Sellwood Senior Living

10 Tag infoAssisted 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 02/03/25 and 02/12/25. 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthHS: Hours of sleepLPN: Licensed Practical NurseMT: Medication Technician or Med TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseSP: Service planSPT: Service Planning TeamTAR: Treatment Administration Record

Based on observation, interview, and record review, conducted during a site visit on 02/03/25 and 02/12/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 2 of 3 sampled Residents (#s 1 and 3). Findings include, but are not limited to:The facility utilized the ODHS ABST, and the census was 82. There were 35 residents who were not updated in the ABST as required, and 2 of 3 sampled Residents' (#s 1 and 3's) service plans and ABST profiles did not match regarding services and acuity.Resident 1 was not updated in the ABST. His/Her service plan, dated 01/19/25, indicated s/he was a total assist with dressing and toileting. There was no time assigned in the ABST for either task. The service plan indicated Resident 1 was independent with the use of the call pendant. The ABST had no task time assigned for staff to respond to call lights.Resident 1 was unavailable for interview regarding his/her care needs.Resident 3 was not updated in the ABST. His/Her service plan, dated 01/19/25, indicated s/he required one person total assist with all bathing/showering needs, but later in the service plan stated s/he was independent with bathing/showering. There was task time assigned in the ABST for assistance with bathing.On 02/03/25, Resident 3 stated s/he required assistance with bathing and sometimes lower extremity dressing.The facility's posted staffing plan indicated for day and swing shifts, there were two Med Techs (MTs) and three Caregivers (CGs) scheduled, for night shift, there was one MT and one CG scheduled.On 02/03/25, there were two MTs and three CGs working day shift.Staff schedules, dated 01/28/25 through 02/03/25 indicated the facility did not staff according to their posted staffing plan for two of 21 reviewed shifts.It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 1 and 3.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (LPN Wellness Director), and Staff 3 (Resident Service Director) on 02/12/25.

The findings of the kitchen inspection, conducted 04/25/24, 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 re-visit to the kitchen inspection of 04/25/24, conducted on 07/02/24, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

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 04/25/24 at 11:10 am, the kitchen was observed to have the following concerns:* Two trays of uncovered desserts were stored on a rolling cart in the walk in refrigerator, creating potential cross contamination;* Floors throughout the kitchen underneath counters, sinks, stove/grill and dishwashing areas, including corners, had debris and black matter build-up;* Dishwashing area - the wall and caulking behind the spray hose sink had a build-up of black matter;* The dishwashing machine sides and top had debris and drips/spills; * The walk-in refrigerator ceiling in front of fans had a build-up of dust, creating potential for cross contamination;* The walls behind and beside the stove/grill had grease drips; and* Ceiling lights had missing covers in dishwashing area, prep area, and dry storage.The areas of concern were observed and discussed with Staff 1 (Director of Dining Services) and discussed with Staff 2 (Executive Director). The findings were acknowledged.

The findings of the change of ownership survey conducted 08/28/23 through 08/31/23 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
The findings of the first re-visit to the change of ownership survey of 08/31/23, conducted 11/30/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

The findings of the second re-visit to the change of ownership survey of 08/31/23, conducted 02/28/24, 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 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





The findings of the third re-visit to the change of ownership survey of 08/31/23, conducted 05/09/24, 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. 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
The findings of the fourth re-visit to the re-licensure survey of 08/31/23, conducted on 07/17/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services for 2 of 6 sampled residents (#s 2 and 3). Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including kidney failure and was receiving dialysis services. The service plan dated 05/10/23 lacked clear direction to staff in the following area:* Fistula care and safety.On 08/31/23, the need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the findings.
2. Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure.Observations were made of the resident's care on 08/29/23. Interviews with facility staff and the resident were conducted. The current service plan dated 07/03/23 was reviewed. Resident 3's service plan lacked clear instructions to staff in the following areas:* Non-pharmaceutical interventions for pain, including how Resident 3 expressed pain or discomfort; and * Oxygen equipment precautions and instructions for proper maintenance.The need to ensure the service plan provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings. No further information was provided.

