Bonaventure of Salem Assisted Living

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

Observation of the facility kitchen was completed 07/14/25 from 10:20 am through 11:45 am and the following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease and/or black matter was visible on or underneath the following:

* Juice machine
* Hand washing sink edges/corners
* Floors under equipment/counters in beverage service area
* Interior of ice machine
* Edges of flooring in dry storage
* Flooring and walls under and around dish machine area
* Kitchen drains
* Floors under steam table
* Flooring under and in between large equipment and behind oven/range/grill
* Stainless steel shelving holding clean dishes by service line
* Knobs of ranges/ovens/grill and steam table
* Flooring in under and around dishwashing area
* Walk in freezer floor
* Can rack in dry storage
* Metal racks storing clean dishes
* Stainless steal service area on tray line

b. The following areas were in need of repair:

* Small gap in ceiling by sprinkler

c. Multiple food items found in walk in cooler without proper labels and/or prepared/opened or use by dates as required. Multiple food packages found open in walk in exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler. Multiple items found in walk in cooler that were past 7 days from prepared date and should have been discarded.


d. Facility did not have test strips to verify/validate surface sanitizing chemicals were at appropriate levels for sanitizing as required. Staff 2 (Dining Services Manger) was not aware of the type of chemical dispensing from the wall for 3 compartment sink and surface sanitizer buckets needed different test strips. The chemical contained lactic acid and the facility had quaternary ammonia strips. The facility did not have a system to regularly test the concentration of that solution to ensure at appropriate sanitizing levels.

e. Multiple kitchen staff observed without hair or beard/facial hair restraints.

f. Reach in cooler for beverages including items that were potentially hazardous/protein rich did not have a thermometer to ensure items were stored at appropriate temperatures for cold holding. Staff 2 verified they could not locate a thermometer.

At 11:30 am the above items were reviewed with Staff 2 who acknowledged areas needing correction.
On 07/15/25 at 2:00 pm, identified areas were reviewed with Staff 1 (Executive Director) and Staff 2 who acknowledged the areas of concern.

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 maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include but are not limited to:

Observation of the facility main kitchen was completed on 09/24/25. The following was identified:

An accumulation of food spills, splatters, loose food debris, dirt, dust, grease, and/or black residue was observed on and/or underneath the following:

* Hand washing sink edges/corners;
* Floors under equipment/counters in beverage service areas;
* Edges of flooring in dry storage;
* Flooring and walls under and around dish machine area;
* Floor drains;
* Floors under steam table;
* Flooring under and in between large equipment and behind oven/range/grill;
* Stainless steel shelving holding clean dishes by service line;
* Knobs of ranges/ovens/grill and steam table;
* Flooring in, under, and around dishwashing area;
* Metal racks storing clean dishes;
* Stainless steel service area on tray line;
* Interior of drawers; and
* Wall behind trash can.

The need to ensure the kitchen was kept clean was discussed with Staff 1 (Executive Director) and Staff 2 (Dining Services Manager) on 09/24/25. They acknowledged the findings.

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

Refer to C240.

The findings of the kitchen inspection, conducted 05/08/24 through 05/09/24, 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 revisit to the kitchen inspection of 05/08/24, conducted on 07/18/24, are documented in this report. The facility was determined to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, in a sanitary manner or have a qualified person in charge in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility ALF kitchen was completed 05/08/24 from 9:45 am through 2:30 pm and again on 05/09/24 from 9:45 am thru 11:00 am and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease and/or black matter was visible on or underneath the following: * Dining room floors near tables, table bases;* Ceiling vents above beverage service area; * Ceiling vents above prep and service areas;* Juice machine;* Outlets and light switches;* Floors throughout kitchen and beverage service area;* Interior of ice machine;* Walls throughout kitchen;* Multiple utility carts;* Exterior of robot coupe;* Fans and metal cages of fan by serving area;* Open shelving throughout kitchen and beverage service area;* Large metal pan holding bag of onions;* Interior and exterior of microwave;* Exterior of bulk food bins;* Cover for baking (Go) racks;* Baking (Go) racks; * Interior and exterior of convection ovens;* Exterior and interior of steamer;* Range top, grill top;* Knobs of ranges/ovens/grill and steam table;* Metal shelves storing pots/pans/dishes;* Steam table wells;* Industrial can opener and housing;* Steamer interior and exterior;* Industrial mixer;* Interior and exterior of reach in deli cooler;* Door thresholds with food debris/splatter; * Plate warmer;* Interiors and exteriors of stainless steal drawers;* Flooring in under and around dishwashing area;* Walk in cooler fans and cages;* Walk in cooler ceiling;* Metal racks in walk in cooler;* Kitchen and beverage area drains.* Three compartment sink area;* Can rack in dry storage;* Metal racks storing clean dishes; and * Stainless steal service area on tray line.b. The following areas were in need of repair: * Corners of walls with chips, nicks and gouges;* Multiple tile pieces upon entry to kitchen with cracks with visible debris build up;* Caulking behind three compartment sink with black debris build up; and * Approximate one inch gap observed by ceiling vent by prep area.c. Staff 2 was observed to prepare hamburger and sandwich with lettuce that was not washed. Staff was observed to leave the line, walk into walk in cooler, and remove green leaf lettuce from box, exit walk in and put directly on to hamburger that was served to resident. Lettuce was then put in deli fridge. Surveyor returned to walk in and reviewed box lettuce which indicated the product needed to be washed and trimmed before service/use. Surveyor immediately informed Staff 2 that lettuce was to be washed prior to service per the box instructions. Staff 2 stated that they usually did not wash that product as it "looks very clean and looked prewashed." Surveyor reiterated that the box indicated it needed to be washed and trimmed. Staff 2 verbalized understanding but did not remove lettuce and wash or trim as directed and was observed placing it on a deli sandwich and served to residents.d. Staff 2 was observed during tray line to leave line several times and touch door handles, and other items including a rag with sanitizer solution with gloved hands. Staff 2 did not change gloves or wash hands, when switching tasks or potentially contaminating gloves and preceded to handle ready to eat foods such as garlic bread, hamburger buns, and make deli sandwiches. e. Staff 2 was observed to wipe several plates with a rag stored on the tray line counter. Staff wiped the counter with this rag as well as other plates. The rag was then placed in sanitizer bucket and taken back out to be used to wipe plates and surfaces during tray line. f. Multiple food items were found in walk in cooler without proper labels and/or prepared/opened or use by dates as required. Multiple food packages were found opened in walk in, exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler. g. Multiple food packages were found opened in dry storage without open dates. Multiple food items found not securely closed and/or open to potential contamination in dry storage. h. Staff 2 was observed to not check temperature of service line products including scrambled eggs. Surveyor intervened before delivery and asked staff to check the temperature which was found to be at required levels. i. Multiple kitchen staff were observed without hair or beard/facial hair restraints. Staff 2 was alerted of the need however staff continued to not restrain hair while working with food and clean equipment per rule. j. Dining room was observed with preset tableware that was not covered or inverted and exposed to potential contamination. k. Staff 2 was not able to demonstrate adequate person in charge knowledge for prevention of cross contamination, kitchen employee hygienic practices, proper temping of food items, handling of potential hazardous food items, and proper cleaning methods/procedures. On 05/08/24 at approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Executive Director) and Staff 5 (Memory Care Administrator), who acknowledged the findings. On 05/09/24 from 9:45 am to 10:45 am, the surveyors observed that significant cleaning had occurred with also noted improvements in other identified areas from previous days observations. Staff 4 was interviewed and was able to verbally demonstrate adequate knowledge in most areas with the exception of employee illnesses for exclusion and reporting.Staff 3 (Dining Service Manager) was interviewed on 05/09/24 at 10:00 am. S/he said areas identified in kitchen review were not at their standards of what they would expect the designated Person In Charge to maintain. Staff 3 stated s/he had not at been at facility consistently in PIC role since November 2023. On 05/09/24 at approximately 10:45 am, completed survey findings were reviewed with Staff 1 and Staff 5. They acknowledged the areas in need of correction.

