Courtyard Fountains Assisted Living Community

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 11/06/25 at 11:05 am, the facility kitchen was observed to need cleaning in the following areas:

* Top of dishwashing machine and temperature gauges - dried debris/splatters;

* Wall and caulking behind spray hose – black matter build up;

* Wall below dirty side of dishwashing area – significant brown/black matter build up;

* Commercial can opener blade – build up of dried food debris;

* Side of stove – drips/spills/splatter;

* Wall behind stove – drips/grease/spills; and

* Floor behind convection oven and stove – dried debris/spills/dried dark matter.

Improper frozen food storage:

Open food items not labeled and/or dated – included meat patties, hashbrowns, turkey patties and mixed vegetables.

Other concern included:

*Colored and white cutting boards – stained/worn/ heavily scored.

The areas of concern were observed and discussed with Staff 1 (Cook) and discussed with Staff 2 (Executive Director) on 11/06/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on observation 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 12/10/24 at 10:50am, the facility kitchen was observed to need cleaning in the following areas:

* Ceiling vent in dry storage area – heavy layer of dust buildup;

* Dishwashing pit – top, sides, front of dishwasher had drips/debris/spills, wall and caulking behind spray hose and underneath sink had buildup of black matter and handwashing sink had significant drips/debris in sink and wall behind it;

* Oven door and sides – drips/spills;

* Convection oven doors and sides – drips/spills; and

* Lids on garbage cans – significant buildup spills/food debris.

Staff were not wearing beard restraints.

The areas of concern were observed and discussed with Staff 1 (Director of Dining Services) and discussed with Staff 2 (Executive Director) on 12/10/24. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 10/05/23, 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 re-visit to the kitchen inspection of 10/05/23, conducted 12/14/23, 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 proper food storage, food service, employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The facility kitchen was toured on 10/05/23 at 11:00 am, observations of the assisted living kitchen, including food storage areas, food preparation, food service, and interviews with staff were conducted during the annual kitchen inspection. a. The following areas were in need of cleaning or repair:* The steam machine was inoperable;* The two door reach in refrigerator was inoperable;* The walk-in freezer located in the independent living community, which stored freezer items for the assisted living community was inoperable;* The temporary refrigerated trailer in the parking lot was defrosting and refreezing which created freezer burnt food and a build up of ice on the trailer/freezer floor; * The grease trap on the grill was full; and* The open shelves below the prep table and steam table had a buildup of food debris and spillage. b. Observations of food storage identified the following:* Stainless steel reach in freezer had food debris and spillage on the bottom shelves;* Stainless steel reach in freezer had frozen leftover food that was not labeled and dated;* The white side by side residential freezer/refrigerator lacked a thermometer to ensure the internal temperature was 41 degrees F. or below;* The white side by side residential freezer/refrigerator had food that was improperly shelved to allow air circulation and refrigerated foods were not covered, labeled and dated;* The facility was storing fresh cut watermelon and honeydew on ice in a camping cooler on the floor and the temperature of the fruit was above 41 degrees F.; and* There was a bag of open cooking oats stored underneath the food prep table.c. Observations of the food service and infection control practices identified the following:* Cold coleslaw on the tray line had a temperature above 41 degrees F.;* Staff 3 (Cook) was not using single use gloves properly and was using his gloved hands to plate food (sandwiches, hamburgers, fries, pickles, and fish fillets); * Staff 4 (Server) was not wearing gloves when plating fruit cups and soup from the tray line; and* Residents who chose to dine in their apartments were served on styrofoam, paper and plasticware.The need to ensure proper food storage, food service, employee infection control and to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules was discussed with Staff 1(Administrator) and Staff 2 (Director of Dining Services) on 10/05/23. They acknowledged the findings.

The findings of the re-licensure survey conducted 09/26/22 through 09/29/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 09/29/22, conducted 01/04/23 through 01/06/23, are documented in this report. The survey was conducted to determine compliance with 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 a day

The findings of the second re-visit to the re-licensure survey of 09/29/22, conducted 06/06/23 through 06/08/23, 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 interview and record review, it was determined the facility failed to immediately and thoroughly investigate an unwitnessed fall and injury of unknown cause to rule out potential abuse or neglect for 1 of 1 sampled resident (#6) who experienced an unwitnessed fall and an injury of unknown cause. Findings include, but are not limited to:Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.The resident's 12/01/22 through 01/03/23 progress notes and incident reports were reviewed and revealed the following:* 12/19/22 - "Res had an injury fall at around 12 am. Both MT and staff found Res on the hallway floor, with dried blood on [his/her] hairline, blood on [his/her] left eyebrow, and dried blood all inside and outside [his/her] mouth. Res was very confused saying [s/he] had to go to the bathroom."The corresponding investigation was initiated on 01/03/22 and did not clearly identify the fall as the direct cause of the injuries and did not rule out abuse or neglect. The incident was reported to the Seniors and People with Disabilities (SPD) office on 01/03/23.The need to ensure unwitnessed falls and injuries of unknown cause are promptly investigated to rule out abuse or neglect was discussed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. On 09/26/22, the main kitchen, where food was prepared for the assisted living residents, was observed to need cleaning and repair in the following areas:* Floors throughout the kitchen had black matter build-up and food debris in corners and around perimeter edges; * Grease build-up and food debris was observed on stainless steel tables, stoves and ovens, ice machine and underneath appliances;* Top of dish machine, walls, pipes, gauges, and flooring behind/underneath the dish machine and sink had an accumulation of black matter, dirt, and debris;* Ceiling vents had an accumulation of dirt and dust; * Walls throughout the kitchen had multiple spills and food splatters; * Janitor closet had scattered cleaning supplies on the floor and empty chemical containers in the sink; * Refrigerated holding cart was broken; and* Janitor closet ceiling tiles were missing with exposed insulation.2. On 09/27/22, the kitchen on the assisted living unit was observed to need cleaning and repair in the following areas:* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment, and around perimeter edges;* Walls and ceiling throughout the kitchen had multiple spills, smears and splatters; * Buildup of dust and dirt on ceiling exhaust vents;* Black soot stains on the walls and ceiling of the dish machine area;* Pipes behind multiple appliances had grease, dirt, and debris on them;* Food splatters and drips on the exterior and interior of the three stand-up refrigerators; * Refrigerators shelves had areas where rust had developed; * Interior and exterior of the ovens had a buildup of grease and burnt food debris; * Dish machine had dried food matter and splattered debris on the sides and top of the machine. The pipes and equipment below the dish machine and sinks had a buildup of splattered food, dust, and dirt; * Ceiling above the dish machine had a significant crack; * Ceiling tiles were missing in the dry food storage area; * Caulking in multiple areas throughout the kitchen, including the dish machine area were blackened and stained; * The flat top grill was broken; and* Cleaning supplies and equipment lacked proper storage. The need to ensure the kitchens were kept clean and in good repair and were following the Food Sanitation Rules, OAR 333-150-000 was discussed with Staff 1(Administrator) on 09/27/22. She acknowledged the findings

