 and 07/07/23;*Risperidone - 07/03/23 and 07/07/23;*Solifenacin - 07/03/23 and 07/07/23;*Nystatin Powder - 07/03/23; and*Zinc paste - 07/03/23. b. Resident 3 was prescribed PRN Milk of Magnesia (for constipation) and PRN Miralax (for constipation). The MAR lacked parameters instructing staff on which medication to use first. The need to ensure MARs were accurate and had clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition, was reviewed with Staff 1 (Executive Director) on 07/20/23. She acknowledged the findings.
2. Resident 4 was admitted to the facility in 04/2023 with diagnoses including generalized anxiety disorder and lymphedema. Resident 4's signed physician orders and 07/01/23 through 07/16/23 MAR/TAR were reviewed during the survey and revealed the following:a. The following medications lacked medication specific instructions for administration, dose to administer, or resident specific parameters for PRN dosing:* Fosamax 70 mg;* Imitrex 50 mg; * Voltaren;* Acetaminophen 325 mg; and* Acetaminophen-Codeine 300-60 mg.In an interview with Staff 12 (MT) on 07/20/23 at 10:29, he confirmed the identified required information was not available in the electronic MAR.b. Resident 4 had an order for Xanax 0.5 mg - two tablets by mouth every 12 hours as needed for anxiety. According to the resident's narcotic log and bubble pack, s/he received the medication on 07/11/23 and 07/13/23; however, the MAR was blank for those dates.Staff 12 (MT) reported on 07/20/23 at approximately 11:30 am that he and a MT he was training administered the doses and forgot to sign the MAR.The need to ensure the facility maintained an accurate MAR was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed psychotropic medications. Findings include, but are not limited to:Resident 4 was admitted to the facility in 04/2023 with diagnoses including general anxiety disorder.Review of Resident 4's MAR, dated 07/01/23 through 07/16/23, and physician orders revealed the following:Resident 4 was prescribed PRN Xanax for anxiety or insomnia, and it was documented as administered to the resident on 15 occasions between 07/02/23 and 07/15/23.The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications, and the MAR lacked information on non-pharmacological interventions to attempt.In an interview on 07/20/23, Staff 12 (MT) confirmed the MAR system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication. On 07/21/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed at least quarterly for assistive devices with potentially restraining qualities for 1 of 3 sampled residents (#5) reviewed who had a supportive device. Findings include, but are not limited to:Resident 5 was admitted to the facility in 04/2021 with diagnoses including bipolar disorder and obesity.During the entrance conference, 07/17/23, Resident 5 was identified as having side rails on his/her hospital bed. Observations of the resident and the resident's room showed the left side rail was in the up position on 07/19/23 and the left and right side rails were in the up position on 07/20/23. During an interview with Resident 5 on 07/20/23, s/he reported that s/he used the left side rail to assist with repositioning and transferring, and that s/he preferred the right side rail down.There was no quarterly assessment for the bilateral side rails completed by the RN, PT or OT for use of the assistive devices with potentially restraining qualities. There were no instructions to staff in the resident's service plan regarding the use or safety precautions of the side rails. The need to complete assessments of supportive devices with restraining qualities at least quarterly was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident entries were reflective of resident care needs and were updated quarterly for 3 of 5 sampled resident (#s 3, 4 and 5) whose ABST were reviewed. Findings include, but are not limited to:Review of three sampled residents' records, interviews with staff, and observations of the residents noted ABST entries were not reflective of the current care needs and/or updated quarterly. The ABST data showed multiple areas which reflected zero minutes when the resident required more than zero minutes of assistance in several of the marked areas. Inaccuracies on resident entries for the ABST tool was discussed with Staff 1 (ED) on 07/20/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to:On 07/18/23, review of facility fire drill and fire and life safety instruction records, from 02/2023 through 07/2023, and interviews with staff revealed the following was not documented on fire drills; * The escape route used;* Problems encountered and comments related to residents who resisted or failed to participate in the drills was not documented; * Evacuation time needed: and* Number of occupants evacuated. On 07/18/23, the need to ensure fire drills had all required elements was discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C303 and C613.

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 interior of the facility was toured on 07/17/23. The following areas needed cleaning or repair:* Gouges, scrapes, and chunks of missing wood on resident and bathroom doors throughout the facility;* Gouges and scrapes on handrails throughout the facility;* Black streaks and chipped paint on metal exit doors throughout facility;* Dark carpet stains outside multiple resident room doors on the first floor; and* Black matter and gray build-up in all elevators' sill grooves.The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director) on 07/19/23. They acknowledged the areas needing cleaning and repair.
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. This is a repeat citation. Findings include, but are not limited to:The interior of the facility was toured on 02/20/24. The following areas needed cleaning or repair:* Wood pillars and baseboard had scrapes and gouges on exposed corners in the lobby, fireplace seating area and at the resident mailboxes;* The wood entry doors and door jambs in the lobby facing the front desk had gouges and scrapes; * The baseboard across from the med room had scrapes and gouges;* The activities room on the first floor had scrapes and chipped paint on the drywall next to the windows;* There were gouges and scrapes on handrails near room 107 and across from elevator on the 4th floor;* There were black streaks and chipped paint on metal exit doors and door jambs near room 101;* There were gouges, scrapes, and chunks of missing wood on resident apartment doors and door jambs including rooms 102, 201, 203, 204, 205, 207, 208, 209, 210, 211, 215, 216, 301, 302, 305, 309, 310, 312, 313, 314, 315, 316, 318, 401, 402, 404, 407, 412, 413 and 415;* There were gouges, scrapes and chunks of missing wood on doors and door jambs including communication room, bathroom next to activities room, activities room, bathroom across from room 216, staff lounge, second floor laundry room, and the bathroom near room 417;* Several chairs and loveseats throughout the facility had stains, spots, or dried matter including one chair near room 104, two chairs near the second floor elevator, one chair near the second floor VP room, one tan chair near room 302, one loveseat near room 306, two red chairs near room 404 and one loveseat near fourth floor stairwell and janitor/mechanical room;* The elevator door jambs on the first, second, third and fourth floors had scrapes and gouges; and* The elevators' sill grooves on the first, second, third and fourth floors had black matter and gray build-up.The building was toured and areas needing cleaning or repair were discussed with Staff 1 (ED) and Staff 8 (Maintenance Director) on 02/20/24. They acknowledged the areas needing cleaning and repair.