The findings of the re-licensure survey, conducted 12/12/23 through 12/14/23, 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 sugarCG: caregivercm: centimeterED: Executive DirectorF: Fahrenheit HH: Home Health LPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration Record MCC: Memory Care Community mg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first revisit to the re-licensure survey of 12/14/23, conducted 03/18/24 through 03/19/24 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, OARs 411 and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second revisit to the re-licensure survey of 12/14/23, conducted on 05/14/24, 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 and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 2 of 2 sampled residents (#s 1 and 4) who used call pendants. Findings include, but are not limited to:During the survey process, 12/12/23 through 12/14/23, the following was identified:a. Resident 4 was admitted to the facility in 09/2021 with diagnoses including high blood pressure. Record review and interviews revealed the following:Resident 4 experienced a fall on 11/18/2023 at 3:45 am. In an interview on 12/13/23, Witness 2 (Family member) reported Resident 4 had pressed his/her call pendent for assistance after a fall and had waited approximately 30 minutes for assistance. When staff did not come, Resident 4 called a family member for assistance. The family member called the facility's front desk who had caregiving staff respond and assist Resident 4 off the floor.The resident's fall on 11/18/23 was discussed with Staff 5 (Health and Wellness Director) on 12/14/23. He explained the reason why staff did not come sooner to assist the resident when s/he used the call pendant was that either Resident 4 did not push it hard enough or the pendant's battery was not functional. Staff 5 was not able to provide evidence the call pendant was checked by staff to indicate if the pendant was in working order following the fall. He was unable to report how often call light pendants and batteries were checked and tested for functionality, but stated it was a maintenance task.There was no documented evidence Resident 4's call pendent was tested to determine functionality after experiencing a fall and pressing his/her call pendant.b. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and high blood pressure.The resident's move-in evaluation, dated 09/22/23, stated the resident would "utilize a pendant for safety" and identified three times that the resident had previously fallen. The resident experienced an unwitnessed fall in his/her room at 5:10 pm on 10/29/23. The occurrence report stated the resident "had to scoot to the wall to call us since [his/her] wrist button wasn't working."In an interview on 12/14/23, Staff 3 (Assisted Living Director) reported that after the fall, she replaced the battery on Resident 1's wrist pendant. She stated she was not aware of a current process for monitoring or checking call pendant batteries, though she believed this was performed by the maintenance team.During an interview on 12/14/23, Staff 7 (Maintenance) stated he was not aware of a current system or process in place to check call light pendants and batteries. He stated that at this time, he only replaces single batteries or pendants as needed when a caregiver notifies him that one has not worked when a resident called for help.The facility lacked documented evidence that there was a system in place for monitoring the effectiveness of residents' call pendants.On 12/14/23, the need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 3 and Staff 5. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia.Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCP), and Alert Charting records were reviewed during the survey. Interviews were conducted with caregiving staff and the resident.The current service plan, dated 12/07/23, lacked information regarding Resident 5's private caregiver including:* Name and contact information for the home health agency providing the service;* The name of the private caregiver;* The private caregiver's schedule; and* Instructions for providing additional care, if necessary, at times when the private caregiver was not on-site.The lack of information about the private caregiver and instructions for facility caregivers for ensuring care was provided when the private caregiver was not on-site was reviewed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the information lacking from the service plan.
Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 3 of 5 sampled residents (#s 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 09/2022 with diagnoses including artherosclerotic heart disease, hypertension, and shortness of breath.The resident's 09/27/23 service plan, 09/29/23 through 12/04/23 Charting Notes, and Resident Temporary Care Plans were reviewed. Staff were interviewed and observations were made of the resident. The following areas of the service plan were not reflective of the resident's current care needs and did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided:* Continuous positive airway pressure (CPAP) use including assistance needed with the mask and water, and what to do if staff noticed it was in disrepair;* Pacemaker placement;* Outpatient PT services;* Short-term memory loss;* Interventions relating to cognition deficits;* Personalized interventions for behaviors;* What triggered the resident's behaviors;* Environmental factors that impact the resident's behavior;* Activities of interest both in the facility and independently;* Assistance needed for dressing;* Cueing needed for personal hygiene tasks;* Toileting assistance and brief use; and* Staff to monitor for bruising relating to a blood thinning medication.The need for service plans to accurately reflect residents' current needs and provide clear instructions to staff was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 07/2023 with diagnoses including Parkinson's disease and spinal stenosis.The resident's current service plan, dated 09/09/23, was reviewed, observations were made, and interviews with staff were conducted. Resident 3's service plan was not reflective of the resident's status in the following areas:* Modified diet texture; and* Home Health therapies.In addition, Resident 3's service plan did not provide instructions to caregivers on the correct use of side rails and precautions related to their use.The need to ensure service plans reflected the residents' needs and provided clear direction to staff was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine, document, and communicate to staff what action or intervention was needed for a resident in response to a short-term change of condition, and failed to document weekly progress until the condition resolved, for 2 of 5 sampled residents (#s 1 and 5) who experienced changes of condition requiring monitoring. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia.Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCPs), and Alert Charting records were reviewed during the survey.The resident experienced the following changes of condition:* 09/18/23, 10/11/23, and 11/15/23: Significant weight gains; and* 11/27/23: Change in behavior including increased confusion, fearful, wanting to leave building, and grasping his/her cat unsafely.The following deficiencies were identified:a. The facility wrote a TCP in response to each weight increase. Each TCP included the following interventions:* Offer or encourage healthier choices at meals; and* Encourage more physical activity such as walking around the facility.The facility failed to include instructions for staff as to what to monitor and document. There was no documented evidence the facility monitored whether the interventions were attempted by caregivers, whether the resident was agreeable to trying the interventions, or whether the interventions were effective in meeting the treatment goal.b. The facility instituted its alert charting process in response to the change in behavior on 11/27/23 by creating an Alert Charting entry electronically. Review of the Alert Charting entry with Staff 5 (Health and Wellness Director) on 12/14/23 indicated the entry lacked resident-specific instructions for staff as to what behaviors staff should monitor and report or document on.The need to ensure the facility provided resident-specific instructions for what exactly to monitor and document following a resident's change of condition was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 on 12/14/23. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and osteopenia.Observations of the resident, interviews with staff, and review of the resident's most recent service plan, dated 11/08/23, Shift-to-Shift Communication Logs, Temporary Care Plans, Occurrence Reports, physician communications, and Charting Notes from 09/12/23 through 12/11/23 were completed.The facility record lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution for the following short-term changes of condition:* 10/04/23: New medication: Coumadin (blood thinner);* 10/22/23: Missed medication: metoprolol (for high blood pressure); and* 10/29/23: Unwitnessed fall with injury.The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and changes of condition were monitored through resolution, was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols during meal service. Findings include, but are not limited to:During lunch service on 12/12/23 and 12/13/23 multiple care staff, who performed duties including resident ADL care, were observed assisting with meal service, which included entering the kitchen to obtain food for the residents. Though the kitchen staff were wearing aprons, care staff did not don aprons or some other barrier to prevent potential cross contamination when assisting with meal service.The need to establish and maintain infection prevention and control protocols, including protocols to prevent the development and transmission of communicable diseases, was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication administration system. Findings include, but are not limited to:During the re-licensure survey, conducted 12/12/23 through 12/14/23, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following area:* C 303: Medication and Treatment Orders.On 12/14/23, the delays in updating the MAR with new orders, obtaining new prescriptions, and administering medications as ordered was reviewed with Staff 5 (Health and Wellness Director). When asked to explain the current process for auditing resident MARs, he stated the MARs were audited once per month.On 12/14/23, Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 were informed the oversight of the medication administration system was determined to be inadequate based on the medication type and potential impact on the resident and the extended length of time the facility was administering medications to residents which did not align with the current physician orders. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and osteopenia.The resident's MARs, dated 10/01/23 through 12/11/23, and all physician orders were reviewed.a. The resident had a physician's order dated 10/18/23, with a fax stamp indicating the facility received the order on 10/18/23 at 10:10 am, for changes to Coumadin (blood thinner) administration, to be followed until new orders were received. The MAR was not updated between 10/14/23 and 10/30/23, resulting in the resident receiving an incorrect dosage of Coumadin on the following dates:* 10/18/23;* 10/20/23;* 10/25/23; and* 10/27/23.b. The facility did not carry out prescribed physician orders for metoprolol (for high blood pressure), resulting in the resident not receiving medication on:* 10/21/23; and* 10/22/23.c. The facility did not carry out prescribed physician orders for Coumadin from 10/31/23, resulting in the resident receiving 2.5 mg instead of 5 mg on 10/31/23.d. The facility did not carry out prescribed physician orders from 11/04/23 indicating the resident should receive 5 mg of Coumadin daily. The MAR was blank, with no documented evidence the resident received Coumadin on the following dates:* 11/05/23;* 11/06/23; and* 11/07/23.e. Medications and a treatment on 12/06/23 were not provided per physicians orders, including metoprolol, Coumadin, lidocaine patch (for pain management), and wound care to the right forearm. The MAR exception stated "medication given late," but in an interview on 12/12/23 Staff 9 (MT) stated the resident did not receive the medications and treatment.The need to ensure all orders were carried out as prescribed was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. 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 5 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 07/2023 with diagnoses including Parkinson's disease and spinal stenosis.Review of the resident's physician orders included an order dated 10/18/23, with a fax stamp indicating the facility received the order on 10/19/23, for midodrine (for Parkinson's disease) increased from 2.5 mg three times a day to 5 mg three times a day.The 11/2023 MAR listed the 2.5 mg order stop date as 11/03/23, and the 5 mg order origination date as 11/03/23, with documentation of 2.5 mg given through 11/02/23 and increased to 5 mg on 11/03/23. There was no documented evidence the medication started on 10/19/23, per physician's orders.Staff 4 (RN) reported in an interview on 12/13/23 that she did not know why the medication had not been increased to 5 mg until 15 days after the order was received.The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 3 (Assisted Living Director), Staff 4, and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility administered for 3 of 3 sampled residents (#s 7, 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure .The resident's MAR, dated 02/01/24 through 03/18/24, and physician's orders were reviewed and revealed the following: * On 02/05/24 a decreased dose of Lisinopril to 20 mg a day was ordered for a duration of 30 days; and* Furosemide 20 mg a day was ordered for 30 days. The MAR indicated both medications were administered starting on 02/06/24 and should have stopped after the 03/06/24 administration. The Lisinopril 20 mg and Furosemide continued to be administered after the 30 days through 03/18/24 when the surveyor notified Staff 4 (RN). The RN acknowledged the findings and reported she would contact the physician immediately for further orders.* On 03/06/24 Bacitracin-neomycin-polymyxin ointment was ordered to be applied to the skin twice daily (wound right forearm). The MAR revealed the facility was documenting administration of the ointment one time daily, not twice daily as was ordered. The need to ensure physician's orders were carried out as prescribed was discussed with RN and Staff 6 (Director of Health Services) on 03/18/24, and Staff 2 (ED), Staff 5 (Previous Health and Wellness Director) and Staff 17 (Regional Director of Operations) on 03/19/23. They acknowledged the findings.
2. Resident 8 was admitted to the facility in 05/2022 with diagnoses including dementia, type 2 diabetes and hypertension. The resident's MAR, dated 02/01/24 through 03/18/24, charting notes from 02/14/24 through 03/18/24, and physician's orders were reviewed and revealed the following: The resident was administered sulfamethoxazole-trimethoprim 800-160 mg (for urinary tract infection) between the dates of 02/15/24 through 02/20/24. Charting notes from 02/15/24 stated the medication was dropped off at the facility by the resident's daughter. The facility was unable to provide any documentation that a physican's order was received for this medication. The need to ensure signed physician's orders were documented in the resident's record for all medications the facility administered was discussed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations) on 03/18/24 and 03/19/24. No additional information was provided, and they acknowledged the findings.3. Resident 9 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and type 2 diabetes. The resident's MAR, dated 02/01/24 through 03/18/24, and physician's orders were reviewed and revealed the following: The resident had a physicians order, dated 01/15/24, for ergocalciferol 5,000 unit tablet (for severe vitamin deficiency) to be given once every week for eight weeks, then switched to 1,000 unit tablets daily thereafter. The resident's MAR showed that the facility was continuing to administer the 5,000 unit tablet after the ordered eight weeks had been completed. The facility had also been simultaneously administering the 1,000 unit dose daily throughout the look-back period. The need to ensure all medication orders were carried out as prescribed was discussed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations) on 03/18/24 and 03/19/24. No additional information was provided, and they acknowledged the findings.