Based on observation and interview, it was determined the facility failed to ensure the kitchens were clean and in good repair in accordance with Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:1. The main campus kitchen, which provided food to the assisted living, was toured on 01/04/23 at 2:30 pm.a. Observation revealed an accumulation of grease, food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:* Shelving and counter of prep station;* Garbage cans throughout the kitchen;* Ovens;* Stove;* Shelving near steam table;* Push carts;* Baking racks;* Garbage disposal mechanism;* Pipes under warewasher;* Ceiling vents;* Walls throughout the kitchen;* Flooring and baseboards throughout the kitchen;* Floor drains throughout the kitchen; and* Doors throughout the kitchen.b. The following main kitchen items needed repair:* Drywall near stand up refrigerator; and* Corner guard near the warewasher.c. Garbage cans throughout the main kitchen were left uncovered when not in use.2. The assisted living kitchen was toured on 01/04/23 at 12:45 pm.a. Observation revealed an accumulation of grease, food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:* Coffee machine and coffee grinder;* Toaster;* Counters around drink station;* Ice machine;* Steam table;* Steam table shelving;* Oven;* Stove;* Pipes behind cooking appliances;* Clean dish shelving;* Push carts;* Baking racks;* Warewasher;* Pipes around warewasher;* Garbage disposal mechanism;* Ceiling vents;* Walls throughout the kitchen;* Flooring and baseboards throughout the kitchen;* Floor drains throughout the kitchen; and* Doors throughout the kitchen.b. The following assisted living kitchen items needed repair:* Floor drain underneath the steam table;* Baseboard near clean dish rack; and* Flooring underneath warewasher.c. Multiple potatoes in the assisted living kitchen prep area were sprouting.d. Garbage cans throughout the assisted living kitchen were left uncovered when not in use.e. The handwashing station in the assisted living kitchen did not have paper towels.The areas that required cleaning and repair were observed and discussed with Staff 1 (ED 2) on 01/04/23 at 11:22 am and 2:30 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure evaluations were performed and updated within the first 30 days of move in and were kept in the resident's files in an accessible location and available to staff for 5 of 5 sampled residents (#'s 1, 2, 3, 4 and 5). Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 07/2022.There was no documented evidence an evaluation of Resident 4 had been completed within the first 30 days of move in with updates and changes as appropriate. A review of progress notes from 07/29/22 through 08/29/22 showed Resident 4 experienced two falls and was experiencing some join pain. The evaluation had not been updated to reflect the changes that had occurred within the first 30 days.2. A review of the resident files that were accessible to staff on 09/26/22 showed resident evaluations were not available to staff for Residents # 1, 2, 3, 4 and 5.An interview with Staff 1 (Administrator) on 09/27/22 confirmed the evaluations were not available to staff and would be placed in resident charts.The need to ensure 30 day evaluations were completed with changes and updates as appropriate and evaluations were accessible to staff was discussed with Staff 1 on 09/28/22. She acknowledged the findings.
3. Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.The quarterly evaluation available to staff and the survey team was reviewed and updated on 07/01/22. An interview with Staff 1 (ED 2) on 01/05/23 confirmed the most recent quarterly evaluation for Resident 6 was completed 12/30/22; however, it was not in the resident's chart and was not available to all staff.The need to ensure quarterly evaluations were available to staff was discussed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings. 4. Resident 9 was admitted to the facility on 12/21/22 with diagnoses including dementia.a. Resident 9's clinical record was reviewed on 01/04/23 and 01/05/23. There was no documented evidence a move-in evaluation had been filed in the resident record; therefore, it was not accessible to staff.An interview with Staff 1 (ED 2) on 01/06/23 confirmed the move-in evaluation had been completed on 12/21/22; however, it was entered in the computer and the caregivers did not have access to the system. Staff 1 confirmed the resident's evaluation would be placed in the resident's chart immediately.b. Resident 9's move-in evaluation, dated 12/21/22, was reviewed and failed to address the following required components:* Customary routines, including sleeping, eating and bathing; * Visits to health practitioner(s), ER, hospital or NF in the past year; * Mental health issues, including history of treatment and effective non-drug interventions; and* Interests, hobbies, social and leisure activities.During an interview on 01/06/23 at 11:35 am, Staff 1 acknowledged the new move-in evaluation did not include all required elements. The need to ensure new move-in evaluations included all required components and all evaluations were available to staff was discussed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements to develop an initial service plan to meet the resident's needs and evaluations were performed at least quarterly and available to staff, for 4 of 4 sampled residents (#s 6, 7, 8 and 9) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 06/2021 with diagnoses including type 2 diabetes.Resident 7's most recent evaluation was completed on 05/12/22. There was no documented evidence a quarterly evaluation had been completed after 05/12/22.The need to ensure quarterly evaluations were completed was reviewed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 09/2021 with diagnosis including type 2 diabetes. Resident 8's most recent evaluation was completed on 07/13/22; however, the evaluation was not accessible to staff. There was no documented evidence a quarterly evaluation had been completed after 07/13/22.During an interview on 01/06/23, Staff 1 (ED 2), confirmed the facility was behind on the completion of evaluations and service plans. The need to ensure quarterly evaluations were completed was reviewed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

