Arcadia Senior Living

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 06/23/25.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 caregiving staff (#s 21, 22, 24, and 26) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to: The facility's training records were reviewed with Staff 3 (Business Office Manager) on 01/14/25 at 11:00 am. Staff 21 (MT), hired 11/25/24, Staff 22 (MT) hired 10/22/24, Staff 24 (CG), hired 11/26/24, and Staff 26 (CG), hired 10/22/24, lacked documented evidence they had demonstrated competency in all areas within 30 days of hire, including but not limited to: • Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; • Conditions that require assessment, treatment, observation and reporting; and/or • First Aid and Abdominal thrust. The need to ensure staff had demonstrated competence in all required areas within 30 days of hire was reviewed with Staff 2 (Executive Director) and Staff 3 on 01/15/25 at 9:19 am. They acknowledged the findings.

1. Actions to be Taken: a. Arcadia training/orientation has been updated to include: b. Identification of changes in the resident’s physical, emotional, and mental functioning and documentation and reporting on the resident's changes of condition that require assessment, treatment, observation, and reporting. c. First Aide and Abdominal Thrust 2 NewHire training has been updated as of 01/28/2025 by the Executive Director and Health Services Director. This addition is a permanent change and will make it so that all future employees will receive this training. This has been included in the training that all new hires complete and added to the training checklist that is signed by both the trainer completing the training and the employee. Once the direct care staff have completed the online training and the floor training the Health Care Coordinator or the Resident Care Coordinator will complete the skills competency checklist to ensure that all staff are able to perform all of the care duties, this competency evaluation will also be completed within 30 days of hire. A copy will be maintained in the employee file.We will complete an audit by February 14, 2025 and any missing training will be completed by March 16, 2025. This wil inclide all staff byOnce the direct care staff have completed the online training and the floor training the Health Care Coordinator or the Resident Care Coordinator will complete the skills competency checklist to ensure that all staff are able to perform all of the care duties, this competency evaluation will also be completed within 30 days of hire. A copy will be maintained in the employee file.We will complete an audit by February 14, 2025 and any missing training will be completed by March 16, 2025. This will include all employees but speficially those listed in the SOD Staff 21, 22, 24 and 26. 3. The Health Services Director will complete this training with all current staff by Feb.28, 2025. A signed in-service sheet will be signed off on and included in the training tracking binders This training gets reviewed quartly by the Health Services Director and Executive Director to determine if it needs to be changed or updated. 4. The Health Services Director will be responsible for making sure this training is completed, and the Health Care Coordinator will assist in completing this training and tracking completion.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document 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, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

Based on interview and record review, it was determined the facility failed to ensure 7 of 7 long-term staff (#s 17,18,19, 20, 23, 25, and 27) completed six hours of annual in-service training hours related to dementia care topics and/or annual infectious disease training based on their anniversary date of hire, and/or HCBS training was completed by 04/01/24, as required. Findings include, but are not limited to: Staff training records were reviewed with Staff 3 (Business Office Manager) on 01/14/25 at 11:00 am. There was no documented evidence staff completed the following required trainings: a. Staff 23 (MT) hired 08/21/18 and Staff 27 (CG) hired 06/30/21 completed a minimum six hours of annual in-service training related to dementia care and infectious disease outbreak and control. b. Staff 17 (Dietary Server) hired 08/26/23, Staff 18 (Line Cook) hired 06/11/22, and Staff 19 (Housekeeping) lacked annual infectious disease outbreak and control. c. Staff 17, Staff 20 (MT) hired 10/21/20, Staff 23, and Staff 25 (CG) hired 07/01/21 lacked completion of HCBS training by 04/01/24, as required. The need to ensure long-term staff completed and documented annual in-service training including a minimum of six hours related to dementia care, annual infectious disease training and HCBS training was discussed with Staff 2 (Executive Director) and Staff 3 on 01/15/25 at 9:19 am. They acknowledged the findings.