3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia.Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCP), Alert Charting records, and the resident's ABST data were reviewed during the survey. Interviews were conducted with caregiving staff and the resident.Resident 5 had a private caregiver who provided ADL care for approximately four hours per day on Monday thru Friday. No private caregiving was scheduled on the weekends.The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include:* Assisting with ambulation, escorting to and from meals or activities;* Supervising, cuing or supporting while eating, including tray delivery and pick-up;* Cuing or redirecting due to cognitive impairment or dementia;* Ensuring non-drug interventions for behaviors; and* Monitoring behavioral conditions or symptoms.The need to ensure Resident 5's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 09/2022 with diagnoses including artherosclerotic heart disease, hypertension, and shortness of breath.The resident's 09/27/23 service plan, 09/29/23 through 12/04/23 progress notes, Resident Temporary Care Plans, 11/01/23 through 12/11/23 MARs, and Resident 2's ABST data was reviewed. Staff were interviewed and observations were made of the resident.a. The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include:* Personal hygiene;* Responding to call lights;* Leisure activities;* Non-drug interventions for behaviors;* Redirecting due to cognitive impairment or dementia;* Passing out medications;* Escorting to and from meals or activities;* Helping with bowel and bladder management; and* Grooming.During multiple observations on 12/12/23 and 12/13/23, the resident requested or required staff's assistance with responding to call lights, escorting to and from meals or activities, interventions for behaviors, and redirecting due to cognitive impairment. However, either no staff time, or an insufficient amount of staff time, was assigned to these elements in Resident 2's ABST.b. There were no minutes assigned for the "NOC" shift (from 10:00 pm to 6:00 am); however, there was documented evidence the resident received PRN medications and staff were providing Resident 2 care and companionship during the shift.The need to ensure resident's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to develop an acuity-based staffing tool (ABST) that reflected an accurate time frame needed for each component to generate an accurate staffing plan for 3 of 5 sampled residents (#s 2, 4, and 5) whose ABST data was reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 09/2021 with diagnoses including high blood pressure and hypertension.The resident's 12/01/23 service plan, 11/15/23 through 12/12/23 progress notes, Resident Temporary Care Plans, and ABST data was reviewed. Staff were interviewed and observations were made of the resident.The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include:* Providing treatments (e.g. skin care, wound care);* Transferring in or out of bed or a chair;* Helping with bowel and bladder management;* Dressing and undressing; and* Additional care services such as pet care.On 12/14/23, the need to ensure resident's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director) and Staff 5 (Health and Wellness Director). They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) assessment for two unsampled residents and update the ABST after a significant change of condition for 1 of 2 sampled residents who experienced a significant change of condition (#8). This is a repeat citation. Findings include, but are not limited to:1. The facility's ABST was reviewed upon survey entrance on 03/18/24. Two unsampled residents did not have minutes entered to reflect their care needs.2. Resident 8 was admitted to the facility in 05/2022 with diagnoses including dementia and type 2 diabetes. Review of the resident's ABST showed it was last updated on 01/06/24. On 02/29/24, the resident returned to the facility from a hospital stay. A significant change of condition assessment was completed by Staff 4 (RN) on 03/01/24 and described the resident's increased level of confusion, generalized weakness, and need for increased assistance from staff including "monitoring resident frequently" and "offer assistance to meals." The ABST was not updated to reflect the resident's care needs following the significant change of condition. The need to ensure an ABST assessment was completed for all residents and updated after significant changes of condition was reviewed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations). They acknowledged the findings, and no additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure direct care staff completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting for 2 of 2 long-term staff (#s 9 and 15) whose training records were reviewed and failed to ensure all staff completed annual training on infectious disease outbreak and infection control for 1 of 2 non-care staff (#16) whose training records were reviewed. Findings include, but are not limited to:Training records were reviewed with Staff 1 (ED) on 12/13/23. The following deficiencies were identified:1. Based on review of training records, the facility conducted monthly in-service training for all staff which included training on topics related to the provision of care for persons in a community-based care setting, but did not document the portion of time specifically spent on such topics. As a result, Staff 9 (MA), hired 03/2022, and Staff 15 (CG), hired 11/2022, failed to have documented evidence of completing 12 hours of required annual in-service training, based on their anniversary date of hire.2. Based on review of training records, Staff 16 (Housekeeping), hired 10/2012, failed to have documented evidence of completing annual training on infectious disease outbreak and infection control. The facility provided evidence that Staff 16 completed the training on 12/12/2023 while the survey team was on site.The need to ensure direct care staff completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting and ensure all staff completed annual training on infectious disease outbreak and infection control was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:On 12/12/23, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed:1. Staff did not evacuate or relocate residents during all fire drills. Therefore, fire drill records did not include information on:* The escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and* Number of occupants evacuated.2. There was no documented evidence the facility provided fire and life safety training to staff on alternate months.The need to ensure the facility conducted unannounced fire drills according to the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.
Based on interview and record review, it was determined the facility failed to document all required elements on fire drill documentation, per the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:Fire and life safety records dated 02/14/24 through 03/18/24 were reviewed on 03/18/24. Fire drill documentation did not include one or more of the following required elements:* Time of fire drill;* Location of simulated fire origin;* Problems encountered, comments relating to residents who resisted or failed to participate in the drill; * Evacuation time-period needed; and* Number of occupants evacuated.The need to follow all OFC requirements for fire drills and documentation was discussed with Staff 2 (ED), Staff 17 (Regional Director of Operations), Staff 6 (Director of Health Services), and Staff 5 (Previous Health and Wellness Director) on 03/19/24. They acknowledged the findings. No additional information was provided.

Based on interview and record review, it was determined the facility failed to re-instruct each resident, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and failed to keep a written record of fire safety training. Findings include, but are not limited to:On 12/12/23, Staff 2 (Assistant ED) stated prior to each fire drill all residents were given a handout with instructions regarding what to do during a fire drill. However, Staff 2 was unable to produce a copy of the handout. Also, the facility had no written record of fire safety training, including content of the training sessions and the residents attending.The need to ensure residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places and the facility kept a written record of fire safety training was discussed with Staff 1 (ED) and Staff 2 on 12/12/23. They 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 C 303, C 361, C 420 and C 630.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair and all chemicals were maintained in a locked storage unit. Findings include, but are not limited to:On 12/12/23, during a tour of the exterior and interior of the facility, the following were identified:* Exterior pathways in the courtyard and around the perimeter of the building contained multiple drop-offs up to approximately four inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents; and* Cabinets in the second floor kitchenette were unlocked and contained toxic chemicals.On 12/13/23, the exterior drop-offs and the unlocked interior chemicals was toured and reviewed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:On 12/12/23, the facility interior was toured. Multiple vertically opening windows above the first floor, with window sills lower than 36 inches from the floor, lacked a system which limited how far the window could be opened to prevent accidental falls.On 12/13/23, the lack of a mechanism to prevent accidental falls from upper floor windows was discussed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the stove in the activity room had a keyed remote switch or safety device to ensure staff control. Findings include, but are not limited to:The interior of the facility was toured on 12/12/23. The stove in the activity room, located on the second floor and accessible to all residents, was able to be turned on without the use of a key, remote switch, or other safety device to ensure staff control.On 12/13/23, the need to ensure a safety device was used for the stove when staff were not present was discussed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure that when washing soiled linens and soiled clothing washing machines had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used. Findings include, but are not limited to:During a tour of the facility laundry rooms on 12/12/23 and 12/13/23, it was observed the facility washed all linens and clothing in residential washers. There was no documented evidence the washers had a minimum rinse temperature of 140 degrees Fahrenheit to sanitize the soiled items. Interviews with Staff 14 (Housekeeping) and Staff 13 (CG), stated they washed soiled linens and soiled clothing, respectively, in accordance with instructions posted by the facility in each laundry room. The instructions did not include direction to use a chemical disinfectant when washing soiled linens and clothing.The need to ensure facility staff used a chemical disinfectant when washing soiled linens and clothing in a washing machine that did not have a minimum rinse temperature of 140 degrees F was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure that when washing soiled linens and soiled clothing washing machines had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used. This is a repeat citation. Findings include, but are not limited to:During a tour of facility laundry rooms on 03/18/24 and 03/19/24, it was observed that facility staff washed linens and clothing in residential washers on floors one through three. There was no evidence the washers had a minimum rinse temperature of 140 degrees Fahrenheit to sanitize soiled items. When asked how soiled linens and soiled clothing were washed, staff reported they used the resident's personal laundry detergent, and if they did not have one, they would then use the facility-provided powdered detergent. The detergent was provided to staff in a glass bowl with a small plastic cup inside. There was no marking on the cup or instructions posted to indicate how much of the detergent to use or that it should be used for soiled linens and soiled clothing. There was no posted signage in any of the laundry rooms which described the need to use a chemical disinfectant when washing soiled linens and clothing.Posted in the second floor laundry room, there was a hand-written sign which stated "Before putting soiled laundry in machine first rinse thoroughly in residents shower put in trash bag to get it to laundry room then put in machine cold water cycle."During interviews with Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations), they stated the soiled linen handling policy had been reviewed at an employee in-service on 12/28/23 and 01/04/24. They acknowledged that the current posted soiled laundry policy did not include information about use of a chemical disinfectant. The need to ensure facility staff used a chemical disinfectant when washing soiled linens and clothing in a washing machine that did not have a minimum rinse temperature of 140 degrees F was reviewed with Staff 2 (ED), Staff 6 and Staff 17 03/19/24. They acknowledged the findings, and no additional information was provided.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 04/03/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on record review and interview, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:A review of Resident #2 (R2) service plan showed that the facility did not update quarterly. The service plan is dated 12/31/2022.On 04/19/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: S1 will update service plan to reflect resident's current needs.

Based on interview, observation, and record review it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include:During separate interviews 04/03/2023, Resident #5 (R5) stated call lights take a long time for staff to respond especially during meals times. During an unannounced site visit on 04/03/2023, Compliance Specialist (CS) entered the facility at 10:30 AM and did not observe any med techs or caregivers until 11:30AM.A review of the staff schedule for February and March 2023, call light logs from 03/20/2023-3/24/2023, and the acuity-based staffing tool (ABST). The call light log showed 12 occurrences where they call lights exceed the facility's 10-minute response time, with 2 exceeding 20 minutes. Both schedules show multiple days were the facility had open shifts not filled. The facility ABST is not updated correctly, not showing the correct staffing levels reflective of all resident's needs. On 04/03/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: Not provided.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate interviews on 04/03/2023, Staff #1-3 (S1, S2, and S3) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. During an unannounced site visit on 04/03/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working. A record review of the posted staffing plan, staff schedule for February- March 2023, resident roster updated on 04/01/2023, Resident #1-2 (R1 and R2) service plans dated 12/31/2022 and 02/24/2023, progress notes from 01/03/2023 - 04/03/2023, and the breakdown of their care on the facility's ABST. R2 service plan had not been updated quarterly. The exported data in the ABST showed 38 of the 45 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 07/08/2022-01/02/2023. Matching the roster with the ABST showed that the ABST has 45 residents entered in the tool while the resident roster has 48 residents listed. On 04/03/2023, these findings were reviewed and acknowledged by S1.