5. Resident 3 was admitted to the facility in 02/2020 with diagnoses including edema.Interviews with staff and review of the service plan dated 07/07/22, revealed the service plan was not reflective in the following area: * Two-person assistance with transfers. The need to ensure the resident's service plan was reflective of the care and services to be provided by staff was discussed with Staff 1 (Administrator) on 09/27/22. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, readily available to staff and provided clear direction regarding the delivery of services for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, and sleep apnea. Review of the resident's current service plan dated 07/01/22, observations and interviews conducted between 09/26/22 and 09/28/22, revealed Resident 1's service plan was not reflective and did not provide clear direction to staff in the following areas:* Diagnosis of peripheral artery disease and right knee hematoma;* Recent ER visits and discharge instructions;* Episode of an adverse effect of a medication and precautions;* BiPAP therapy and assistance needed with setup;* Mental health and well-being;* Level of assistance needed with ADLs; * Skin condition and treatments; and* Preferred use of resident's laundry detergent instead of facility detergent.During the acuity interview on 09/26/22, the facility stated service plans were kept in the residents' binders and accessible to the caregiving staff; however, there was no current service plan available in Resident 1's binder. The need to ensure service plans were reflective, readily available to staff, and provided clear direction regarding delivery of services was discussed with Staff 1 (Administrator) on 09/28/22. She acknowledged the findings.2. Resident 2 was admitted to the facility in 08/2021 with diagnoses including chronic venous insufficiency diabetes type 2, and suicidal ideation. Review of the most current service plan dated 07/13/22 and observations and interviews conducted between 09/26/22 and 09/28/22, identified Resident 2's service plan was not reflective and did not provide clear direction to staff in the following areas: * Preference for sleeping in a recliner chair;* Mental health status and interventions;* Level of assistance needed with ADLs; * Assistance with putting on and removing compression stockings and leg wraps;* Staff to hand wash compression garments;* Preferred shower schedule; * Toileting assistance and brief changes* Use of a power scooter for mobility;* Laundry service to include folding and putting away clothes; * Pain status, including pharmaceutical and non-pharmaceutical interventions; and* Current skin condition and treatment. Resident 2's current service plan was not accessible to the caregiving staff.The need to ensure service plans were reflective, readily available to staff, and provided clear direction regarding delivery of services was discussed with Staff 1 (Administrator) on 09/29/22. She acknowledged the findings.
3. Resident 4 was admitted to the facility in July 2022 with diagnoses including venous insufficiency and colon cancer. Review of the most current service plan, dated 07/31/22, was not available to staff in the resident chart, where service plans were kept. In addition to the review of the service plan, interviews conducted on 09/29/22 showed Resident 4's service plan was not reflective and did not provide clear direction to staff in the following areas: * fall interventions identified following two recent falls; and* joint pain requiring use of pain medication. 4. Resident 5 was admitted to the facility in March 2020 with diagnoses including aortic atherosclerosis. Review of the most current service plan, dated 06/30/22, was not available to staff in the resident chart, where service plans were kept. The service plan available to staff in the resident's chart was dated 12/2020. In addition to the review of the service plan, interviews conducted on 09/27/22 showed Resident 5's service plan was not reflective and did not provide clear direction to staff in the following areas: * falls and fall interventions;* use of compression stockings; * activity preferences and needs; and* emergency evacuation needs. The need to ensure service plans were readily available to staff, reflective of resident needs and provided clear direction regarding delivery of services was discussed with Staff 1 (Administrator) on 09/28/22. She acknowledged the findings.


3. Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.The resident's current service plan available to staff, dated 07/01/22, was reviewed and interviews were conducted between 01/05/23 and 01/06/23. Resident 6's service plan was not reflective and did not provide clear instruction to staff in the following areas: * Use and maintenance of hearing aids;* Fall interventions;* Use of a four wheeled walker; * Bathing frequency and preferences;* Frequency of evening safety checks; and* Level of assistance with transportation arrangements.The need to ensure quarterly service plans were readily available to staff, reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED 2) and Staff 17 (Health Wellness Director/RN) on 01/06/23 at 12:47 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of residents' needs, provided clear direction regarding the delivery of services and were accessible to staff for 3 of 3 sampled residents (#s 6, 7 and 8). This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 06/2021 with diagnoses including type 2 diabetes. a. There was no documented evidence the facility completed a quarterly service plan. The most recent service plan available to staff was completed 05/12/22. b. The 05/12/22 service plan was not reflective of the resident's current care needs and status and lacked clear instructions to staff in the following areas:* Preference to have meal service delivered to his/her room;* Wheelchair escorts to the dining room;* Bilateral edema and intervention to elevate legs;* Pressure wounds on coccyx and interventions to promote healing; and* Use of outside services including HH PT and HH RN services.During an interview on 01/05/23, Staff 1 (ED 2) confirmed the facility was behind on completing service plans. The need to ensure service plans were updated quarterly, accessible to staff and provided clear instruction to staff was discussed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 09/2021 with diagnoses including type 2 diabetes. The most recent service plan, dated 07/13/22 was not accessible to staff. The most recent service plan that was available to staff was completed on 03/15/22. There was no documented evidence the facility completed quarterly service plans for Resident 8. In an interview on 01/05/23, Staff 1 (ED 2), confirmed the facility was behind on completing service plans. The need to ensure service plans were updated quarterly and accessible to staff was discussed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 02/2020 with diagnoses including edema.A review of Resident 3's clinical record, chart notes and interviews with staff indicated the following: Monthly weights were recorded in the resident's chart: * 07/25/22 - 122.00 lbs;* 08/25/22 - 109.8 lbs; and* 09/25/22 - "Not able to stand for us to take her weight." Between 07/25/22 and 08/25/22 the recorded weights showed a severe weight loss of approximately 10% of his/her total body weight, or 12.2 lbs. in a one month period. This represented a severe weight loss in a one month period which required referral to the facility RN. No reweigh was done to verify the weight loss.There was no documented evidence the facility had evaluated the weight loss, monitored for further weight loss, developed and implemented interventions for weight loss, or referred to the RN for a significant change of condition. During survey, on 09/27/22, Resident 3's current weight was requested and was reported as 119.2 lbs. During a discussion with Staff 1 (Administrator), it was determined the weight taken on 08/25/22 was an error.The need to ensure changes of condition were evaluated, actions or interventions developed and referred to the RN when a resident experienced a significant change of condition was discussed with Staff 1 on 09/27/22. She acknowledged the findings.
4. Resident 1 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease and osteoarthritis. The resident's 08/01/22 through 09/13/22 progress notes and hospital visit summaries were reviewed. The resident experienced multiple short term changes of condition without documented monitoring until resolution and/or resident specific directions to staff in the following areas:* Adverse medication reaction and ER visit; * Bruising, swelling and rash on right leg; * Hematoma on right leg and ER visit; * Mental Health; and * Increased pain.The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (Administrator) on 09/29/22. She acknowledged the findings. 5. Resident 2 was admitted to the facility in 08/2021 with diagnoses including type 2 diabetes, high blood pressure and major depressive disorder. The resident's 07/25/22 through 09/25/22 progress notes, and physician communications were reviewed. The resident experienced multiple short term changes of condition without documented monitoring until resolution and/or resident specific directions to staff in the following areas:* Mental health; * Missed medications; * Refusal of medications; and * Skin rash.The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (Administrator) on 09/29/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents who experienced short term changes of condition had resident-specific instructions or interventions developed, the conditions were monitored at least weekly to resolution and that the changes were communicated to the facility nurse to determine if further assessment was needed for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) who experienced changes of condition. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in March 2020 and had diagnoses including a sacral wound and chronic heart failure. Interviews with the resident and staff, a review of the service plan dated 06/30/22 and progress notes dated 07/10/22 through 09/26/22 were reviewed. a. The resident experienced a sacral wound requiring treatment from facility staff and outside providers, identified on 07/16/22. While the record reflected ongoing treatment and monitoring of the wound through 08/25/22, the record lacked documented evidence the wound was resolved. b. Progress notes, dated 07/27/22, documented the resident's weight of 121 pounds. This represented a weight loss of nine pounds since the previous weight of 130.6 pounds was obtained on 06/20/22. There was no documented evidence the weight change was referred to the facility RN for assessment, monitored or a determination made if interventions were needed. The resident's weight remained stable at 128 pounds in August and 125.8 pounds in September.2. Resident 4 was admitted to the facility in July 2022 with diagnoses including colon cancer and venous insufficiency.A review of the clinical record showed the resident experienced two falls between 08/11/22 and 08/16/22. The record lacked documented evidence interventions were identified and communicated to staff to address the falls.The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were developed was discussed with Staff 1(Administrator) and Staff 2 (LPN/RCC) on 09/28/22. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to evaluate and determine actions or interventions needed, communicate resident specific interventions and instructions to staff, monitor changes of condition with weekly progress noted in the resident's record until resolved and refer to the facility RN, as appropriate, for 3 of 3 sampled residents (#s 6, 7 and 8) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease and falls.Resident 6's progress and electronic MAR notes, dated 12/01/22 through 01/03/23, were reviewed and revealed multiple short-term changes of condition.a. The following short-term change of condition lacked documented evidence it was evaluated to determine if any actions and/or interventions were needed:* 12/19/22 - Fall with head laceration.There was no documented evidence the facility staff reviewed service plan fall interventions for effectiveness. b. The following short-term changes of condition lacked documentation of monitoring, at least weekly, through resolution:* 12/01/22 - Increased confusion and disorientation; * 12/02/22 - Missed dose of amlodipine 5 mg and atorvastatin 10 mg;* 12/19/22 - Laceration to head;* 12/19/22 - Multiple missed medications; and* 12/20/22 - Sleeping on floor, increased confusion and not wearing clothing.There was no documented evidence the facility staff referred the continued increased confusion and disorientation to the facility RN.The need to ensure the facility evaluated the resident, determined actions or interventions needed, communicated resident specific interventions and instructions to staff, monitored changes of conditions with, at least, weekly progress noted in the resident's record until resolved and referred to the facility RN was discussed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings, and no additional information was provided.Refer to C 280, example 1 b

2. Resident 7 was admitted to the facility in 06/2021 with diagnoses including type 2 diabetes. During the entrance conference interview the resident was identified with a pressure wound. The resident's 12/06/22 through 01/03/23 progress notes, 11/28/22 through 01/03/23 MARs, and outside provider notes were reviewed. The resident experienced the following change of condition:* 12/17/22 progress note identified a wound on coccyx. There was no documented evidence the facility evaluated the wound, determined action or intervention needed, communicated resident specific interventions and instructions to staff, monitored the change of condition with weekly progress noted in the resident's record and referred to the facility RN, as appropriate.During an interview on 01/06/23, Staff 17 (Health and Wellness Director/RN) reported she had met with the HH provider and the resident on 01/05/23. Staff 17 was able to observe and assess the resident's wound. The wound was healing and would likely be resolved in the next couple weeks. The need to ensure the facility evaluated the resident's wound, determined action or intervention needed, communicated resident specific interventions and instructions to staff, monitored the wound with weekly progress noted in the resident's record and referred to the facility RN was discussed with Staff 1 (ED 2) and Staff 17 on 01/06/23. They acknowledged the findings. 3. Resident 8 was admitted to the facility in 09/2021 with diagnoses including type 2 diabetes. The resident's 12/03/22 through 01/06/23 progress notes and 11/28/22 through 01/03/23 MARs were reviewed. The resident experienced the following changes of condition:* 11/29/22 and 11/30/22 - hypoglycemic event (CBG values dropped to 54 and 47, respectively);* 12/03/22 - head injury wound;* 12/28/22 - abdominal rash; and* 01/01/23 and 01/02/23 - missed insulin medication. There was no documented evidence the facility evaluated, determined action or intervention needed, communicated resident specific interventions and instructions to staff, monitored the change of condition with weekly progress noted in the resident's record until resolved and referred to the facility RN, as appropriate.The need to ensure the facility evaluated, determined action or intervention needed, communicated resident specific interventions and instructions to staff, monitored the changes of condition with weekly progress noted in the resident's record until resolved and referred to the facility RN, as appropriate was discussed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