2. Resident 4 was admitted to the facility in 04/2019, with diagnoses including major neurocognitive disorder, stage 3b kidney disease, and history of diverticulitis with abscess.Review of progress notes indicated Resident 4 experienced the following changes of condition between 07/21/23 and 07/28/23:* 07/21/23 Resident 4 returned from a five day hospitalization for diverticulitis, a TSP was completed informing staff "GI problems, UTI, new med changes";* 07/22/23 Resident 4 was sent back to the hospital due to "painful sore throat, unable to swallow and complaining of severe pain" and returned on 07/23/23 with new diagnoses of pharyngitis (inflammation of the back of the throat) and dehydration; and* 07/28/23 Alert note "res requested to be changed in bed and have meals in bed as well...res states isn't able to walk or stand."The hospitalizations, new diagnoses, med changes, and rapid decline in mobility constituted a significant change of condition.There was no documented evidence the facility evaluated the resident and referred to the facility nurse for assessment.In interview on 08/30/23, Staff 17 (RN Consultant) confirmed she had not been notified of Resident 4's change of condition and had not completed an RN assessment. The need to ensure the facility RN was notified when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to evaluate the resident, refer to the facility RN, and update the service plan as needed when a resident experienced a significant change of condition, for 2 of 2 sampled residents (#s 1 and 4). Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety.Review of the record indicated Resident 1 fell and sustained a right wrist fracture in 05/2023. Interviews with Staff 2 (LPN) and Staff 3 (RCC) confirmed the resident needed increased staff assistance with ADLs following the injury.The wrist fracture and increase in care needs represented a significant change of condition for which the facility was required to notify the facility RN. There was not documented evidence the facility notified the facility RN of Resident 1's wrist fracture. In interviews on 08/30/23, Staff 3 and Staff 17 (RN Consultant) confirmed Staff 17 was not notified of Resident 1's significant change of condition.The need to ensure the facility RN was notified when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2 and Staff 3 on 08/31/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system for tracking controlled substances, for 1 of 2 sampled residents (#1) who was administered narcotic medications. Findings include, but are not limited to:Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety.The resident had an order for oxycodone 15 mg immediate-release tablet - take one tablet every three hours as needed for pain. Between 08/01/23 and 08/27/23, the Controlled Substance Log Book indicated staff signed as having removed an oxycodone pill from locked storage 62 times. However, the MAR, during that same time period, indicated the resident was administered the medication only 34 times. This was a discrepancy of 28 pills.The log book documentation and the MAR were reviewed on 08/30/23 with Staff 2 (LPN) and Staff 14 (CG/MT). They acknowledged the discrepancy.The discrepancy between the log book and the MAR was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (RCC) on 08/31/23. Staff 3 stated she believed, based on the resident's pattern of use, that the medications had been administered to the resident but that staff had failed to document the administrations on the MAR. Staff 2 agreed and said the facility would address the lack of documentation with the appropriate staff.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#1) who was administered as needed narcotic medication. This is a repeat citation. Findings include, but are not limited to:Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety.Resident 1 had a physician order for Oxycodone 15 mg immediate-release tablet - take one tablet every three hours as needed for pain. Resident 1's 11/01/23 through 11/30/23 Controlled Substance Disposition Logs and MAR were reviewed and revealed the following:Between 11/01/23 through 11/30/2023 there were 17 occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card. However, the MAR lacked documentation the resident received the PRN medication.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the discrepancy. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 2 and Staff 3 on 11/30/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 1 and 10) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety.The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 02/01/24 through 02/27/24 were reviewed.Resident 1 had a physician order for hydromorphone 2 mg - take one tablet by mouth every three hours as needed for pain.Between 02/01/24 through 02/27/24, the Controlled Substance Disposition logs indicated staff signed as having removed a tablet of hydromorphone from locked storage 83 times. However, during the same time period, the MAR indicated the resident was administered the medication 49 times. This was a discrepancy of 34 pills.The controlled log documentation and the MAR were reviewed on 02/28/24 with Staff 2 (LPN) and Staff 3 (Resident Service Director). They acknowledged the discrepancies.The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 22 (ED), Staff 2, and Staff 3 on 02/28/24. They acknowledged the findings.2. Resident 10's physician orders, the Controlled Substance Disposition logs and the MAR, dated 02/01/24 through 02/27/24 were reviewed.Resident 10 had physician orders for the following controlled medications:* Hydromorphone HCL 2 mg - take two tablets by mouth every six hours as needed for pain; * Morphine sulfate 15 mg - give one tablet by mouth twice daily for cancer pain; and* Oxycodone HCL 5 mg - give one tablet by mouth every eight hours as needed for pain.The following inconsistencies between the resident's MAR and the Controlled Substance Disposition log were identified:* Between 02/20/24 and 02/27/24, the Controlled Substance Disposition log indicated a hydromorphone tablet was removed from locked storage on 17 occasions. However, during the same period, the MAR indicated the resident was administered eight tablets. This was a discrepancy of 9 pills.* Between 02/01/24 and 02/27/24, the Controlled Substance Disposition log indicated a morphine sulfate tablet was removed from locked storage on six occasions. However, the MAR indicated the resident was administered eight tablets. This was a discrepancy of two tablets.* Between 02/01/24 and 02/21/24, the Controlled Substance Disposition log indicated an oxycodone tablet was removed from locked storage on 14 occasions. However, the MAR indicated the resident was administered six tablets. This was a discrepancy of eight tablets.The inconsistencies between the MAR and the Controlled Substance Disposition log were reviewed with Staff 22 (ED), Staff 2 (LPN) and Staff 3 (Resident Service Director) on 02/28/24. They acknowledged the discrepancies.The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 22, Staff 2 and Staff 3 on 02/28/24. They acknowledged the findings.




Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#12) who was administered as needed narcotic medication. This is a repeat citation. Findings include, but are not limited to:Resident 12 moved into the facility in 12/2022 with diagnoses including dementia.Resident 12 had a physician order for oxycodone 5 mg, 0.5 tablets (2.5 mg) by mouth every four hours as needed for pain.Resident 12's 04/01/24 through 05/09/24 MAR's and Controlled Substance Disposition Logs were reviewed and identified the following:a. Between 04/01/24 through 05/09/2024 there were two occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card. However, the MAR lacked documentation the resident received the PRN medication.b. Between 04/01/24 through 05/09/2024 there were five occasions staff signed the MAR however, the drug disposition log lacked documentation that the medication was administered.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 2 (LPN) and Staff 22 (ED) on 05/09/24. They acknowledged the discrepancy. 1A. Resident 12 MAR updated late entries.1B. Resident 12's drug disposition log updated with late entries2A. In-service on Controlled Substance Management, Missed or Refused Medications, Medication Records, end of shift reporting policies provided to all Medication Technicians and clinical support staff.2B. Medicatin Technicians will run shift EMAR prn report at end of shift and compare with aPRN shift form and narcotic log.3A. Nurse, Resident Services Director, RN, or designee will audit narcotic log, shift form, and narcotic logs on a daily basis for the first 30 days, Bi-weekly audits will be perfomed for the next 30 days. Weekly audits will be performed 30 days post intial 60 days. Monthly audits on 30% of residents will be completed moving forward for next six months.

2. Resident 5 was admitted to the facility in 10/2021 with diagnoses including hypertension.A review of the 08/01/23 through 08/28/23 MAR and current physician's orders revealed the following:Resident 5 had a physician order for amlodipine (to control blood pressure) 5 mg to be given once per day. If the resident's systolic blood pressure was below 120 mmHg the facility was to hold the medication.On three occasions, 08/22/23, 08/26/23 and 08/27/23, the medication was given outside the parameters when it should have been held. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 7 sampled residents (#s 3 and 5) whose orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure.Resident 3's current physician orders and MARs from 08/01/23 through 08/28/23 were reviewed. The resident's physician orders included the following, which was received at the facility by fax on 08/05/23: * Please weigh resident and call if more than a 3 pound weight gain in a week or more than a 5 pound weight gain in a month.* Please check for swelling in legs and call if present.* Please check vital signs three times a day for the next 48 hours. Call if oxygen levels below 90% on oxygen. Please call if resident becomes short of breath and can not speak a complete sentence before taking another breath. There was no documented evidence the resident's weight was obtained, swelling in the legs was assessed and vital signs were checked three times a day for 48 hours [starting 08/05/23].The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RCC) on 08/30/23. They acknowledged the findings. No further information was provided.