Based on record review and interview, the facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned. Findings include:During separate interviews 04/03/2023, Staff #1 (S1) stated that competencies should have been verified by a med tech and a nurse, as per their policy.A review of training records for Staff #3-5 (S3, S4 and S5) revealed that S4 hired on 03/21/2023 did not complete the safety and health program which includes reporting protocols, accident prevention plan, OSHA requirements, employee focused- resident safe handing, proper body mechanic/safe transfers and the use of a camel. On 04/03/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: Not provided.

Based on interview and record review it was confirmed the facility failed to provide records to the Department upon request. Findings include:Compliance Specialist (CS) requested documentation from the facility for an investigation conducted on 04/03/2023 and did not receive them. Reviewed email request dated 04/05/2023 following up on the request for additional documentation to Staff #1 (S1). The facility did not provide the documentation requested. On 04/19/2023 CS informed S1 about documentation not being provided upon request. Plan Of Correction: S1 will be providing documentation upon site visit.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 03/01/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it was confirmed the facility failed to provide personal and other laundry services. Findings include:During separate interviews on 03/01/2023, Witness #1 (W1) and Resident #1 (R1) stated that housekeeping services have not been done in a while. A review of Resident #1-3 (R1, R2, and R3) service plan, resident council notes for 02/21/2023, and the housekeeping checkoff binder for February 2023. The housekeeping binder showed that housekeeping had only been completed 2 out of the 4 weeks in February for all residents. The individual check off sheet for R2 showed that their bed sheets had not been washed all month. The review of their service plans stated all 3 residents are to received weekly housekeeping services. On 03/01/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: The facility has hired a new housekeeper and will do training on housekeeping and completing housekeeping sheets.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate interviews on 03/01/2023, Staff #1-4 (S1, S2, S3 and S4) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. During an unannounced site visit on 03/01/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working. A record review of the posted staffing plan, staff schedule for February 2023, resident roster, Resident #1-3 (R1, R2 and R3) service plans, progress notes, and the breakdown of their care on the facility ' s ABST. The exported data in the ABST showed 40 of the 49 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 07/08/2022-12/18/2022. Matching the roster with the ABST showed that Residents #3-6 (R3, R4, R5 and R6) had not been entered into their tool. R3 moved into the facility on 02/15/2023, R4 moved in on 02/04/2023, and R5 and R6 moved in on 02/23/2023.On 03/01/2023, these findings were reviewed and acknowledged by S1.

Based on interview, observation, and record review it was confirmed the facility failed to keep clean all interior and exterior materials and surfaces. Findings include: During separate interviews on 03/01/2023, Witness #1 (W1) and Resident #1 (R1) stated that housekeeping services have not been done in a while. Staff #1 and 4 (S1 and S4) stated that Resident #3 (R3) is a newer resident and the belongings stacked in the hallway by their room belonged to R3. During an unannounced site visit on 03/01/2023, Compliance Specialist (CS) observed many boxes of belongings stacked in a hallway.A review of Resident #1-3 (R1, R2, and R3) service plan, resident council notes for 02/21/2023, and the housekeeping checkoff binder for February 2023. The housekeeping binder showed that housekeeping had only been completed 2 out of the 4 weeks in February for all residents. The individual check off sheet for R2 showed that their bed sheets had not been washed all month. The review of their service plans stated all 3 residents are to received weekly housekeeping services. R3 service plan showed R3 moved into the facility on 02/15/2023. On 03/01/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: The facility has hired a new housekeeper and will do training on housekeeping and completing housekeeping sheets. S4 stated that they will call R3 ' s power of attorney to remove the belongings from the hallway.

The findings of the kitchen inspection conducted 01/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 1/11/23, conducted 3/22/23, 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 01/11/23, conducted 06/06/23, 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 third revisit to the kitchen inspection of 1/11/23, conducted 7/19/23, 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 in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 01/11/23 at 10:30 am the kitchen was observed to need cleaning in the following areas: * Vents above stove/grill/deep fat fryer;* Black matter on floor and around drain under steamer;* Four food storage bin lids under prep counter; * Front and sides of grill/ovens; * Vents above salad prep area; * Doors on the outside of the sandwich refrigerator; and * Front of bread drawer under toaster. The garbage can next to plate warmer and near the steam table was uncovered when not in use. The above areas were discussed with Staff 2 (Executive Director) on 01/11/23. The findings were acknowledged.
Based on observation, record review and interviews, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to:On 3/22/23 at 11:30 am the main kitchen area was observed to need cleaning in the following areas:*Interior and exterior of grill, stove, convection oven;*Interior of drawer under toaster;*Interior and exterior of microwave;*Industrial mixer;*Industrial can opener and housing;*Open stainless steel shelving by prep areas and under steam table;*Interior doors of sandwich refrigerator;*Handle of walking cooler;*Floors in corners, edges and under/between equipment; and*Walls with food/debris splatter throughout kitchen.The following areas were found to need repair:*Multiple sprinkler heads had gaps in the ceiling;*Hole just above floor tile by prep table; and*Cutting boards on steam table and sandwich prep area were heavily scored/stained or chipped and were not a smooth cleanable surface.*The large industrial mixer was observed not covered when not in use. The industrial slicer was also not covered when not in use. Staff 2 (Director of Dietary Services) confirmed there were not covers for those items.*There were three cases of food items observed stored on the Walk-in cooler floor. Staff 2 verified that stock was not delivered that day. The facility received stock a full two days prior. Staff 2 acknowledged stock should not be stored on the floor.*Multiple dishwashing racks were observed stored on the floor. The Surveyor reviewed the new cleaning list with required sign off of tasks as part of plan of correction. Staff 1 (Executive Director) and 2 acknowledged there were multiple areas that were not signed off as required to indicate the daily and weekly cleaning tasks were completed. Staff 1 and 2 toured kitchen and acknowledged the above areas of concern.
Facility has created cleaning task list that includes daily, weekly and monthly cleaning tasks to address kitchen cleanliness in all areas. Staff will be required to initial and date each task as it is completed. Task list will address as needed cleaning tasks with a separate area for staff to sign and date the task completed as needed between scheduled cleanings. Task list will be completed daily and turned into the Dining Services Manager and the Executive Director. Weekly task lists will be discussed at weekly meetings between the Dining Services Manager and the Executive Director, as well as planning of monthly cleaning parties to address deep cleaning needs that cannot be address during hours the kitchen is in use. Task list will address the following items at a minimum:* Air vents - cleaned weekly*Floors & floor drains - cleaned twice daily*Walls will be cleaned after every food service and as needed to ensure that any food that builds up is cleaned off in a timely manner. Staff will wipre down walls every day at the end of servide for the day* Food storage bin lids - to be stored in proper storage area at all times throughout the course of the day* Grill & oven - all areas including front and sides to be cleaned daily. Grill will be covered on side nearest deep fat fryer with foil that will be replaced daily. Oven will be cleaned weekly to prevent buld up of carbon residue and food debris. This will be noted weeklyon checklist.* Doors on sandwich refrigerator, walk-in cooler and all reach-in's - cleaned daily & as needed during service throughout the day* Bread drawer under toaster - will be cleaned out after each meal service is completed.* Garbage cans - all garbage cans will be covered by lids when in the kitchen*Industrial mixer and slicer will have covers in place at all times when not in use. Staff will replace cover as needed to ensure it is clean and will date the over at the time it is placed on machine.*Industrial can opener and housing will be replaced and cleaned when finihed with every use to prevent future acid erosion and etching.*Cutting boards on steam table have been removed and stainless steel surface to be wiped down between meal prepartation and food service and as needed for sanitation. Staff will clean and sanitize surface at the end of service for the day.*Cutting board on sandwich prep counter to be replaced and cleaned daily to prevent staining. Weekly deep cleaning of cutting board to prevent stain build up which will be noted on cleaning checklist.*Sprinkler heads will have proper fitting escutcheons to ensure that no open areas are visible around sprinkler heads.*Hole above floor tile by prep table to be repaired.*Dishwashing racks to be stored on shelves off the floor or on rolling cart when not in use.*All stock from deliveries will be sorted and put away at the time it arrives to ensure that food storage regulations are met at all times. Dining services manager will check walk-in cooler 3 times per day to ensure that all food is properly stored on shelving and off the floor and noted on check list.
Based on observation, interviews and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to:On 06/06/23 at 11:15 am the main kitchen area was observed to need cleaning in the following areas:*Interior and exterior of stove, convection oven;*Knobs and handles of equipment;*Interior of drawer under toaster;*Interior and exterior of microwave;*Dust build up on walk-in cooler ceiling;*Dust build up on vents and ceiling between tray line and ware washing area;*Industrial mixer;*Open stainless steel shelving by prep areas and where dishes were stored;*Interior doors of sandwich refrigerator;*Commercial grade toaster with dust/dirt debris build up on air vents;*Handle of walk-in cooler;*Walk-in cooler/freezer floor with food debris;*Floors in corners, edges and under/between equipment; and*Walls with food/debris splatter throughout kitchen.The following areas were found to need repair:*White cutting boards used for food prep were found heavily scored/stained or chipped and were not a smooth cleanable surface.*There was a case of food items observed stored on the walk-in cooler floor. There were multiple cases of food items observed stored on the walk-in freezer floor. Staff 2 acknowledged stock should not be stored on the floor.*Multiple staff were observed preparing or serving food items without hair and/or facial hair restrained as required. Staff 3 (Assistant Administrator) toured kitchen with surveyors and acknowledged the above areas of concern. At approximately 12:00 pm, Staff 2 (Dietary Services Manager) and surveyors reviewed areas of needed attention. Staff 2 acknowledged identified issues. At 12:15 pm the sanitation concerns were reviewed with Staff 1 (Executive Director) He acknowledged the areas of non-compliance.
1) The kitchen has been deep cleaned (including walls, walk-in, equipment, appliances, vents, racks and floors) and all food has been appropriately stored. Hair and beard barriers have been provided to all staff who are preparing food. All cutting boards that are damaged are being replaced.2/3/4) All employees who are involved with the preperation of food will be required to wear a hair/beard barrier. An in-service will be completed for all kitchen staff by 6/20/2023 on proper cleaning procedures. Additionally, the administrator or designee will review the kitchen daily to ensure it is properly cleaned and maintained including floors, walls, kitchen equipment, food storage areas and containers. All food will be properly stored when the food is delivered. An in-servie will be completed for all kitchen staff to address proper food storage by 6/20/23. The dry storage, walk-in freezer and refigerator will be walked by the adiministrator or designee each day to ensure all food is properly stored. All cutting boards that are damaged or are worn will be replaced and maintained appropriately. All cutting boards will be inspected monthly to ensure they are in good condition