Based on interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition for 1 of 2 sampled residents (# 3) who experienced a significant change of condition. Findings include, but are not limited to:Resident 3 was admitted to the facility in 02/2020 with diagnoses including edema.Review of the resident's clinical records indicated that on 09/20/22, Resident 3 was identified by Staff 8 (MT/CG) to be on alert "for an open pressure sore. The skin on [his/her] sore is rubbing off like a blister."The development of the open area constituted a significant change of condition.There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (Administrator) on 09/27/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 2 of 3 sampled residents (#s 6 and 7) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.a. Resident 6's weight records were reviewed and revealed the following:* 11/10/22 - 101 pounds; and* 12/20/22 - 107 pounds.From 11/10/22 to 12/20/22, Resident 6 had a weight gain of 6 pounds or 5.61% of his/her body weight in one month. This weight gain indicated a significant change of condition and required an RN assessment.On 01/06/23, Staff 17 (Health and Wellness Director/RN) confirmed there was no nursing assessment for the weight gain.b. During the acuity interview on 01/04/23, Resident 6 was identified as having had a significant decline in cognitive function affecting his/her memory. Resident 6's progress notes, dated 12/01/22 through 01/03/23, were reviewed. Resident's cognitive decline and increased confusion was first identified by staff in the progress notes on 12/01/22. The resident demonstrated continued confusion through 12/20/22. This represented a significant change of condition for the resident.On 01/06/22, Staff 17 confirmed she completed an RN assessment on 12/28/22 (28 days following the change of condition). There was no documented evidence the RN had assessed the cognitive decline of the resident prior to 12/28/22.The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (ED 2) and Staff 17 on 01/06/23. They acknowledged the findings, and no additional documentation was provided.
2. Resident 7 was admitted to the facility in 06/2021 with diagnoses including edema, neuropathy and type 2 diabetes. During the entrance conference interview on 01/04/23, it was reported the resident had a pressure wound. A review of the resident's clinical records indicated on 12/17/22 caregivers identified a wound on the resident's coccyx. The open wound constituted a significant change of condition.There was no documented evidence the RN had assessed the wound, documented findings as a result of the assessment or developed interventions related to the resident's significant change of condition.The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.Refer to C 270, example 2

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 1 of 1 sampled resident (#2) reviewed for the delegation of diabetic injections by unlicensed staff. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.Resident 2 was identified as having insulin-dependent diabetes and was administered insulin injections by non-licensed staff.On 09/27/22, the facility's RN delegation records were requested and revealed the following:* The previous facility delegating RN left the position on 09/24/22; and * There was no transfer of delegation documentation completed. In an interview with Staff 1 (Administrator), she stated the previous facility RN was no longer employed and a regional RN would be helping the facility for the interim; however, there was no transfer of delegation done and no MT staff had current delegations in place to administer insulin injections in the facility. Staff 1 made the decision to have Staff 2 (LPN) be the only staff to administer insulin until all MT (unlicensed) staff training and documentation of the delegating process was completed. The need to ensure RN delegation was completed and maintained as required by rule was discussed with Staff 1, Staff 2, and Staff 4 (Director of Regional Operations) on 09/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47 for 1 of 1 sampled resident (#8) reviewed for the delegation of diabetic injections by unlicensed staff. This is a repeat citation. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.Resident 8 was identified as having insulin-dependent diabetes and was administered insulin injections by non-licensed staff.On 01/04/22, the facility's RN delegation records were requested and revealed the following:a. Re-delegation was not completed within 60 days of the initial delegation for the following unlicensed staff:* Staff 6 (Med Aide) due 12/04/22;* Staff 8 (Med Aide) due 12/04/22; and* Staff 22 (Med Aide) due 12/12/22.b. Initial delegation was not completed for Staff 19 (Med Aide). A review of Resident 8's 11/28/22 through 01/03/23 MARs documented, Staff 6, 8, 19 and 22 administered insulin injections on multiple occasions with out being re-delegated or delegated to perform the task. During an interview on 01/04/23 at 3:29 pm, Staff 1 (ED 2), made the decision to have Staff 2 (RCC/LPN) and Staff 17 (Health and Wellness Director/RN) be the only staff to administer insulin until all MTs (unlicensed) staff demonstrated competency and documentation of the delegation process was completed. On 01/05/23, the survey team received updated MARs which verified Staff 2 and Staff 17 had administered insulin to Resident 8 and three other non-sampled residents who were administered insulin injections.The need to ensure RN delegation was completed and maintained, as required by rule, was discussed with Staff 1, Staff 2 and Staff 17 on 01/06/23. They acknowledged the findings.

Based on interview, it was determined the facility failed to ensure it had a trained Infection Control Specialist as prescribed in OAR 333-019-1011. Findings include, but are not limited to:In an interview on 09/26/22, Staff 1 (Administrator) reported the facility did not currently have a designated Infection Control Specialist who had completed the required specialized, Department-approved training in infection control prevention and control protocols.The need to ensure the facility had a designated Infection Control Specialist who had completed all required training was reviewed with Staff 1 on 09/27/22. She acknowledged the findings and stated there will be two staff taking the training to become designated infection control specialists.
Based on observation and interview, it was determined the facility failed to ensure they consistently complied with masking requirements as prescribed in OAR 333-019-1011. This is a repeat citation. Findings include, but are not limited to:Per Oregon Administrative Rule 333-019-1011 (6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly (exposing their nose, or nose and mouth).On 01/04/23 at 12:45 pm, Staff 23 (Server) was observed wearing a face mask positioned below the nose and mouth while in the facility kitchen preparing lunch for the residents. On 01/04/23 at 2:42 pm, two members of the main kitchen staff were observed without wearing face masks while performing cooking and cleaning duties in the main facility's kitchen. On 01/05/23 at 1:00 pm and 01/06/23 at 8:35 am, Staff 2 (RCC/LPN) was observed not wearing a mask in his office with the door open. His office was near the unit of a resident who actively had Covid. On 01/06/23 at 8:30 am, a housekeeper was observed not wearing a mask while in a resident's room with the resident. The resident's unit was open to the hallway.On 01/06/23 at 8:45 am, a housekeeper was observed with a face mask below the chin while in the residents' corridor.The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (ED 2), Staff 2 and Staff 17 (Health and Wellness Director/RN) during the exit interview on 01/06/23. They acknowledged the findings.