1. Actions to be Taken: All staff must have 12 hours of continuing education annually from their anniversary date of hire. Six hours must be dementia-related, 1 hour of HCBS training, 1 hour of infection control, 1 hour of LGBTQIA2S training every other year, and the remaining four hours every other year will be direct care related. A copy of the CEU training will be maintained in the employee file.We will complete an audit by February 14, 2025 and any missing training will be completed by March 16, 2025. This will include all staff but specifically Staff 17,18,19,20,23,25 and 27 mentioned in the SOD. a. We are in process of getting the employer module set up with Oregon Care Partners, so that we can assign and track this training more efficiently to ensure the annual training is maintained. 2. The Business Office Manager and the Health Care Coordinator will be completing a complete audit of all current employee training to ensure that this is all completed within the proper time frame. 3. The training for each employee will be reviewed by the Health Care Coordinator upon hire for each new employee, The Health Care Coordinator will utilize the new hire training checklist to ensure that all training has been completed before the direct care employee is working on the floor. This training will be reviewed quarterly to ensure all topics are covered and any new training required will be added as needed. 4. The Health Services Director and Executive Director will review the completed training every quarter to ensure that this training is being completed.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document 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, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

Based on interview and record review, conducted during a site visit on 09/13/23 it was determined the facility failed to implement an acuity-based staffing tool (ABST)  for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: A review of the facility's ABST indicated the facility uses the ODHS tool. A review of the facility's records indicated the facility census at the time of entry was 60 residents.  The ABST's "facility section details" printed and received at 12:19 pm indicated the first floor had 27 residents entered and the second floor had 28 residents entered for a total of 55 residents, and does not include 5 residents who moved in between 08/2023 and 09/2023. A review of Resident 2's service plan and ABST indicated the following: · Resident requires staff to set up for mouth care and no time was allotted in the ABST for personal hygiene. · Resident requires transfer assistance in or out of bed or chair and no time was allotted in the ABST. · Resident requires assistance with ambulation and no time was allotted in the ABST. A review of Resident 3's service plan and ABST indicated the following: · Resident requires staff to set up for mouth care and no time was allotted in the ABST for personal hygiene. · Resident requires transfer assistance and no time was allotted in the ABST. In an interview on 09/13/23, Staff 1 (Executive Director) stated the facility lumps services together so safety checks are designated in the service plan to be done with care and grooming and personal hygiene time are combined in the ABST under the grooming time. Also, transfer assistance would never be done by itself so the time to transfer a resident is combined with the care time that staff would provide. Staff 1 confirmed the facility had 60 residents currently and 1 resident moving in soon. The facility failed to fully implement an acuity-based staffing tool that met regulations. The findings of this investigation were reviewed with and acknowledged by Staff 1 on 09/13/2023.

Based on interview and record review, conducted during a site visit on 09/13/23 it was determined the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge for 1 of 1 sampled residents (# 2). Findings include, but are not limited to: In an interview on 09/13/23, Staff 2 (Health Services Director) stated Resident 2 was in the ICU and not thought to make a recovery that would allow him/her to return to the facility. The resident did get well enough to possibly come back to the facility on hospice. The first conversation that was had with the discharge planner was on 08/25/23 stating resident was ready to be discharged, discharge planner left a voicemail on 08/27/23 and the resident was reassessed on 08/28/23 to return on 08/29/23 and have their hospice assessment done upon return. A review of progress notes for Resident 2 indicated the following: · 08/25/23 there was a conversation with the care manager at the VA hospital. · 08/27/23 Staff 2 called to speak to care manager. Staff 2 will come to VA hospital tomorrow (08/28/23) to assess resident for re-admission. · 08/28/23 Staff 2 reassessed resident for re-admission. · 08/29/23 Resident 2 re-admitted to facility. The facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge. The findings of this investigation were reviewed with and acknowledged by Staff 1 on 09/13/2023. Verbal Plan of Correction: The nursing staff was unaware of the 24-hour response time, but moving forward between the 3 nursing staff members they will ensure that this deadline is met for all discharge evaluations.

The findings of the on-site investigation, conducted 09/13/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on interview and record review, it was determined the facility failed to ensure medication and/or treatment orders were carried out as prescribed for 1 of 1 sampled resident (# 6), whose orders included specific instructions to notify the physician of weight gain. Findings include, but are not limited to: Resident 6 was admitted to the facility in June 2021 with diagnoses including congestive heart failure and primary hypertension. Interviews with staff and review of the resident's admission orders and MARs dated 6/25/21 - 8/1/21 indicated the following: Resident 6's orders and MARs included an order to obtain the resident's weight daily and "notify the [primary care provider] if 3 pounds or more weight gain over 2 days or 5 pounds in over 4 days". Per MAR documentation, on 6/28/21 the resident's weight was recorded as 124.5 pounds and on 7/1/21 the resident's weight was recorded as 130.5 pounds, indicating a weight gain of 6 pounds over two days. There was no documented evidence the physician was notified of the weight gain . The need to ensure physician orders were carried out as prescribed was discussed with Staff 4 (LPN) and Staff 3 (Director of Operations) on 8/4/21. They acknowledged the findings.