Based on interview, observation and review of documentation, 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.
Based on interview, observation and review of documentation, 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 240.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 01/05/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it was confirmed the facility failed to implement and compete service plans before a resident moves in or quarterly evaluations. Findings include:During separate interviews on 01/05/2023, Staff #1-3 (S1, S2, and S3) stated that the facility is behind on service plans and admits there are a handful out of date. S2 stated that they have been working on updating them and made that their priority. A review of the facility ' s service plan binder indicates at least 8 service plans to be out of date. The dates the service plans should have been completed are 12/6/2022, 12/21/2022, 12/12/2022, 10/19/2022, 1/2/2023, 10/2/2022, and 2 are new residents that did not receive updated service plans after they moved in 30 days later. On 01/05/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: S2 had made updating service plans their priority. S2 has been and continues to update service plans to make them all in compliance with resident ' s current needs.

Based on interview, observation, and record review it was confirmed the facility failed to establish, maintain, and comply with infection prevention and control protocols. Findings include: During an interview on 01/05/2023, Staff #1 (S1) stated that this is the resident ' s home, and we suggest guests wear masks but do not require them too. S1 also stated observing guests enter the facility without a mask on and that S1 did not ask them to wear a mask while in the facility.During an unannounced site visit on 01/05/2023, Compliance Specialist (CS) observed no required signs posted for infection control or mask requirements on the entrance or throughout the building. A review of the Oregon Health Care Association covid updated guidelines for facility ' s dated 11/23/2022 states that masks requirements remain. Consistent masking by health care providers in health care settings, as well as masking by visitors. Also stating, Visitors: No screening requirements for visitors entering facility, but facility should provide guidance (e.g., posted signs at entrances, reception area and/or visitor sign-in area). Infection prevention, such as providing instructional signage in the facility on hand hygiene, use of a mask, or other applicable facility practices). Visitors who do not adhere to the core principles of infection prevention may be asked to leave. On 01/05/2023, these findings were reviewed with S1.Plan of Correction: Starting on 01/05/2023. S1 will be finding the proper sign posting for the entrance of the facility and will remind visitors to put masks on when entering the facility.

Based on interview and record review it was confirmed that the facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. Findings include: During an onsite interview on 01/05/2023, Staff #1 (S1) stated that they were administering insulin and other medications in October and November 2022. S1 stated that they were administering insulin before their delegation from the Registered Nurse. A review of S1 Initial staff skills assessment for RN delegation dated 11/11/2022 and the complaint dated 11/3/2022 shows that S1 was administering insulin before the delegation was provided. S1 did not provide other training or delegations for medication administration. The delegation for insulin is not for specific residents but a general one for the building. On 01/05/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: S1 is no longer working as a med tech. There is now a delegation for S1 to administer insulin.

The findings of the re-licensure survey conducted 4/5/21 through 4/7/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the re-visit to the re-licensure survey of 4/7/21, conducted 6/1 through 6/2/21, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to ensure the accuracy of resident records for sampled and non-sampled residents whose MARs were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, 4 and 5's MARs were reviewed between 3/1/21 and 4/5/21. Each record had multiple medication administration entries documented as "Meds given on time/late documentation."The 8:00 am medication pass was observed on 4/6/21. Staff 10 (MT) was observed by two surveyors to administer her last medication to an unsampled resident at 10:15 am. Upon exiting the resident's room, Staff 10 verbally acknowledged she had finished her 8:00 am medication pass. This meant the morning medication pass had been completed 75 minutes after the prescribed time. At 3:30 pm on 4/6/21, the surveyor requested the MAR for that unsampled resident. Documentation that was initialed by Staff 10 for the five medications ordered to be administered daily at 8:00 am read "Meds given on time/late documentation." The 8:00 am medication pass was observed on 4/7/21. Staff 10 administered morning medications to three unsampled residents at 9:38 am, 9:43 am and 9:55 am, respectively. Staff 10 administered morning medications to Resident 2 at 9:52 am. MARs for these four residents were requested and reviewed on 4/7/21 at 1:45 pm. Documentation on each of the MARs again read "Meds given on time/late documentation."In an interview on 4/7/21 at 1:50 pm, Staff 10 acknowledged she had not completed the above mentioned 8:00 am medication passes by 9:00 am. She explained that the electronic MAR did not have an option for documenting the medications were given late and she thought this was the most appropriate way to document in the facility's system.The inaccurate documentation was reviewed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the documentation was not accurate. Staff 3 reviewed the electronic MAR and confirmed there were limited options for staff to document from the drop-down menu. Staff 2 stated he would request that the technical support team develop a solution as soon as possible.

Based on observation, interview and record review, it was determined the facility failed to ensure incidents and accidents were promptly investigated to rule out abuse and neglect, ensure incidents were reported to the local SPD office as appropriate and took measures necessary to protect residents and prevent reoccurrence of abuse, for 2 of 2 sampled residents (#s 4 and 5) with reportable incidents. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in November 2017 with diagnoses including anxiety.Review of incident investigations, service plans, progress notes and physician communications for 1/5/21 through 4/5/21 showed the following: The resident was previously made a two person transfer after a fall with head and arm injury on 1/24/21.In interviews on 4/5/21 and 4/6/21 Staff 9 (CG) and Staff 12 (CG) indicated the resident required staff assistance for transfers, toileting and ADLs. The resident usually preferred to go to bed on the early side, 8-9:00 pm. * On 2/14/21 it was noted the resident returned from the ER after being evaluated for a fall. On 2/15/21 the progress notes indicated the resident was in pain from the cut to her/his leg after a fall with injury. On 2/24/21 it was noted the staples to the lower right leg were intact.A temporary care plan dated 2/15/21 indicated the resident had an assisted fall and sustained a skin tear on the right calf. Interventions were noted as "2 people transfer until assessment is done for either a sit to stand or Hoyer." There was no documentation of a thorough and complete investigation of the incident to ensure the service plan was followed and to rule out abuse and neglect. No evidence could be located to show the incident was reported to the local SPD office. The need to ensure resident incidents were promptly investigated and reported as appropriate to the local SPD was discussed with Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. The staff acknowledged the findings. Staff 3 was asked to report the February incident on 4/7/21. Confirmation of the report was received prior to survey exit. 2. Resident 5 was admitted to the facility in September 2018 with diagnoses including nerve pain, anxiety and depression.Review of incident investigations, service plans, progress notes and physician communications for 1/5/21 through 4/5/21 showed the following: The resident's service plan indicated the resident required one staff assistance for dressing, transfers and toileting. * On 3/1/21 at 11:56 pm it was noted the resident "was not put to bed during swing shift, called down at 11:15 pm to be cleaned up and put to bed. Had to give shower because there was feces all over [the resident] ..." There was no documentation of a thorough and complete investigation of the incident to rule out potential staff neglect. No evidence could be located to show the incident was reported to the local SPD office. The need to ensure resident incidents were promptly investigated and reported as appropriate to the local SPD was discussed with Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. The staff acknowledged the findings. Staff 3 was asked to report the February incident on 4/7/21. Confirmation of the report was received prior to survey exit.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations were reflective of the residents' status and addressed all required elements and failed to ensure evaluations were completed quarterly for 3 of 5 sampled residents (#s 3, 4 and 5). Findings include, but are not limited to:1. Resident 3 moved into the facility in February 2021. Review of Resident 3's initial evaluation dated 2/15/21 revealed it lacked information regarding the following required elements: *Customary routines for eating and bathing;*Personality - How the person copes with changes or challenging situations;*Nutritional habits, fluid preferences;*Recent losses; and *Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. The 2/15/21 move-in evaluation was not reflective of Resident 3's back and left shoulder pain. 2. Review of Resident 4's clinical record revealed a lack of documented evidence a quarterly evaluation had been completed for February 2021. 3. Review of Resident 5's clinical record revealed a lack of documented evidence a quarterly evaluation had been completed for January 2021. The need to ensure new move-in evaluations were reflective and included all required elements and evaluations were completed quarterly was discussed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) prior to exit. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status, provided clear instruction to staff for the delivery of services, were updated as needed and were followed for 1 of 5 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in February 2021.Review of the Resident 3's 1/15/21 service plan revealed it was not reflective, did not provide clear instruction, was not updated as needed and/or followed in the following areas: * ADL assist;* Mobility;* Frequency of showers; * Presence of indwelling urinary catheter; * Instructions for catheter care/perineal hygiene; and * Back and left shoulder pain. The failure of the facility to ensure Resident 3's service plan was reflective of the resident's current status, updated as needed and followed was discussed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings.