2. Resident 4 was admitted to the facility in 04/2019, with diagnoses including major neurocognitive disorder, stage 3b kidney disease, and history of diverticulitis with abscess.Review of the MAR from 08/01/23 through 08/27/23 indicated the resident refused the prescribed carboxymethylcellulose .5% ophthalmic eye drops on 25 of 27 days.There was no documented evidence the facility notified Resident 4's physician of the multiple refusals.The need to ensure the facility notified the physician or other practitioner if a resident refused consent to an order was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused consent to an order, for 2 of 4 sampled residents (#s 1 and 4) with documented refusals of medications. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety.Review of the MAR from 08/01/23 through 08/27/23 indicated the resident refused the prescribed lidocaine patch (for pain) on 14 of the 27 days.There was no documented evidence the facility notified Resident 1's physician of the multiple refusals.The need to ensure the facility notified the physician or other practitioner if a resident refused consent to an order was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 3), who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to:Resident 3 was admitted in 05/2021 with diagnoses including vascular dementia.The resident's 11/2023 MAR was reviewed and revealed facility staff documented Resident 3 refused all medication and treatment orders 19 times throughout the month. There was no documented evidence the facility notified Resident 3's physician each time the resident refused to consent to the medication and treatment orders.On 11/30/23 the requirement to notify the physician/practitioner when a resident refused to consent to orders was discussed with Staff 2 (LPN) Staff 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included dosage, route, resident-specific parameters, and instructions for PRN medications for 1 of 6 sampled residents (#1) whose MAR was reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure.Resident 3's MAR from 08/01/23 through 08/28/23 and physician orders were reviewed and revealed the following:a. The following PRN medications lacked resident-specific parameters and instructions, including sequential order of use:* Albuterol 0.083%/3ml (for shortness of breath);* Albuterol HFA (hydrofluoroalkane) 90mcg (for shortness of breath); and* Oxygen (for shortness of breath). b. Oxygen order lacked dosage and route for administration.The need to ensure MARs were accurate and provided dosage, route, resident-specific parameters, and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RCC) on 08/30/23. They acknowledged the findings. No further information was provided.