1.  The primary care provider was notified of the weight variances on 7/1/21. 2.  Med tech training will be provided and residents will be encouraged to provide their own scale whenever possible for consistency. 3.  Weight monitoring will be done by nursing staff at least once per week. 4.  The Health Services Director will monitor residents for weight variances and notify providers if outside parameters.

Based on interview and record review, it was determined the facility failed to carry out medication and treatment orders as prescribed, for 2 of 3 sampled residents (#s 8 and 9) whose orders and MAR were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 8 and 9's signed physician orders and 10/3/21 through 10/26/21 MARs were reviewed during the survey. The following were identified: 1. Resident 8 was admitted to the facility in 09/2021 with diagnoses including coronary artery disease, systolic heart failure and dementia. a. Admission orders included a prescription for memantine (to treat confusion related to Alzheimer's dementia) to be administered BID every morning and evening. Review of the MAR indicated the facility was not administering the medication. In an interview on 10/27/21 at 2:30 pm, Staff 21 (MT) confirmed the facility had the medication but the MAR did not direct the medication technicians to administer the medication. Staff 21 confirmed she had not administered the medication that morning and the MAR did not direct her to administer the medication later in the day. In an interview on 10/27/21 at 2:45 pm, Staff 3 (Director of Operations) acknowledged the electronic MAR had not been set up correctly, and the facility had not been administering the medication as ordered. b. Resident 8 had an order dated 9/22/21 to check weekly weights and notify the MD (Medical Doctor) if the resident's weight was greater that 195 pounds. The weekly weight taken on 10/7/21 was 196 pounds. The facility did not notify the MD as ordered until 10/14/21. The need to ensure signed physician orders were carried out as prescribed was reviewed with Staff 3, Staff 18 (ED) and Staff 19 (Health Services Director) on 10/27/21. They acknowledged the findings. 2. Resident 9 was admitted tot the facility in 03/2021 with diagnoses including diabetes mellitus type 1 and congestive heart failure. a. The MAR directed staff to notify the nurse if the resident's daily weight changed by three pounds or more from the previous day. Resident 9's weight changed by 3 or more pounds on 10/5/21, 10/9/21 and 10/17/21. There was no documented evidence the nurse was notified of the weight changes. b. Resident 9 had orders to call the MD (Medical Doctor) if his/her CBG value was above 500. Resident 9's CBG taken prior to the lunch meal on 10/5/21 was documented to be 522. The facility did not notify the physician of the CBG until 10/27/21 when the facility LPN sent a record of the resident's CBGs for the month. c. Resident 9 had orders to administer insulin prior to each meal per a sliding scale (dosage is based on pre-defined CBG ranges). Review of the MAR indicated the facility administered incorrect dosages of insulin on 10/15/21, 10/19/21 and 10/26/21. The need to ensure signed physician orders were carried out as prescribed was reviewed with Staff 3 (Director of Operations), Staff 18 (ED) and Staff 19 (Health Services Director) on 10/27/21. They acknowledged the findings.

1.. Resident 8's physician order for prescription Memantine was corrected in the electronic MAR so that it would direct the medication technician to administer the medication every morning and every evening.    All Medication Technicians received additional training on thoroughly reading all parameters and acting on parameters that are outside of parameters immediately.  Staff received training on how to read the parameters, who to report the outside parameters to, and to chart on the reporting of the outside parameters.   2  HSD and RCC will be looking at all paraemeters weekly to verify they are being charted and followed up on correctly.  New HSD was shown where the mistake was made on the order entry so that there would not be any errors made on any other entered orders. All new orders will be double checked daily  by Med Tech, RCC then HSD.  All have been shown how this mistake was made to avoid it happening again. HSD will print out a schedule for daily, weekly and monthly weights for all residents and place these on the Medication technicians cart as a reminder for the med tech to weight the residents when needed. The HSD and RCC will verify that the correct weight has been recorded in the electronic MAR and that any paraemeters have been addressed. 3. Medication orders will be checked daily. Parameters will be checked weekly. Weights will be verified weekly and monthly. 4. RCC will be responsible for checking new medications daily for 2nd check.  HSD will be responsible for checking and approving new medications orders and verifying they are on the MAR and that Medication technicians are directed to give the medication daily.   The RCC and HSD will be checking all charts with parameters weekly. RCC and HSD will verify weight reports weekly and monthly according to orders.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all medications administered by the facility for 1 of 1 sampled resident (# 6), whose MARs included medication specific parameters/instructions. Findings include, but are not limited to: Resident 6 was admitted to the facility in June 2021 with diagnoses including congestive heart failure, primary hypertension and atrial fibrillation. Interviews with staff and review of the resident's admission orders and MARs dated 6/25/21 - 8/1/21 indicated the following: Resident 6's orders and MARs included an order for Metoprolol (for atrial fibrillation), which included specific instructions for staff to hold the medication for systolic blood pressure less than 110. The MAR indicated staff administered the medication but the blood pressure section of the MAR was left blank 6/25/21 through 7/26/21. No further documentation for a blood pressure record was provided. The need to ensure MARs were accurate was discussed with Staff 4 (LPN) and Staff 3 (Director of Operations) on 8/4/21. They acknowledged the findings .