3. Resident 5 was admitted to the facility in September 2018. The resident's 3/3/21 service plan, 1/5/21 through 4/5/21 progress notes and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, effectiveness of initiated interventions and lacked resident specific directions to staff in the following areas:* Difficulty breathing;* Injury and Non-injury falls; and* Skin issues related to the calf and abdominal folds.The need to ensure monitoring of short term changes were documented at least weekly to resolution and provided clear resident specific directions to staff was discussed on 4/6/21 with Staff 1 (ED) and Staff 2 (Director of Operations). The staff acknowledged the findings.
4. Review of the resident's progress notes indicated Resident 2 experienced the following changes of condition:* 1/17/21 - the resident had a bout of diarrhea.* 2/8/21 - the resident received his/her COVID vaccination.There was no documented evidence the facility determined and documented what actions or interventions was needed for the resident in response to those changes of condition.The need to ensure actions or interventions were documented in the resident's record and communicated to staff was discussed with Staff 1 (Executive Director), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed when residents experienced changes of condition, communicate the actions and interventions to staff on each shift, monitor weekly progress until the condition resolved and refer to the RN when conditions required RN assessment for 4 of 5 sampled residents (#s 1, 2, 3 and 5) who experienced changes of condition. Resident 3 experienced ongoing pain after the facility ran out of the resident's pain medication. Findings include but are not limited to: 1. Resident 3 was admitted to the facility in February 2021 with diagnoses including multiple rib fractures, chronic pain and benign prostatic hyperplasia. Resident 3's 2/15/21 service plan, 2/11/21 physician orders, 2/19/21 through 4/5/21 MAR, progress notes and physician faxes were reviewed. Interviews with the resident and staff were conducted. a. Review of Resident 3's 2/11/21 physician orders revealed Resident 3 had orders for three pain medications, including: * Acetaminophen, 1000 mg every eight hours;* Lidocaine patch 4% to be applied to chest wall daily, on 12 hours/off 12 hours; and * Oxycodone 2.5 mg every four hours as needed. Review of 2/19/21 through 4/5/21 MAR revealed the Lidocaine patch had not been administered as ordered 17 times due to the facility not having the medication in stock. Oxycodone was administered 17 times during the same time frame and was regularly documented as effective in addressing the resident's pain. During an interview on 4/5/21, Resident 3 reported that s/he regularly had left shoulder pain and right back pain, cannot put pressure on left arm when using walker, can only use it to guide walker and had to sleep on his/her right side due to pain. A fax was sent to the physician on 3/17/21 stating Resident 3 needed an oxycodone refill. In a faxed response from the physician dated 3/22/21, the physician indicated their records showed the resident had orders for hydrocodone not oxycodone and requested the MAR be sent. There was no documented evidence located in the resident's clinical record indicating the MAR had been sent as requested. During interviews with Staff 10 (MT) on 4/6/21, she indicated that the facility was out of Resident 3's oxycodone and Lidocaine patches. Review of Resident 3's MAR revealed oxycodone was last administered on 3/22/21.Progress notes after the facility ran out of Resident 3's oxycodone revealed the following: 3/23/21: "Resident is in quite a bit of pain." 3/24/21: "Resident still has arm pain not too bad mainly when [s/he] moves."3/25/21: "Resident has arm pain from [his/her] hurt arm."On 4/6/21, the surveyor requested Staff 2 (Director of Operations) follow up regarding the order for oxycodone. He reported at approximately 4 pm that the facility did not have a current order for the medication. There was no documented evidence the facility monitored pain medications were administered to the resident as prescribed, monitored the stock of medication to ensure they were available for administration, followed up on physician request for the MAR to be sent, determined what actions or interventions were needed to address Resident 3's pain when the resident ran out of oxycodone and Resident 3 experienced ongoing pain after the facility ran out of the resident's pain medication. These deficiencies were discussed with Staff 1 (Executive Director), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings. b. Review of Resident 3's progress note dated 3/21/21 indicated the resident was sent to the emergency department. Review of the after-visit summary sent from the hospital revealed the resident had been diagnosed with urinary retention and an indwelling urinary catheter had been placed. Placement of a urinary catheter constituted a significant change of condition. Review of the clinical record revealed the facility failed to evaluate the resident, refer timely to the facility nurse, document the change, and update the service plan as needed following the significant change of condition. An RN change of condition assessment was not documented in the progress notes until 3/26/21, five days after the catheter was inserted, five days after the catheter was inserted. The TAR did not indicate until 3/26/21 that staff should empty the resident's catheter bag and provide assistance with catheter care and perineal hygiene.Failure of the facility to evaluate the resident, refer timely to the facility nurse, document the change, and update the service plan as needed following the significant change of condition was discussed with Staff 1 (Executive Director), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director). They acknowledged the findings. 2. Resident 1 was admitted to the facility in October 2020 with diagnoses including diabetes. Resident 1's 1/5/21 - 4/5/21 progress notes, Shower Skin Log and Resident Occurrence Report dated 3/24/21 and current service plan were reviewed. Review of a Resident Occurrence Report dated 3/24/21 revealed a "nickel-sized open sore" on top of the right foot had been observed during a shower. There was no documented evidence the facility had determined what actions and interventions were needed to address the resident's condition, no documented monitoring of the wound and no referral to the RN for assessment. On 4/5/21, an RN progress note indicated "top of right foot abrasion is healed."The failure of the facility to determine and document what actions or interventions were needed when the resident experienced a change of condition, communicate the actions and interventions to staff on each shift, monitor weekly progress until the condition resolved and refer to the RN for assessment was discussed with Staff 1 (Executive Director), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings.

Based on interview and record review, the facility failed to ensure an RN assessment was completed in accordance with residents' condition, or was completed timely, for 2 of 4 sampled residents (#s 1 and 3) who experienced changes of condition which required an RN assessment. Findings include, but are not limited to: Refer to C 270, examples 1b and 2.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed staff. Findings include, but are not limited to:Resident 3 was admitted in October 2020 with diagnoses including diabetes and required sliding scale insulin injections three times daily by unlicensed staff.Delegation records for Staff 16 (MT), reviewed on 4/7/21, indicated Staff 5 (RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including: * Willingness of the caregiver;* Task was taught to CG and they were competent to safely perform the task;* CG taught task was specific and not transferable; and * That RN takes responsibility for delegating the task and ensures supervision will occur for as long as RN is supervising performance. The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 2 (Director of Operations), Staff 3 (Interim Assisted Living Director) and Staff 4 (RN). Staff 4 indicated Staff 16 would not administer insulin until the delegation was complete.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure documentation of visits was maintained in the resident's record for 1 of 2 sampled residents (#4) who were receiving home health services from outside providers. Findings include, but are not limited to:Resident 4 was admitted to the facility in November 2017 with diagnoses including a leg infection. During the acuity interview on 4/5/21, Resident 4 was identified as receiving outside provider services related to physical therapy (PT) and wound care. Review of the resident's progress notes and outside provider notes 3/1/21 through 4/5/21 showed physical therapy services started on 3/20/21, skilled nursing services for wound care started on 3/23/21 and occupational therapy services started on 3/26/21. Outside provider visit notes were documented as follows:* Physical therapy visit notes were documented on 3/20/21 and 3/24/21. There were no additional visit notes documented in the resident's record and no indication of the frequency PT services would be provided. * Occupational therapy (OT) visit notes were documented on 3/26/21. There were no additional visit notes documented in the resident's record or indication of the frequency OT services would be provided. * Skilled nursing visits began on 3/23/21. There was one visit documented in the resident's record on 4/2/21 which indicated all dressing changes would be completed by home health. Visits were to occur twice a week on Tuesdays and Fridays. The need to ensure on-going coordination of care was maintained and documented was discussed with Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in September 2018 with diagnoses including nerve pain.Review of the resident's 12/22/20 physician orders and 3/1/21 through 4/5/21 MARs showed an order for hydrocodone-acetaminophen 5-325 mg tab twice daily as needed for pain. The order origination date was noted as 1/15/20. Observation of the locked controlled substances drawer showed no medication card for the resident's ordered PRN pain medication. In interview on 4/6/21 Staff 13 (MT) indicated the resident did not have the medication in the drawer and had not for at least several months. She was aware of the order on the MAR but had no other information on the Hydrocodone. The need to ensure all orders were accurate and medications were filled timely for administration was discussed with Staff 1 (ED) and Staff 2 (Director of Operations) on 4/6/21 and 4/7/21. Staff 2 indicated after additional investigation there was a problem with the pharmacy filling the medication and the facility was now working to get an updated prescription and the medication onsite.3. Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:C 155: Facility Administration: Records;C 282: Delegation;C 302: Systems: Tracking Controlled Substances;C 303: Systems: Medication and Treatment Orders; C 305: Systems: Resident Right to Refuse;C 310: Systems: Medication Administration; andC 315: Systems: Treatment Administration.The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (ED) and Staff 2 (Director of Operations) on 4/6/21 and 4/7/21. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight over the medication and treatment administration system. Findings include, but are not limited to: 1. Review of Resident 3's 2/19/21 through 4/5/21 revealed medications were not administered due to the facility being out of the medication for a total of 145 occurrences. On multiple occasions, documentation on the MAR indicated inconsistent availability of medications. The following is one example: Physician order dated 2/11/21 indicated Resident 3 was to be administered methocarbamol every six hours for muscle spasms. Review of the exception log to the MAR revealed the following: 3/13/21: 12 am: Medication not arrived;6 am: Resident refused;12 pm: Med not in cart:; and6 pm: Initialed as administered.3/14/21: 12 am: Medication initialed as administered6 am: Medication not arrived; and12 pm: Medication not arrived. Other medications with documentation of inconsistent availability included: *Amlodipine;*Finasteride;*Lisinopril;*Metropolol;*Pravastin;*Tamsulosin; and *Trazadone. The failure of the facility to ensure a safe medication system and adequate professional oversight over the medication and treatment administration system was discussed with Staff 1 (Executive Director), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe system for tracking controlled substances, for 2 of 2 sampled residents (#s 2 and 3) who were prescribed and administered narcotic medications. Findings include, but are not limited to:Resident 2 and 3's MARs were reviewed between 3/1/21 and 4/5/21. The following discrepancies related to administration of controlled substances were identified:a. Resident 2 was prescribed oxycodone immediate (a narcotic pain medication) 5 mg tablet - 1 tablet once a day as needed. The Controlled Substance Disposition Record indicated 1 oxycodone tablet was removed from locked storage on 3/18/21 and 3/19/21. However, there was no documentation on Resident 2's MAR that the medications were administered. b. Resident 3 was prescribed oxycodone 5 mg tablet - 1/2 tablet every 4 hours as needed. The medication was documented as removed from locked storage but not documented as administered a total of eight times between 3/17/21 and 3/25/21 as follows:* Once on 3/17/21, 3/18/21, 3/22/21, 3/23/21, 3/24/21 and 3/25/21; and* Twice on 3/19/21.The discrepancies between the Disposition Record and the MARs were reviewed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the documentation was not accurate.

