Kellogg Assisted Living at Mary's Woods

The findings of the re-licensure survey, conducted 10/24/23 through 10/26/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 10/26/23, conducted 02/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugarCG: caregivercm: centimeterED: Executive DirectorF: Fahrenheit HH: Home Health LPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration Record MCC: Memory Care Community mg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 10/26/23, conducted 05/10/24, 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 ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to:The facility was toured on 10/24/23 at 10:30 am. The following items were not posted as required:* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility;* The current facility staffing plan; and* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.The need to ensure all required items were posted was reviewed with Staff 1 (Administrator) and Staff 3 (Maintenance Manager) on 10/26/23. Staff 1 acknowledged the items were not posted as required.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements for 1 of 1 sampled resident (#1) whose initial evaluation was reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 07/2023 with diagnoses including chronic kidney disease and mild cognitive impairment.Resident 1's initial move-in evaluation lacked information regarding the following elements:* Customary eating routine;* Cultural preferences and traditions;* Effective non-drug interventions in regards to mental health issues;* Personality, including how the person copes with change or challenging situations;* How the person expresses pain or discomfort;* Nutritional habits and fluid preferences;* History of dehydration;* Emergency evacuation ability; and* Unsuccessful prior placements.The need to ensure evaluations included all required information was reviewed with Staff 1 (Administrator) and Staff 2 (RN Manager) on 10/25/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to Oregon Fire Code (OFC) and failed to keep a complete fire drill record. Findings include, but are not limited to:Fire drill records were reviewed on 10/25/23. The following deficiencies were identified:a. Fire drills conducted on 04/19/23 and 06/27/23 did not require the residents to participate in the drill. Additionally, the fire drill records lacked documentation of the following information:* 04/19/23: Number of occupants evacuated.* 06/27/23: Location of simulated fire origin, escape route used, number of occupants evacuated and problems encountered and comments relating to residents who resisted or failed to participate in the drills.b. The facility conducted a full building evacuation (called a "Code Black") on 09/21/23. The fire drill record lacked documentation of the following information:* Location of simulated fire origin;* Escape route used; and* Number of occupants evacuated (the form indicated "all").c. The facility was not relocating residents and due to the lack of documentation, it was unclear as to whether alternate exit routes were used during fire drills to react to varying potential fire origin points.The need to ensure fire drills were conducted and documented as required was reviewed with Staff 1 (Administrator) and Staff 4 (Safety Manager) on 10/26/23. They acknowledged the deficiencies.

Based on observation and interview, 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 C630.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to:The facility was toured on 10/24/23 at 10:30 am. Each resident apartment had its own washer and dryer. Additionally, there was a room on the second and third floors that contained a hopper sink and a separate room, also on the second and third floors, containing multiple residential-type washers and dryers. None of the washers had a hot water rinse setting option. No chemical disinfectant products were observed in the hopper or laundry rooms.In an interview on 10/25/23, Staff 7 (MT) stated that when she discovered soiled linens or clothing, she bagged the items, rinsed them as needed in one of the hopper sinks and then either washed the items in the laundry room or in the resident's apartment washer, depending on the size of the load. She stated staff used the resident's personal laundry detergent. She did not indicate the facility utilized a chemical disinfectant and stated the residents were not required to provide a disinfectant, though a few resident's had some type of a spray she could use on any stains prior to the wash.In an interview on 10/26/23, Staff 8 (CG) stated that when she discovered soiled linens or clothing, she rinsed the items in the resident's apartment sink, if needed, and washed the items in the resident's apartment washer, unless the load was too large and needed to be washed in the laundry room. She confirmed staff used the resident's laundry detergent. She did not indicate the facility utilized a chemical disinfectant.The interviews were reviewed with Staff 1 (Administrator) and Staff 3 (Maintenance Manager) on 10/26/23. Staff 1 stated staff were supposed to bag soiled items and transport them to a separate building where the items would be laundered in a commercial washer that provided proper disinfection. She acknowledged the staff interviewed were not following proper procedures.
Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used when washing soiled linens and soiled clothing. This is a repeat citation. Findings include, but are not limited to:The facility was toured on 02/14/24 at 10:30 am. Each resident apartment had its own washer and dryer. Additionally, there was a room on the second and third floors that contained a hopper sink and a separate room, also on the second and third floors, containing multiple residential-type washers and dryers. None of the washers had a hot water rinse setting option. No chemical disinfectant products were observed in the hopper or laundry rooms.In interviews on 02/14/24, Staff 6 (MT) and Staff 7 (MT/CG) stated when they discovered soiled linens or clothing, the items were rinsed in one of the hopper sinks and then either washed in the laundry room or in the resident's apartment. Staff 6 and Staff 7 stated they used the resident's personal laundry detergent and they were unaware of laundry detergent with a chemical disinfectant in the laundry room. In an interview on 02/14/24 at 11:35 am, Staff 1 (Administrator) confirmed the facility did not have laundry detergent with a chemical disinfectant available in the laundry rooms for staff or residents to use with soiled linens or 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 and Staff 2 (RN Manager) on 02/14/24. They acknowledged the findings.