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. Findings include, but are not limited to:a. Staff 19's (Med Aide) training records identified the staff failed to have documented competency with medication and treatment administration. Staff 19 had administered medications for Resident 7 and 8 on multiple occasions from 11/28/22 through 01/03/23. b. There were no current delegation records for any unlicensed staff who administered insulin injections to Resident 8 and three unsampled residents.c. On 11/29/22 and 11/30/22, Resident 8 had a hypoglycemic event in which his/her CBG values dropped to 54 and 47, respectively. The facility staff failed to refer to the LN or the RN to administer the resident's as needed Glucagon hypoglycemic kit. d. During the first revisit to the re-licensure survey of 09/29/22, conducted 01/04/23 through 01/06/23, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:* C 282: Systems: RN Delegation;* C 303: Systems: Medication and Treatment Orders;* C 305: Systems: Resident Right to Refuse; * C 310: Systems: Medication Administration; and* C 372: Training within 30 days: Medication training for Direct Care StaffThe above information was discussed with Staff 1 (ED 2), Staff 2 (RCC/LPN) and Staff 17 (Health and Wellness Director/RN) during the exit interview on 01/06/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 02/2020.A review of the 09/01/22 through 09/26/22 MAR and current physician's orders revealed the following medications were not administered as prescribed:* Preservision Areds (supplement);* Calcium plus D;* Vitamin D3;* Multivitamin with minerals; and* Levothyroxine (hypothyroidism).The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) on 09/27/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure orders were administered as prescribed and signed physician orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 3 of 4 sampled residents (#s 2, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 08/2021 with diagnoses including type 2 diabetes, peripheral venous insufficiency and urinary urgency. a. Review of the resident's 09/01/22 through 09/26/22 MAR identified 26 occasions when the following medications were not administered as prescribed because the medication was not available:* Rosuvastatin 40 mg tablet daily (for high cholesterol); * Tamsulosin 0.4 mg capsule daily (for enlarged prostate); and* Vitamin D3 1000IU tablet daily (supplement).b. The current orders in the resident's record, dated 09/03/22, were not signed by a physician.Interview on 09/27/22, Staff 2 (RCC/LPN) confirmed the resident had not received the above three medications for 26 days and that the facility was waiting for them to be delivered. On 09/29/22, Staff 2 received confirmation from the pharmacy that Resident 2's medications would be arriving later that day. The need to ensure written, signed physician orders were documented in the resident's facility record and medication orders were followed was discussed with Staff 1 (Administrator) on 09/29/22. She acknowledged the findings.
3. Resident 4 was admitted to the facility in July 2022 with diagnoses including heart disease and venous insufficiency.A review of the 9/01/22 through 09/26/22 MAR and current physician's orders revealed the following medications were not administered as prescribed due to "medications not available, awaiting delivery from pharmacy":* Omeprazole 20 mg every morning (to treat heartburn) was not administered on 19 of 26 occassions between 09/01/22 through 09/26/22; and* Eliquis 5 mg to be taken twice daily (to prevent blood clots) was not administered on 15 of 18 occassions between 09/01/22 and 09/26/22.The need to ensure physician's orders were carried out as prescribed was reviewed with Staff 1 (Administrator) on 09/28/22. She acknowledged the findings and stated an inservice with MT's would be completed on 09/28/22.