4. Resident 4 was admitted to the facility in November 2017 with diagnoses including high blood pressure and atrial fibrillation.Review of the resident's 12/10/20 signed physician orders and 3/1/21 through 4/5/21 physician communications and MARs showed the following:* An order for Eliquis (blood thinner) 5 mg tablet twice daily at 12:00 pm and 8:00 pm.The medication was administered at 11:00 pm from 3/4/21 through 3/18/21. There was no order in place reflecting the time change for the medication.* An order for metoprolol tartrate (blood pressure medication) 25 mg tablet twice daily at 12:00 pm and 8:00 pm. The medication was documented as administered at 11:00 pm beginning on 3/4/21. There was no order in place reflecting the time change for the medication. * Multiple medications were not documented as administered on 3/12/21, including antibiotics, antidepressant medication, yeast rash ointment, blood thinner and blood pressure medications.The need to ensure medications were administered as ordered by the physician was discussed with Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/6/21. The staff acknowledged the findings.5. Resident 5 was admitted to the facility in September 2018 with diagnoses including edema.Review of the resident's 12/22/20 signed physician orders and 3/1/21 through 4/5/21 physician communications and MARs showed the following:* An order for gabapentin 300 mg daily at bedtime, 8:00 pm. The MAR showed the medication was administered at 6:00 pm daily. There was no order in place reflecting the time change for the medication administration.* Multiple medications were not documented as administered on 3/12/21 and 3/21/21, including eye drops, supplements, blood pressure medications and an anti-depressant.The need to ensure medications were administered as ordered by the physician was discussed with Staff 1 (ED) and Staff 2 (Director of Operations) on 4/6/21. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the residents' record for all medications that the facility was responsible to administer and failed to ensure orders were carried out as prescribed for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5), whose orders were reviewed. Resident 3 was not administered two medications to treat benign prostatic hypertrophy on multiple occasions, was sent to the emergency department twice for urinary retention and a urinary catheter was placed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility February 2021 with benign prostatic hypertrophy (BPH), hypertension, multiple rib fractures and chronic pain. Physician orders dated 2/11/21, 2/19/21 through 4/5/21 MAR, progress notes and physician faxes were reviewed. Interviews with facility staff and Resident 3 were conducted. a. Physician orders dated 2/11/21 indicated Resident 3 was prescribed tamsulosin and finasteride, medications used to treat BPH, for which symptoms can include urinary retention. Review of the 2/11/21 through 4/5/21 MAR revealed the resident was not administered tamsulosin 2/21/21, 2/23/21, 3/10/21 - 3/17/21, 3/19/21, 3/20/21, 3/22/21, and 3/23/21. Resident 3 was not administered finasteride 3/2/21, 3/3/21, 3/13/21, 3/14/21, 3/15/21 and 3/16/21. A progress note dated 3/18/21 indicated Resident 3 was sent to the Emergency Department for constipation. Review of the after-visit summary sent from the Emergency Department indicated the resident was diagnosed with constipation and urinary retention. Another progress note dated 3/21/21 indicated Resident 3 was sent to the Emergency Department that day. Review of the after-visit summary from the ED indicated the resident was diagnosed with abdominal pain, constipation and acute urinary retention and that an indwelling urinary catheter had been placed.Resident 3 was not administered tamsulosin or finasteride to treat benign prostatic hypertrophy on multiple occasions, was sent to the emergency department twice for urinary retention and a urinary catheter was placed. b. Review of the 2/19/21 through 4/5/21 MAR revealed the facility failed to administer multiple medications as ordered for a total of 145 occurrences due to the facility not having the medication, including: * Acetaminophen (pain);* Amlodipine (hypertension);* Lidocaine patch (pain);* Artificial tears (dry eyes): * Docusate sodium (bowel management);* Finasteride (BPH);* Levothyroxine (thyroid);* Lisinopril (hypertension);* Melatonin (sleep support);* Metropolol (hypertension);* Polyethylene glycol (bowel management);* Pravastin (cholesterol);* Senna (bowel management); * Tamsulosin (BPH); and * Trazadone (Sleep). c. Artificial Tears: Review of the MAR revealed multiple occasions from 3/24/21 - 3/31/21 when Artificial Tears were not administered. Staff indicated on the exception log that the medication was held per physician order. There was no documented evidence of an order from the physician to hold the medication. d. Amlodipine: Physician order dated 2/11/21 indicated the medication should be held for systolic BP lower than 110. There was no documented evidence the facility had monitored Resident 3's blood pressure per the physician order. e. Levothyroxine: Physician order dated 2/11/21 instructed the medication was to be administered on an empty stomach. Breakfast was served starting at 7:30 am in the facility. During an interview with Staff 10 (MT) on 4/6/21, she stated she often gave Resident 3 his/her morning medication at breakfast and had done so that day. Resident 3 confirmed during an interview on 4/6/21 that s/he had received his morning medications at breakfast.The failure of the facility to ensure written, signed physician orders were documented in the residents' record for all medications that the facility was responsible to administer and that medications were administered as prescribed was discussed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings. 2. Resident 1 was admitted to the facility in October 2020 with diagnoses including diabetes. Review of Resident 3's 1/8/21 physician orders and 3/1/21- 4/5/21 revealed the following: There was no documented evidence the facility administered Insulin Lispro as ordered on the following occasions: * 3/4/21, 5 pm dose;* 3/7/21, 8 am dose; * 3/9/21, 8 am dose; * 3/21/21, 8 am and 12 pm dose;* 3/23/21, 8 am dose;* 3/24/21, 8 am dose;* 3/27/21, 8 pm dose, * 3/28/21, 12 pm dose, * 3/29/21, 8 am dose, and* 3/30/21, 8 am dose. The failure of the facility to administer medications per physician orders was discussed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings.
3. Review of Resident 2's MAR, dated 3/1/21 to 4/5/21 identified the following deficiencies:* On 3/3/21 PRN acetaminophen was administered for "foot pain", but physician orders stated it was prescribed for fever.* The MAR lacked documentation the following medications were administered as ordered: - Doxycycline on 3/12/21, 3/15/21, 3/16/21, 3/27/21 and 4/2/21; - Ferrous Sulfate on 3/12/21; - Gabapentin on 3/12/21; - Oxycontin on 3/12/21; - Pantoprazole on 3/21/21; - Pravastatin on 3/12/21, 3/15/21, 3/16/21, 3/27/21 and 4/2/21;* The MAR lacked documentation the following therapeutic garments were removed in the evening as ordered: - Compression stockings on 3/12/21, 3/15/21, 3/16/21, 3/27/21 and 4/2/21; - Circaids compression wraps on 3/12/21; and* Daily blood pressure was not documented on 4/1/21 as ordered. On 4/7/21 the need to ensure all written orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Assisted Living Director). They all acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 3 sampled residents (#s 3, 4 and 5) who had documented medication and/or treatment refusals. Findings include, but are not limited to:Resident 4 and 5's 3/1/21 through 4/5/21 MARs and Resident 3's 2/19/21 through 4/5/21 MARs were reviewed. The residents' records showed multiple medication and treatment refusals. There was no documented evidence the facility notified the physician each time the residents refused to consent to the orders. On 4/6/21 and 4/7/21, the need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (ED) and Staff 2 (Director of Operations). They acknowledged the findings.

2. Refer to C 155.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included reasons for use for all medications and included clear instructions for all medications and treatments the facility was responsible to administer for 1 of 4 sampled residents (#3) whose MARs were reviewed. Findings include, but are not limited to:1. Review of Resident 3's 2/11/21 physician orders and 2/19/21 through 4/5/21 MAR revealed the following: a. There were multiple blanks on the MAR where staff failed to initial whether the resident was administered the medication. b. The following medications lacked reasons for use: * Lidocaine patch;* Finasteride;* Warfarin;* Lisinopril; and * Metropolol tartrate. The failure of the facility to ensure Resident 3's MAR was accurate and included reasons for use for all medications was discussed with Staff 1 (Executive Director), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR/TAR, with clear instructions to staff, accurate documentation and specific treatment orders by a legally-recognized practitioner was maintained for 3 of 3 sampled residents (#s 3, 4 and 5) with treatments in place. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in November 2017 with diagnoses including edema and a leg infection. Review of the resident's temporary service plans, progress notes, MARs/TARs, physician orders and home health notes from 1/5/21 through 4/5/21 showed the following: * On 2/15/21 the resident was noted to have a wound to the right leg which resulted from a fall. The resident was seen at the hospital and staples were placed. * Progress notes between 2/28/21 and 4/2/21 indicated staples were removed from the wound, the resident was treated for cellulitis of the wound and wound treatments were being completed by staff. The treatments noted in the progress notes included wrapping of the leg, non stick pads and antibiotic ointment.A dressing change and/or wrap was noted on seven occasions in the progress notes. However, there was no specific instruction for staff and no physician's order as to what kind of treatment and dressing change was to be utilized for the leg wound. In interview on 4/7/21 Staff 10 (MT) indicated the wound on the resident's leg was being cleaned and the dressing changed 2-3 times a day, including antibiotic ointment, a non stick pad and a gauze wrap. Staff 10 further indicated the nurse showed her what to do before she started taking care of the treatments. Staff 10 stated she usually documented on the MAR but home health was now handling all of the dressing changes for the resident's leg. The need to ensure the facility obtained signed physicians orders for treatments, included clear instructions for staff and documented treatments administered on the treatment administration record was discussed with Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. They acknowledged the findings. 2. Resident 5 was admitted to the facility in September 2018.Review of the resident's temporary service plans, progress notes, MARs/TARs and physician orders from 1/5/21 through 4/5/21 showed the following: * The resident had an order for Nystatin cream to be applied topically to affected area for yeast rash.* Progress notes indicated Nystatin cream was applied to open, sore areas in the residents panus (abdominal folds) once on 3/29/21, twice on 3/30/21, once on 4/1/21 and once on 4/4/21.The facility staff failed to document any of the treatments administered on the resident's treatment administration record. The need to ensure all treatments administered by the facility were documented on the treatment administration record was discussed with Staff 1 (ED) and Staff 2 (Director of Operations) on 4/6/21. The staff acknowledged the findings.
3. Resident 3 was admitted to the facility in February 2021. Visit summary notes sent from Resident 3's visit to the Emergency Department on 3/21/21 indicated that an indwelling catheter had been placed. On 3/26/21, entries were added to the MAR indicating staff were to empty Resident 3's catheter bag and provide "peri care/catheter care" to the resident. No instructions for cleaning the catheter or for performing perineal care were included on the TAR. During an interview on 4/6/21, Staff 13 (MT) stated she had not been provided any instruction regarding catheter care or assisting the resident with perineal hygiene. The failure of the facility to ensure clear instruction to staff was included on the TAR for all treatments the facility was responsible to administer was discussed with Staff 1 (ED), Staff 2 (Director of Operations) and Staff 3 (Interim Director of Operations) on 4/7/21. They acknowledged the findings.