The findings of the initial survey conducted 12/15/20 through 12/17/20 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 first re-visit to the initial survey of 12/17/20, conducted 3/10/21, 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 and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 5 was admitted to the facility in March 2020 with diagnoses including dementia.Review of the resident's progress notes, incident investigations and physician communications for 9/1/20 through 12/15/20 showed the following:* On 10/7/20 it was noted the resident's PRN Oxycodone was given outside physician orders directing bedtime administration only, the medication was given at all times of the day and evening if/when requested. The supply of medication was depleted faster than planned and the pharmacy would not refill the medication because it was too soon. The medication error was investigated but there was no documentation to reflect the response of the staff at the time of the event and follow-up action by staff;* The resident's spouse reported s/he gave 325 mg of Tylenol to the resident on 10/12/20. There was no documentation the incident was investigated; * The resident was found on the floor on 10/12/20 having a panic attack, the resident was found to have reddened knees but no other injuries. The incident was not thoroughly investigated in a timely manner including follow-up action by staff to the event and administrator review to rule out abuse and neglect; and* The resident slipped out of bed and was found on the floor on 12/2/20, no injuries were noted. The incident was not thoroughly investigated in a timely manner, including follow-up action by staff to the event and administrator review to rule out abuse and neglect. The need to complete a thorough investigation including follow-up action by staff to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC) on 12/16/20. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure investigations of all incidents were thorough and complete, reviewed by the administrator and all incidents of suspected abuse or neglect and injuries of unknown cause were reported to the local SPD office in a timely manner for 2 of 2 sampled residents (#s 1 and 5). Findings include, but are not limited to:1. Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation.a. An investigation report dated 9/16/20 indicated the resident had a 12 cm x 1 cm scratch on his/her left hip that could have been from "brief scratching during removal... too small or from a nail scratch." The resident, who had memory impairments, was not interviewed for the report. There was no documented evidence abuse and neglect had reasonably been ruled out, that the injury of unknown cause had been reported to the local SPD office or that the investigation had been reviewed by the administrator.b. An investigation report dated 10/2/20 following a fall indicated staff discovered "scattered bruising on body at various stages of healing." There was no documented evidence of the bruises prior to the investigation, no subsequent investigation and/or report of the injury of unknown cause to the local SPD office and no administrator review of the investigation report. c. An investigation report dated 11/7/20 indicated Resident 1 had a fall with injuries which included hematomas to left calf and left cheek. The resident was unable to inform staff how she fell. There was no documented evidence the investigation reasonably ruled out abuse and neglect, was reviewed by the administrator or that the injuries of unknown cause had been reported to the local SPD office. d. An investigation report dated 12/1/20 following a fall indicated "three small scratches that appeared old were on the resident's right buttock." There was no documented evidence the facility had investigated the injury of unknown cause prior to or subsequent to their discovery on 12/1/20, no evidence the scratches had been reported to the local SPD office and no evidence the administrator had reviewed the investigation. e. A progress note dated 12/2/20 stated Resident 1 had bruising and edema on his/her left foot. There was no documented evidence the facility investigated the injury of unknown cause to rule out abuse and neglect or notified the local SPD. The need to thoroughly investigate incidents of suspected abuse and/or neglect and injuries of unknown cause in a timely manner and the need to report to SPD if unable to reasonably rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). They acknowledged the findings.Staff 1 was asked to report the incidents to the local SPD office and provided confirmation of the reports prior to survey exit.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Residents 5's service plan dated 12/9/20 was not reflective of the resident's current status and lacked clear direction to staff in the following areas:* Falls;* Wanderguard use;* Behaviors/angry outbursts;* Dressing;* Arm fracture; and* Cast placement and care.The need to ensure all resident service plans were reflective and provided directions to staff was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and 3 (RCC). The staff acknowledged the findings.