Based on observation, interview and record review, it was determined the facility failed to ensure orders were administered as prescribed for 3 of 3 sampled residents (#s 6, 7 and 8) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility with diagnoses including Alzheimer's disease.Resident 6's MARs, dated 12/01/22 through 01/03/23 and corresponding electronic MAR notes were reviewed. The following medications were documented as not administered on the following occasions, because the medication was not in the facility: * 12/02/22 - Amlodipine 5 mg (for cardiac maintenance);* 12/02/22 - Atorvastatin 10 mg (for hyperlipidemia);* 12/05/22 - Aspirin EC 325 mg (for cardiac maintenance);* 12/05/22 - Calcium+D3 600 mg/800U (supplement);* 12/05/22 - Centrum Silver Adults 50+ (supplement);* 12/05/22 - Omega 3 Ethyl Esters 1g (supplement);* 12/05/22 - Vitamin D3 2000 IU (supplement);* 12/14/22 - Pantoprazole 20 mg (gastroesophageal reflux disease); and* 12/25/22 - Melatonin (for insomnia).On 01/05/23 at 10:22 am, the surveyor and Staff 6 (Med Aide/CG) observed and checked the MARs and medication supply. Staff 6 confirmed the above medications had not been administered. The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 06/2021 with diagnoses including type 2 diabetes. A review of the current signed physician orders dated 12/09/22 and the 11/28/22 through 01/03/23 MARs noted the following medication was not administered as prescribed:* Sertraline 50 mg tablet, "give two tablets by mouth every day" for depression. Observation of the medication card (bubble pack) with Staff 1 (ED 2) and Staff 6 (Med Aide/CG) on 01/06/23, noted the resident was administered one 50 mg sertraline tablet per day, instead of the two prescribed. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1, Staff 2 (RCC/LPN) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings. 3. Resident 8 was admitted to the facility in 09/2021 with diagnoses including insulin dependent type 2 diabetes. A review of the current signed physician orders, dated 11/15/22, and the 11/28/22 through 01/03/23 MARs noted the following medications were not carried out as prescribed: a. Glipizide 5 mg tablet, hold if CBG was under 60. If CBG was 80 or below, give four ounces of orange juice and recheck in 15 minutes. * Glipizide was not held on 11/29/22 and 11/30/22 when Resident 8's CBG was 54 and 47, respectively; and* Parameters and instructions to give four ounces of orange juice and recheck in 15 minutes when CBG was 80 or below was not followed on 11/29/22, 11/30/22, 12/27/22, 12/30/22 and 01/03/23. b. PRN Glucagon 1 mg (hypoglycemic kit), give when CBG was below 60. * PRN Glucagon was not administered on 11/29/22 and 11/30/22 when Resident 8's CBG was 54 and 47, respectively; c. On 12/10/22, Humalog lacked initials on the MAR which indicated the order was not followed; d. On 12/14/22, Lantus Solostar lacked initials on the MAR which indicated the order was not followed; ande. During the month of 12/2022, an order to check the resident's CBG value three times per day was not completed on 12 occasions.The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED 2), Staff 2 (RCC/LPN) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 2 sampled residents (# 2) who had documented medication refusals. Findings include, but are not limited to:Resident 2 was admitted to the facility in 03/2022 with diagnoses including type 2 diabetes. Resident 2's 09/01/22 through 09/26/22 MAR and progress notes dated 07/23/22 through 09/25/22 were reviewed. The following refusals were identified: * 07/23/22 - refused insulin;* 08/08/22 - refused all medications; and* 09/15/22 - refused all medications.There was no documented evidence the facility notified Resident 2's physician of the medication refusals.The requirement to notify the physician when a resident refused to consent to orders was reviewed with Staff 1 (Administrator) on 09/29/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 2 sampled residents (#7) who had documented medication refusals. This is a repeat citation. Findings include, but are not limited to:Resident 7 was admitted to the facility in 06/2021 with diagnoses including type 2 diabetes. Resident 7's 12/01/22 through 12/31/22 MAR noted the following medication refusals:* 12/14/22 all medications at the 10:00 am medication pass.There was no documented evidence the facility notified Resident 7's physician of the medication refusals.The requirement to notify the physician when a resident refused consent to orders was reviewed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2021 with diagnoses including spinal stenosis and dermatitis. The resident's 09/01/22 through 09/26/22 MAR was reviewed, and the following was identified: * Multiple medications lacked reasons for use; and * PRN medications lacked resident specific parameters and instructions. Interviews conducted during the survey with the resident and staff revealed MT staff were applying PRN lidocaine patches daily to the resident's lower back and applying PRN miconazole powder; however, administration of these treatments was not documented on the MAR. The need to ensure an accurate MAR was kept of all medications administered by the facility was discussed with Staff 1 (Administrator) on 09/29/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, included reasons for use and medication specific instructions for 2 of 4 sampled residents (#s 2 and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 4's 09/01/22 through 09/26/22 MAR was reviewed and showed the following:* multiple routine medications were missing the reasons for use; and* a routine blood pressure medication was missing instructions to staff on when to contact the provider or the nurse when blood pressures were high or low. The need to ensure an accurate MAR was reviewed with Staff 1 (Administrator) and Staff 4 (Director of Regional Operations) on 09/28/22. They acknowledged the findings.
3. Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.Resident 6's MAR, dated 12/01/22 through 01/03/23, were reviewed.The following PRN medication lacked specific instructions to staff:* Loperamide 2 mg - take one capsule by mouth three times daily as needed for diarrhea.On 01/05/23, Staff 6 (Med Aide / CG) confirmed there were no additional instructions to staff, parameters or information about when to contact the RN or PCP listed in the electronic MAR.The need to ensure medications on the MAR included resident-specific instructions for PRN medications was discussed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, included medication specific instructions including significant side effects and parameters for as needed medications for 3 of 3 sampled residents (#s 6, 7 and 8) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 06/2021 with diagnoses including type 2 diabetes.A review of Resident 7's 11/28/22 through 01/03/23 MARs identified the following inaccuracies:* Multiple routine medications were missing medication specific instructions including significant side effects and when to notify the nurse or prescriber; and* As needed (PRN) bisacodyl suppository, PRN docusate sodium capsule, PRN Milk of Magnesium and PRN polyethylene glycol powder (each used for constipation), lacked parameters and instructions regarding the sequence of use for each medication and when to notify the nurse or prescriber, if the condition persisted. On 01/05/23, surveyor and Staff 6 (Med Aide/CG) reviewed the electronic MAR (EMAR) for additional instructions, including parameters for unlicensed staff to follow. Staff 6 confirmed there were no additional instructions for any of the medications for Resident 7 or parameters for the bowel medications in the EMAR. The need to ensure MARs included medication specific instructions and parameters for multiple PRN medications was reviewed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.2. Resident 8 was admitted to the facility in 09/2021 with diagnoses including type 2 diabetes. A review of Resident 8's 11/28/22 through 01/03/23 MARs identified the following inaccuracies:* Multiple routine medications were missing medication specific instructions including significant side effects and when to notify the nurse or prescriber; * As needed (PRN) Glucagon lacked physician ordered parameter to administer when CBG was 60 or below;* PRN nystatin lacked clear medication specific instructions on where to apply the medication;* PRN Tylenol, PRN diclofenac sodium tablet, and PRN oxycodone tablet (each used for pain), lacked parameters and instructions regarding the sequence of use for each medication and when to notify the nurse or prescriber.The need to ensure MARs included medication specific instructions and parameters for multiple PRN medications was reviewed with Staff 1 (ED 2) and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 2 of 2 newly-hired staff (#s 12 and 14) and infectious disease prevention training was completed for 2 of 2 veteran staff (#s 7 and 13). Findings include, but are not limited to: On 09/27/22 training records were reviewed with Staff 1 (Administrator). The following deficiencies were identified: a. Staff 12 (CG) hired on 05/06/22 and Staff 14 (Sales/Marketing) hired on 06/06/22, had not completed pre-service training in the following areas prior to beginning their job responsibilities: *Resident rights and values of CBC care; *Abuse reporting requirements;*Infectious disease prevention training was not completed by July 1, 2022; and *Fire safety and emergency procedures.b. Staff 7 (MT/CG) hired on 06/14/16 and Staff 13 (Dietary Aide) hired on 03/14/19 had not completed infectious disease prevention training by July 1, 2022.The need to ensure that all newly hired staff completed pre-service orientation training prior to beginning their job responsibilities, and veteran staff completed infectious disease prevention was discussed with Staff 1 on 09/27/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation and pre-service dementia training was completed and documented and failed to ensure the infectious disease training curriculum was approved by the Department for 4 of 4 newly-hired staff (#s 18, 19, 20 and 21). This is a repeat citation. Findings include, but are not limited to: On 01/04/23 training records were reviewed with Staff 1 (ED 2). The following deficiencies were identified: a. Staff 18 (Med Aide) hired on 12/06/22, Staff 19 (Med Aide) hired on 10/27/22, Staff 20 (CG) hired on 10/19/22 and Staff 21 (CG) hired on 09/30/22 had not completed pre-service orientation training in the following areas prior to beginning their job responsibilities: * Infectious disease prevention training; and* Written job description for Staff 19.b. Staff 19 and 21 lacked documented evidence pre-service dementia training was completed prior to providing direct care to residents. The need to ensure that all newly hired staff completed pre-service orientation training prior to beginning their job responsibilities and pre-service dementia training prior to providing direct care to residents was discussed with Staff 1 on 01/04/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired, direct care staff (# 12) had demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 09/27/22. There was no documented evidence Staff 12 (CG), hired 05/06/22, demonstrated competency in all assigned job duties within 30 days of hire in the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLS;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* First Aid/Abdominal Thrust.The need to ensure newly-hired, direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) on 09/27/22. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired, direct care staff (#s 19, 20 and 21) had 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 01/04/23 at 2:12 pm with Staff 1 (ED 2). There was no documented evidence Staff 19 (Med Aide) hired on 10/27/22, Staff 20 (CG) hired on 10/19/22, and Staff 21 (CG) hired on 09/30/22, demonstrated competency in all assigned job duties within 30 days of hire in the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation;* Other duties as applicable (Medication and treatment administration); and * First Aid/Abdominal Thrust.The need to ensure newly-hired, direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledge the findings.