3 a. Observation of Resident 4 on 4/5/21 revealed the resident was assisted to the toilet and staff then left the room. When interviewed, the resident stated it had been 10 - 15 minutes since staff had left and said they would be right back. Resident 4 stated if they did not come back soon enough s/he would pull the call light but otherwise s/he would just wait since the staff said they would come back. The call light was not activated during this observation. Staff returned to the room to assist the resident from the toilet approximately 30 minutes after the resident was placed in the bathroom.Resident 4 stated long waits were common and staff had a hard time getting to everyone quickly and some residents take a long time to help. Resident 4 stated s/he needed two people to help with some of her/his care and could tie up the staff on the longer side. Meals to apartments were often slow, medications could be slow along with getting help with care and getting the call light answered. The resident indicated s/he has waited 30 - 60 minutes on the long side for staff to answer the light or return when they have needed to leave the room. Resident 4 indicated s/he has had a couple very bad falls with injury so s/he does not try to get up without staff. b. Observations of the second floor hallways and call light box on the morning of 4/6/21 showed the following:* Room 244 - room call light was on for approximately 41 minutes before staff answered and cleared the light;* Room 239 - room and pendant light were on for approximately 30 minutes before a resident came out of the room searching for assistance in the hallways;* Room 232 - pendant light was on for approximately 55 minutes before staff entered the room to check on the resident. This surveyor checked on the resident prior to staff to ensure safety. Staff entered approximately ten minutes after the surveyor arrived; and* Room 124 - pendant light was on for approximately 22 minutes before staff answered and cleared the light.4. Interviews with four non-sampled residents on 4/5/21 and 4/6/21 revealed call light response time concerns. The residents indicated call lights frequently were not answered for 30 - 45 minutes or more, from the time they requested assistance. The residents stated the facility needed additional staff in order to meet all the residents' needs including those who needed two staff to assist them with care. The residents reported medications were routinely not administered on time with the longest wait times over 60 minutes. Two residents indicated when calls were not answered or medications were late they started walking the halls to find someone to help them with what they needed. Two residents indicated staff turn-over had been frequent and multiple people had been hired and quit in just a few months. One resident was new to the facility and indicated s/he felt very nervous about being able to get anyone to answer her/his calls for help. 5. Interviews were conducted on 4/5/21 and 4/6/21 with multiple staff and showed the following:Staff 8 (CG) and Staff 9 (CG) indicated there were two caregivers and a med tech scheduled on day shift and swing shift. There was also supposed to be a bath aide for part of the shift but that was not consistently happening. The staff indicated they do the best they could to answer lights quickly and at least check in on residents but were not always successful. The staff both indicated there were extended waits for residents before they could answer lights and provide care. They had not left any resident completely unattended but there had been residents left long periods between ADL care so they may have been incontinent, not re-positioned as often or left longer between transfers. The staff indicated there were at least five residents who required two staff assistance for transfers or care, a couple of whom needed mechanical lifts. Staff 9 indicated when they both were in a room the lights on the floor go unanswered as the medication technician was usually busy trying to pass the medications. Staff 11 (CG) stated she had a hard time getting to all her residents in a timely manner. Staff 11 indicated there was supposed to be a part time bath aide but was not consistent which made it difficult to get resident showers done, assist residents with toileting, laid down, etc. Staff 11 stated they had several residents who required two people for transfers and care. She stated she had transferred residents who needed two people,on her own multiple times because there was not a second person available to help. Staff 11 further stated she tried to get to everyone but was not getting everything done and lights often went unanswered for long periods of time.Staff 12 (CG) stated there was supposed to be a part time bath aide which they had for a short period of time. The bath aide quit so all the laundry and showers reverted back to the caregivers. She at least had checked on the residents when lights were going off to make sure they were safe. Staff 12 stated there were several residents who were two-person transfers, two person for care or had a mechanical lift. Meal times, shift change and bed time were some of the busiest times for call lights and assisting residents. Staff 12 indicated if she was giving a shower, residents lights could go 45 minutes or more before staff could answer or assist. The medication technician was not typically helping answer call lights because she was busy trying to get the medications administered. When a staff was on break, call lights could go at least 30 minutes or more before staff had returned from their break and could answer them. Staff 12 indicated she prioritized as much as possible but sometimes things did not get done including laundry and residents' showers. The observations and resident reports of long wait times and failure to complete the morning medication passes timely was discussed with Staff 1 (Executive Director), Staff 2 (Director of Operations) and Staff 3 (Interim Assisted Living Director) on 4/7/21. Staff 2 acknowledged the call light response times were unacceptable and stated he would immediately schedule an additional CG on both the day and evening shifts.
Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Failure to respond to call lights and to complete medication administration timely resulted in significant emotional harm and put residents at risk for serious harm. Findings include, but are not limited to:1. The survey team made observations of call light response times on 4/6/21. Call light room numbers were displayed on LED pads in multiple locations on the first, second and third floor hallways of the Assisted Living. The following was observed:* At 9:00 am, room 244 started flashing.* At 9:08 am, room 239 started flashing and was cleared at 9:39 am;* At 9:10 am, rooms 232 and 345 started flashing.* At 9:26 am, room 343 started flashing.At 9:42 am, room 244's call light was cleared. At 9:45 am, Staff 10 (MT) was observed exiting room 244. She confirmed she had just finished assisting that resident. She explained she was helping the two caregivers respond to the call lights.This surveyor had been sitting near room 345 since approximately 9:20 am. Initially, the resident could be heard moaning and saying "Oh, no" repeatedly. At 9:50 am, the resident began moaning again. At 9:55 am the surveyor knocked on the door (which was fully open) and confirmed the resident had pushed the call light, no one had responded and s/he still needed assistance. The resident stated s/he was having a problem with his/her genital area.This surveyor immediately notified Staff 1 (Executive Director) and Staff 2 (Director of Operations) that multiple call lights had been sounding for over 45 minutes and that the resident in room 345 had been moaning and calling out. Staff 1, one of the CGs, and Staff 5 (RN) responded to room 345 at 10:05 am.* At 10:05 am, a care staff responded to room 343.* At 10:10 am, a care staff responded to room 232.At 10:25 am, this surveyor followed-up with the resident in room 345. The resident began by saying it takes a long time for staff to respond when s/he calls for help and then became teary and started crying. The resident apologized for becoming "emotional" and went on to say s/he didn't know why s/he was in the facility, didn't know what to do and didn't know where to go. The resident was dressed in a t-shirt, incontinent brief and socks, with a blanket covering the lower body. The resident showed the surveyor the incontinent brief s/he had on needed to be changed. The brief was observed to be well-worn with rips along the waistband. Staff 1 returned to assist the resident with a new TV remote at 10:34 am. At 10:35 am, a HH OT arrived and was overheard saying she would be working with the resident on taking a shower.2. The 8:00 am medication pass was observed by the survey team on 4/6/21 and 4/7/21.On 4/6/21, Staff 10 (MT) was observed by two surveyors to administer her last medication to an unsampled resident at 10:15 am. Upon exiting the resident's room, Staff 10 verbally acknowledged she had finished her 8:00 am medication pass. This meant the morning medication pass had been completed 75 minutes after the prescribed time. This surveyor had notified Staff 1 and Staff 2 at 9:55 am that the 8:00 am medication pass had yet to be completed. On 4/7/21, Staff 10 was observed to administer her last medication to an unsampled resident at 9:55 am. At least three other residents were observed to be given their medications after 9:30 am. This meant the morning medication pass had been completed 55 minutes late.In an interview on 4/7/21 at 1:50 pm, Staff 10 acknowledged she had not completed the morning medication passes on 4/6/21 and 4/7/21 within the accepted time frame.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled direct care staff (#s 11 and 12) completed an approved pre-service dementia training. Findings include, but are not limited to:Staff training records were reviewed on 4/7/21 with Staff 1 (Executive Director) and Staff 6 (Assistant Executive Director). Staff 11 (CG) was hired 2/18/21 and Staff 12 (CG) was hired 2/24/21.The facility did not have documentation that Staff 11 and Staff 12 completed the required pre-service dementia training prior to providing direct care to residents.The need to ensure documentation of all completed training was obtained and available for inspection was discussed with Staff 1 and Staff 6. They acknowledged the lack of documentation of the completed training.

Based on interview and record review, it was determined 2 of 2 sampled newly-hired direct care staff (#s 11 and 12) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 4/7/21 with Staff 1 (Executive Director) and Staff 6 (Assistant Executive Director). Staff 11 (CG) was hired 2/18/21 and Staff 12 (CG) was hired 2/24/21.The facility did not have documentation that Staff 11 and Staff 12 completed the required First Aid and abdominal thrust training.The need to ensure all training was completed within required timeframes was discussed with Staff 1 and Staff 6. They acknowledged Staff 11 and 12 had not completed First Aid training.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month according to the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff and recorded on alternate months. Findings include, but are not limited to:On 4/7/21 review of facility records and interviews with Staff 1 (ED) identified the following deficiencies:Written records of fire drills conducted lacked documentation of the following: * Escape route used;* Evacuation time period needed; and* Number of occupants evacuated.There was no documented evidence the facility was providing fire and life safety instruction to staff every other month, as required.On 4/7/21 the need to ensure regular fire drills were conducted every other month according to the OFC and fire and life safety instruction was provided to staff on alternate months was discussed with Staff 1 and Staff 2 (Director of Operations). They both acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all fire drills were conducted according to the Oregon Fire Code (OFC) and residents were instructed about the facility's fire and life safety procedures per OFC. Findings include, but are not limited to:On 4/7/21 review of facility records and interview with Staff 1 (ED) identified the following deficiencies:* Written records of fire drills conducted lacked documented evidence of alternate evacuation routes used; and* There was no documented evidence residents were instructed about the facility's fire and life safety procedures at least annually, with written records kept of training content and residents attending.On 4/7/21 the need to ensure all fire drills were conducted according to OFC guidelines and residents were instructed at least annually on the facility's fire and life safety procedures was discussed with Staff 1 and Staff 2 (Director of Operations). They both acknowledged the findings.