4. Resident 4 was admitted to the facility in 04/2019, with diagnoses including major neurocognitive disorder, stage 3b kidney disease, and history of diverticulitis with abscess.During review of Resident 4's MAR, it was determined the resident self-administered the following medications:* ascorbic acid 500 mg (supplement);* biotin 5,000 mcg capsule (supplement);* fluticasone 50 mcg (for allergy); and* ipratropium .03% spray (broncodilator).The most recent evaluation was dated 03/30/23, prior to Resident 4 experiencing a decline and move to palliative care. The facility failed to evaluate Resident 4's ability to safely self-administer medications at least quarterly.The need to evaluate a resident's ability to safely self-administer medications at least quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.
3. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety.The resident had signed physician orders to self-administer the following PRN medications:* Albuterol sulfate HFA (hydrofluoroalkane) inhaler (for wheezing or shortness of breath);* Voltaren gel (topical medication for pain); and* Calcium antacid chews (for indigestion).The facility failed to evaluate Resident 1's ability to safely self-administer medications at least quarterly. The most recent evaluation was dated 10/10/22.The need to evaluate a resident's ability to safely self-administer medications at least quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.
5. Resident 2 was admitted to the facility in 05/2021 with diagnoses including kidney failure.During the acuity interview on 08/28/23, Resident 2 was identified as administering some of his/her own medications.The 08/01/23 through 08/28/23 MAR and current signed physician orders identified Resident 2 was self-administering the following medications:* Aspart flexpen (insulin);* Levemir (insulin);* Glutose (for low blood sugar); and* Midodrine (hypertension). An evaluation to determine Resident 2's ability to safely self-administer medications was completed in 10/2022. There was no documented evidence of a quarterly evaluation.On 08/31/23, the need to ensure residents were evaluated at least quarterly for their ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the resident's ability to safely self-administer medications for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 6) who were reviewed for self-administration. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure. During the acuity interview on 08/28/23, Resident 3 was identified as self-administering some of his/her medications. This was confirmed by Staff 10 (Medication Technician) in an interview on 08/28/23.Review of the records revealed the last evaluation of Resident 3's ability to safely self-administer medications was completed on 05/23/22.In an interview on 08/29/23, Staff 3 (RCC) acknowledged no evaluation had been completed more recently for the resident, and updated evaluation was done by Staff 3 during the survey.The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the resident's ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 on 08/30/23. They acknowledged the findings. No further information was provided.2. Resident 6 was admitted to the facility in 12/2020 with diagnoses including orthostatic hypotension and depression. During the acuity interview on 08/28/23, Resident 6 was identified as self-administering all of his/her medications. This was confirmed by Staff 10 in an interview on 08/28/23.Review of the records revealed the last evaluation of Residents 6's ability to safely self-administer medications was completed on 11/08/22. In an interview on 08/29/23, Staff 3 acknowledged no evaluation had been completed more recently for the resident, and updated evaluation was done by Staff 3 during the survey.The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the resident's ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 on 08/30/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:The facility's ABST was reviewed and discussed with Staff 2 (LPN) and Staff 3 (RCC) on 08/30/23. They reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident.There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 2 and Staff 3 on 08/30/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly-hired direct care staff (#12) completed all pre-service training prior to beginning job responsibilities and providing care to residents. Findings include, but are not limited to:Staff training records were reviewed on 08/29/23. Staff 12 (MT) was hired on 07/28/23.a. There was no documented evidence Staff 12 completed pre-service orientation on the following topics:* Resident rights and values of CBC care;* Infectious Disease Prevention; and* The employee was not provided a written job description.b. The staffing schedule indicated Staff 12 had been scheduled to work in the milieu with residents during the month of August 2023. However, pre-service dementia training that was provided indicated Staff 12 had not completed the training until 08/29/23 - one day after survey requested the training records. Staff 12 failed to complete the training prior to providing care to residents.The need to ensure newly-hired direct care staff completed all required pre-service orientation and dementia care training prior to providing care to residents was discussed with Staff 1 (ED) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff completed all required pre-service orientation and training prior to beginning their job responsibilities. This is a repeat citation. Findings include, but are not limited to:Training records were reviewed on 11/30/23 and revealed the following:a. Staff 21 and Staff 22 (Resident Aides) hired on 11/15/23, lacked documented evidence of completing the following required elements for pre-service orientation prior to beginning job duties:* Resident rights and values of CBC care;* Abuse reporting requirements;* Infectious disease prevention;* Fire safety and emergency procedures; and * Written job description. b. In addition, Staff 21 lacked documented evidence of completing the following required pre-service dementia care training prior to beginning job duties: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms, including, but not limited to, reducing use of antipsychotics;* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and* Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach.The need to ensure documented evidence newly hired staff completed all required pre-service orientation and dementia care training prior to beginning job duties was reviewed with Staff 2 (LPN) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly-hired direct care staff (#12) had documentation of demonstrated competency in all required areas and had completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 08/29/23. Staff 12 (MT) was hired on 07/28/23.a. Staff 12 failed to have documented evidence of competency demonstrated within 30 days of hire in the following areas:* Changes associated with normal aging;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.b. Staff 12 had not completed First Aid and abdominal thrust training within 30 days of hire.The need to ensure all newly-hired staff had documentation of demonstrated competency in all required areas and had completed First aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 3 long-term staff (#9) whose training records were reviewed. Findings include, but are not limited to:Annual in-service training records were reviewed on 08/29/23. Staff 9 (MT), hired on 01/28/20, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on their hire date, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, and at least six hours of dementia care training, The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 (ED) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC). Findings include, but are not limited to:Review of fire and life safety records for January 2023 through August 2023 identified the following:a. Fire drill records lacked documentation of the following components:* Location of simulated fire origin;* Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* Number of occupants evacuated.b. Because the escape route not being documented, there was no evidence alternative exit routes were used during fire drills.The need to ensure fire drills were conducted and documented as required was reviewed with Staff 1 (ED) on 08/30/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C302, C305 and C370.
Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 302.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 302.