2. Residents 1's service plan dated 10/29/2020 was not reflective of the resident's current status and lacked clear direction to staff in the following areas:* Wheelchair mobility;* Behaviors during personal care;* Afternoon naps;* Groin rash;* Incontinence; * Discontinued use of recliner; and * Use of hospital bed. The need to ensure all resident service plans were reflective and provided directions to staff was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and 3 (RCC). The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident and failed to monitor changes of condition and document on the progress of the condition at least weekly until resolved, for 1 of 2 sampled residents (# 1) who experienced changes of condition requiring monitoring. Findings include, but are not limited to:Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation. The resident's 10/29/20 service plan and 9/1/20 through 12/15/20 progress notes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident specific directions to staff in the following areas:* Bruising;* Edema;* Groin rash;* Symptoms of UTI;* Scratches on buttocks; and* Fall from the wheelchair. The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear resident specific directions to staff was discussed on 12/17/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 5) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:Resident 5 was admitted to the facility in March 2020 with diagnoses including Alzheimer's disease. Resident 5's signed physician orders dated 9/24/20 included the following orders:* Oxycodone 2.5 mg at bedtime PRN for pain. Resident 5's Controlled Substance Disposition logs and MARS, reviewed from 11/1/20-12/15/20 showed the following:* A 12/5/20 dose of Oxycodone at 5:00 am was reflected on the disposition log but not on the MAR; and* A 12/6/20 dose of Oxycodone at midnight was reflected on the MAR but not on the disposition log. Comparison of the medication dosing card to the disposition log, showed the amount of medication left was reflected accurately on the log. The need to ensure an accurate narcotic disposition log was maintained for all controlled substances was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff reviewed the documentation and acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physicians orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 5) whose orders were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in March 2020 with diagnoses including Alzheimer's disease.Review of the resident's 9/24/20 signed physician orders, 9/1/20 through 12/15/20 progress notes, physician faxes and 11/1/20 through 12/15/20 MARs showed the following medications were not administered as ordered by the physician:* 11/5/20 morning medications including Calcium Carbonate (supplement), Vitamin D, Sertraline (antidepressant), Aspirin, Levothyroxine (thyroid medication) and Fosamax (bone health medication) were signed as given between 8:00 and 9:00 am. An exception note indicated the medications were given in the afternoon, approximately 3:00 pm. Physician's orders indicated Levothyroxine was ordered for the morning and Calcium Carbonate was ordered twice a day. The remaining medications were ordered as once daily. There was no indication the nurse or physician was consulted before medications were given late.* Oxycodone 2.5 mg PRN at bedtime for pain was administered on 11/7/20, 11/9/20, 11/19/20 and 12/5/20 between the hours of 1:30 am and 6:00 am rather than bedtime as ordered. The need to ensure all medications and treatments were administered as ordered was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC) on 11/16/20. The staff acknowledged the findings.
2. Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation.Review of Resident 1's 11/1/20 through 12/15/20 MARs, 10/27/20 prescriber orders and interdisciplinary notes revealed the following: Instructions on the MAR indicated medications were to be administered crushed in applesauce or pudding. On 12/16/20, Staff 8 (LPN) and Staff 2 (Unit Manager/RN) confirmed all medications were administered crushed. There was no documented evidence the facility had a signed prescriber order to crush medications. The need to ensure medications were administered as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (RCC) on 12/16/20. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were complete and accurate, contained medication specific instructions and reflected resident specific parameters for PRN medications for 2 of 2 sampled residents (#s 1 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in March 2020 with diagnoses including Alzheimer's disease.Review of the resident's 11/1/20 through 12/15/20 MAR and 9/24/20 physician orders were reviewed and showed the following:* The November and December MAR contained orders for PRN Tylenol for pain and PRN Oxycodone for pain with no instructions on which medication to use first;* Effectiveness of PRN pain medications was inconsistently documented on numerous occasions; and* Potential significant side effects for medications was not reflected for all medications.The need to ensure MARs were complete and accurate was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff acknowledged the findings.
2. Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation.Review of the resident's 11/1/20 through 12/15/20 MAR and 10/27/20 physician orders were reviewed and showed the following:* Potential significant side effects for medications was not reflected for all medications;* Multiple PRN bowel care medications lacked clear direction and instruction to staff regarding administration; and* Multiple blanks on the MAR.The need to ensure MARs were complete, accurate and provided clear instruction to staff was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 1) who had a side rail on their bed. Findings include, but are not limited to:Resident 1 was admitted to the facility in September 2019 with diagnoses including arthritis.During an observation on 12/5/20, Resident 1's hospital bed was observed to have side rails on both sides of the bed. There was no documented evidence a side rail assessment had been completed by an RN, PT or OT which included:*Informing the resident of the risks and benefits associated with the device;*The facility documented other less restrictive alternatives evaluated prior to the use of the device;*The facility had instructed caregivers on the correct use and precautions related to the use of the device; and*Documenting the use of the side rail on the service plan.The need to ensure supportive devices with potentially restraining qualities were assessed prior to use was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to:On 12/15/20 review of facility records and interviews with staff indicated the following deficiencies:* During interviews on 12/15/20, 2 of 2 Staff 7 (MT) and Staff 10 (CG) were unable to identify the designated point of safety for an emergency evacuation from the building.* There was no documented evidence that residents received instruction on fire and life safety procedures within 24 hours of admission.* There was no documented evidence of a system to identify residents who were unable or unwilling to participate in fire drills, and to show immediate changes were made to ensure the evacuation standard was being met.On 12/15/20 the need to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Manager). They acknowledged the findings.