1.  Resident 6's MAR was updated to prompt med techs to enter the blood pressure when administering metoprolol. 2.  All new orders will be double checked including Med Tech, RCC and Health Services Director. 3.  MAR audits will be completed once per month to make sure vital signs are being documented on the MAR and are within parameters. 4.  The Health Services Director will oversee the accuracy of the Medication Administration system and the MAR

Based on interview and record review, it was determined the facility failed to ensure new hires completed all pre-service orientation and dementia training prior to beginning their job responsibilities for 3 of 3 newly hired staff (#s 11, 14 and 16) whose training records were reviewed. Findings include, but are not limited to: Training records for Staff 11 (CG), 14 (CG) and 16 (MT/CG), hired 6/11/21, 5/31/21 and 5/1/21 respectively, were reviewed on 8/4/21. There was no documented evidence the pre-service dementia training had been completed. The need to ensure all required pre-service dementia training was completed prior to beginning job duties was discussed with Staff 3 (Director of Operations) on 8/4/21. She acknowledged the findings.

1.  Staff #11, 14 and 16 training records have been reviewed and the required pre-service dementia training has been completed. 2.  The new hire paperwork checklist will include the required trainings and be reviewed per the Health Services Director's direction and double checked by the business office manager to ensure completion. 3.  Training records will be reviewed upon each new hire and monthly thereafter. 4.  The Executive Director and or Business Office Manager will see that the corrections are completed and ensure training is completed per regulations.

Based on interview and record review, it was determined the facility failed to ensure long term staff completed six hours of training related to the provision of care in CBC and six hours of training related to dementia care annually for 3 of 3 long term employees (#s 12, 13 and 15) whose training records were reviewed. Findings include, but are not limited to: Training records for Staff 12, 13 and 15 (CGs), hired on 2/12/20, 5/4/20 and 6/4/20 respectively, were reviewed on 8/4/21. There was no documented evidence the staff completed the required six hours of annual training related to dementia care. The need to ensure all required annual training was completed was discussed with Staff 3 (Director of Operations) on 8/4/21. She acknowledged the findings.

1.  Staff #12, 13 and 15 have completed 6 hours of annual training related to dementia care. 2.  All employee files have been reviewed and a master training list has been created to track required staff training. 3.  Training records will be reviewed at least once per month. 4.  The Executive Director will ensure the training records are updated.  The business office manager will mange the master list and coordinate staff training.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code and fire drill records included all required components. Findings include, but are not limited to: Fire and life safety records for March through July 2021 were reviewed and indicated the following required components were not included in all fire drill records: * Evacuation time required; * Escape route used; * Resident evacuation problems encountered; and * Number of occupants evacuated. The need to ensure fire drill records included all required components was discussed with Staff 3 (Director of Operations) on 8/3/21. She acknowledged the findings.

1. The Fire and life safety form has been reviewed and updated to include all of the required components. 2.  Fire drills will be performed every other month and include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. 3.  The record will be reviewed after each fire drill and monthly. 4.  The maintenance director will ensure fire drills are conducted every other month and the Fire and Life Safety form is completed.  The executive director will ensure accuracy and completion.

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

Refer to C303

The findings of the re-licensure survey conducted 8/2/21 through 8/4/21, 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/04/21, conducted 10/27/21, 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 08/04/21 conducted on 12/15/21 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.