Refer to C 302

Based on observation and interview, it was determined the facility failed to maintain all interior areas and all equipment necessary for the health, safety, and comfort of the residents clean and in good repair. Findings include, but are not limited to:At the time of the survey the facility did not have a maintenance director. On 08/29/23 the building tour was completed with Staff 1 (ED) and Staff 5 (Housekeeping Manager). The following issues were identified:a. The first floor "Resident Laundry" room:* Two oxygen tanks were stored unsecured;* A broken commercial coffee maker stored on the floor;* Two walkers balanced on top of a counter; and* A broken washing machine filled with black, stagnant water.b. The first floor "Laundry" room:* Hopper room fire door was pinned behind a washing machine and could not close;* Laundry room wall next to the hopper room door had cove based separated from the wall causing the exposed sheetrock to crumble;* Multiple gashes and cracks in the center of the laundry room floor creating an uncleanable surface;* Floor fan with missing safety cover and exposed blade, ceiling vent fan missing safety cover, and* Two washing machines marked "broken" and "out of order".c. Second floor "Resident laundry room":* Two broken washing machines; and* One broken dryer.d. Third Floor "Resident laundry room":* One broken dryer.The need to maintain all equipment clean and in good repair was reviewed with Staff 1 on 08/30/23. She acknowledged the findings.

The findings of the kitchen inspection, conducted 01/26/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 01/26/23, conducted 03/30/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 01/26/23, conducted 06/02/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was stored appropriately, in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 01/26/23 at 12:30 pm, the facility kitchen was observed to need cleaning in the following areas: * Floor under and around stove, oven and counter with microwave had dirt and food debris; and* Wall behind microwave had dried splatters and streaks running down to the floor. Food items not stored appropriately: * Multiple items in the walk-in refrigerator were without dates/labels: Opened bags of cheese (no date), previously cooked hot dogs in reusable bag with white congealed fat and beginning to turn a whitish-green color (no date); leftover pasta with sauce and meat that had been covered with plastic wrap, but the wrap was split down the center with the food exposed (no date and type of meat not identified), red sauce not labeled or dated, multiple other items not labeled or dated; and* Reach-in refrigerator had multiple items not labeled or dated including sour cream and salsa.*The potentially spoiled food items were discarded by Staff 1.The areas described above were discussed with Staff 1 (Executive director) and Staff 2 (Dining Services Manager) on 01/26/23. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was stored appropriately in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The facility's kitchen was toured on 03/30/23 at 1:31 pm.a. An accumulation of food spills, splatters, loose food debris, dirt, dust and garbage was observed on, in and/or underneath the following:* Flooring surrounding microwave, two-door convection oven, griddle and stove;* Shelving under two-door convection oven;* Wire racks under two-door convection oven;* Griddle;* Stove; and* Stand-up refrigerator.b. Observation of the facility's walk-in refrigerator and pantry revealed the following foods were not covered, dated, and/or labeled appropriately:* Hard boiled eggs;* Milk products;* Cream based salad;* Large container of multiple types of cheese;* Large bag of shredded cheese;* Jelly sauce;* Individual servings of canned fruit;* Pasta;* Cereal;* Tortillas;* Rice;* Powdered sugar;* Nuts; and* Chocolate sprinkles.c. Multiple dented cans were visualized in the facility's dry storage area.During a kitchen tour with Staff 1 (ED) and Staff 2 (Dining Services Manager) on 03/30/23 at 3:00 pm, the importance of not using dented cans, the items that required cleaning, dating, labeling and covering were observed and discussed. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C240.