Based on interview and record review, it was determined the facility failed to have documented evidence of 12 hours of annual in-service training including six hours related to the care of residents with dementia, for 3 of 3 long-term staff (#s 7, 9 and 10) whose training records were reviewed. Findings include, but are not limited to:The annual in-service training records were reviewed on 09/27/22.Staff 7 (MT/CG), hired 04/14/16, and Staff 9 (MT/CG), hired 11/06/21 and Staff 10 (CG), hired 12/10/14, failed to have documented evidence of completing 12 hours of hours of annual in-service training, including six hours related to dementia care. The need to ensure staff completed 12 hours of on-going training, including six hours related to dementia, was reviewed with Staff 1 (Administrator) on 09/27/22. She acknowledged the findings.

Based on interview, it was determined the facility failed to ensure fire drills and staff training on fire and life safety were being conducted on alternating months. Findings include, but are not limited to:In an interview on 09/27/22, Staff 1 (Administrator) stated there were no fire drill or related staff training documents available and that previous staff had confirmed fire drills had not been conducted in the past several months.The need to ensure fire drills and staff training were conducted on alternating months was reviewed with Staff 1 (Administrator) on 09/28/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. This is a repeat citation. Findings include, but are not limited to:Fire and life safety records for 12/2022 lacked the following required Oregon Fire Code (OFC) fire drill components: * Escape route used;* Problems encountered, comments related to residents who resisted or failed to participate in the drills and what changes were made to ensure the evacuation standard was met; and* Staff members on duty and participating.During an interview on 01/04/23, Staff 1 (ED 2), confirmed the facility staff had not evacuated or relocated residents to a point of safety and was unable to provided documentation the facility met the evacuation standard. Staff 1 requested and was provided a copy of the current Community Based Care Fire and Life Safety Review form.The need to ensure the facility documented all required fire drill components required by the OFC and were evacuating or relocating residents to the point of safety was discussed with Staff 1 and Staff 17 (Health and Wellness Director/RN) on 01/06/23. They acknowledged the findings.

Based on interview, it was determined the facility failed to provide fire safety instruction for residents within 24 hours of admission and at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:In an interview on 09/27/22 with Staff 1 (Administrator), it was determined the facility lacked documented evidence residents were being instructed on general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside of the building in the event of an actual fire within 24 hours of admission and at least annually. The need to provide and document annual fire safety instruction for residents and within 24 hours of admission, was reviewed with Staff 1 on 09/27/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety procedures for residents, at least annually, in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:Fire and life safety records were reviewed with Staff 1 (ED 2) on 01/04/23. There was no documented evidence a written record of fire safety training for residents, including content of the training sessions and the residents who were in attendance was completed, at least annually. During an interview with Staff 1 on 01/04/23, the requirement to conduct fire and life safety training for residents, at least annually was discussed. Staff 1 confirmed the facility didn't have a process to ensure a written record of fire safety training for residents was completed and documented, at least annually.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240, C 252, C 260, C 270, C 280, C 282, C 295, C 303, C 305, C 310, C 370, C 372, C 420 and C 422.

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Failure to follow infection control guidelines to prevent the spread of COVID-19 put residents at serious risk. Findings include, but are not limited to:During the onsite visit on 04/22/2021, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:*Compliance Specialist (CS) was not screened in until after s/he had been at the facility for over an hour. Screening was then only done at CS insistence to see what happens when screening is done. *Multiple staff members (Staff #3-6, Staff #9) were observed either not wearing eye protection or had their eye protection pushed up to the top of their head. *Staff #7 was observed removing his/her eye protection (face shield) and putting the face shield directly into a PPE storage cube. There was no disinfecting/sanitation performed and it was not placed inside of a plastic bag. *Staff #5 was observed entering the building and proceeded to leave the reception/screening area prior to receiving a face shield. *Staff were observed not hand washing or using ABHS before or after assisting residents. *There was no disinfection station outside of the room where a COVID positive resident resides. *There were numerous unpackaged face shields observed sitting on shelves or carts throughout the facility. *PPE storage area had numerous face shields sitting on shelves, outside their storage bags. During separate interviews with Staff #1-9, this CS was given numerous and often contradicting answers regarding PPE usage and storage, screening, and sanitation and disinfectant usage/practices. *Staff #2 stated a face shield should be thrown away after assisting a COVID positive resident. There were no face shields, new or discarded, observed by this CS outside the COVID positive resident's room. *Staff #4 stated they wear the same face shield all day. S/he stated the face shield is sanitized after caring for a COVID positive resident. *Staff #4 stated s/he used Clorox wipe to disinfect a face shield, and wipes over and over until it seems dry again. *Staff #8 stated s/he used a disinfectant spray to clean face shields, wiping it dry immediately after spraying. Review of facility Check Off List for Sanitizing revealed the facility was inconsistently sanitizing the facility common areas. The above findings were discussed with Staff #1 and Staff #2, who were in agreement.