The Ackerly at Reed's Crossing

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 012925 at 10:40 am, the facility kitchen was observed to need cleaning in the following areas:

* Wall and caulking behind spray hose in dishwashing area – build up of pink matter;

* Food bin lids – food debris build up;

* Hood vents and walls behind cooking equipment – significant build up of grease/dust and drips of grease on walls;

* Juice dispenser tray – contained “mucky” liquid;

* Shelving rack holders stored below juice dispenser used to hold trays for meal service – significant build up of debris;

* Freezer and refrigerators near steam table line – flooring in all had drips/spills/food debris;

* Ice machine interior – build up of pink matter; and

* Flooring behind cooking equipment, under booster in dishwashing area, between deep fat fryer and refrigerator – significant build up of food debris/grease/drips/spills.

Other areas of concern included:

* Three garbage cans uncovered when not actively being used;

* Several colored cutting boards – scored and finished worn off; and

Improper food storage:

* Refrigeration units on the steam table line – multiple containers of food uncovered, without labels or dates (liquid eggs/hash browns/salmon/diced tomatoes).

The areas of concern were observed and discussed with Staff 1 (Executive Chef) and discussed with Staff 2 (General Manager) on 01/29/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

The findings of the initial licensure survey, conducted 02/26/24 through 02/28/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and 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 02/28/24, conducted 08/14/24 through 08/16/24, 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 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 second re-visit to the re-licensure survey of 02/28/24, conducted 02/05/25 through 02/06/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the third re-visit to the re-licensure survey of 02/28/24, conducted 03/26/25 through 03/26/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff. Findings include, but are not limited to:During the initial survey, conducted 02/26/24 through 02/28/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and scope of citations. Refer to deficiencies in the report.

2. Resident 4 moved into the facility in 09/2023 with diagnoses including type 2 diabetes.A review of the resident's 11/28/23 through 02/21/24 progress notes showed the following:* 11/28/23: A pressure sore on the buttocks area;* 12/03/23: Three small wounds on resident's bottom;* 12/11/23: RN documented a stage II pressure ulcer near lower coccyx that was improving; and* 01/23/24: New orders including Calmoseptine to sacrum twice daily.There was no documented evidence the facility monitored the resident's skin condition with progress noted between 12/11/23 and 01/23/24 at least weekly until resolved. On 02/27/24 at 1:50 pm, Staff 2 (Health & Wellness Director/RN) reviewed the above progress notes and she confirmed there was no documentation of the resident's skin condition.The need to ensure the resident's short term changes of condition, including skin, were monitored at least weekly until resolved was discussed with Staff 1 (General Manager) and Staff 2 on 02/28/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to evaluate, determine and document what action or interventions were needed for short term changes of condition, communicate the actions and/or interventions to staff on each shift, monitor the condition at least weekly with progress noted until the condition resolved, and/or failed to monitor residents consistent with evaluated needs or service plan for 2 of 4 sampled residents (#s 2 and 4) whose records were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 12/2023 with diagnoses including osteoporosis, insomnia, and Alzheimer's disease with late onset. A review of the resident's evaluation and service plan dated 12/04/23, temporary care plans, MAR's dated 12/18/23 through 02/26/24, physician orders dated 12/12/23, progress notes dated 12/19/23 through 02/19/24, identified the following: * The resident was evaluated as having chronic pain, skin issues, insomnia and anxiety; and* Current prescriber orders noted to monitor pain every shift and monitor sleep to determine as needed medication use.The following evaluated conditions lacked documented monitoring:* Sleep;* Pain; * Nurse to monitor skin and toes weekly;* On 02/12/24 and 02/18/24 "redness on the bottom due to sit and laid down not much activity.";* Oyst Cal- D (for Osteoporosis) four times per day, from 12/18/23 through 02/19/24 was not administered;* Miconazole Powder, apply topically twice daily was not administered from 12/18/23 through 02/26/24; and* Sertraline (for anxiety) one tablet daily was not administered from 12/29/23 through 02/26/24. Review of the progress notes identified the following:* A progress note on 12/19/23 noted "resident states [s/he] in in pain but refuses PRN pain medication";* A progress note on 12/21/23 noted "resident is in pain but refuses PRN pain medication"; and* A progress note on 02/18/24 noted the resident refused scheduled lidoderm patch (for pain).During an interview on 02/28/24 at 12:55 pm, Staff 1 (General Manager) and Staff 2 (Health &Wellness Director/RN) confirmed the facility had not re-evaluated the resident's pain status and refusal of PRN pain medications. During an interview on 02/28/24, Staff 2 confirmed there was no documented weekly skin monitoring. There was no documented evidence the facility monitored the resident's sleep daily, pain levels on every shift, and skin weekly per evaluation and service plan. There was no documented evidence the facility evaluated the resident's new skin condition noted on 12/12/23 and 02/18/24, or the missed medications to determine what action or interventions was needed, communicated the actions or interventions to staff on each shift, and monitored the resident's condition with progress noted at least weekly until resolved. The need to ensure residents were monitored per evaluated care needs and changes of condition were evaluated with determined actions communicated to staff and conditions monitored at least weekly until resolved was discussed with Staff 1 and Staff 2 on 02/28/24. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 7/2024 with diagnoses including malignant neoplasm of prostate.The resident's 07/09/24 evaluation, MARs dated 07/12/24 through 08/14/24, progress notes dated 07/15/24 through 08/13/24, and current physician orders were reviewed, and staff were interviewed. The following was identified:* New move-in, which was a change in environment;* Medication changes for bowel care and sleep; and* Skin status.There was no documented evidence the facility monitored the resident's short-term changes of condition until resolution.The need to ensure the resident was monitored through resolution was discussed with Staff 1 (Director of Operations) and Witness 1 (Consultant RN) during the survey. They acknowledged the findings. No additional information was received.
4. Resident 8 admitted to the facility in 02/2024 with diagnoses including early stage Alzheimer's disease and anxiety.The resident's 05/01/24 through 08/14/24 MARs, progress notes dated 05/15/24 through 08/12/24, and Care Plan notes (the facility's temporary service plan and monitoring system) dated 05/15/24 through 08/14/24, were reviewed. Staff were interviewed. The following changes of condition were identified:* Missed medications on 18 occasions; and* Increased confusion on 08/03/24.There was no documented evidence the resident was monitored consistent to his/her evaluated needs and service plan which included weekly progress noted through resolution.The need to ensure the resident was monitored consistent with his or her evaluated needs and service plan was discussed with Staff 1 (Director of Operations) and Staff 22 (Health and Wellness Coordinator) on 08/15/24. They acknowledged the findings. No additional information was received.5. Resident 9 admitted to the facility in 10/2023 with diagnoses including congestive heart failure.The resident's MARs, dated 05/01/24 through 08/07/24, and progress notes, dated 05/02/24 through 08/09/24, were reviewed, and staff were interviewed. There was an entry on the MAR directing staff to "weigh [the resident] each day" and to "notify doctor if weight gain of [three] pounds."The following days were noted when Resident 9 had a three pound or more weight gain:* 07/30/24 - 6.1 pounds;* 06/29/24 - 3.8 pounds;* 06/08/24 - 9.1 pounds;* 05/26/24 - 4.2 pounds;* 05/16/24 - 3 pounds; and* 05/02/24 - 4 pounds.There was no documented evidence staff notified the resident's physician.Additionally, there was no documented evidence of weights being taken, or why a weight was not obtained, for 24 out of the 97 days.The need to ensure the resident was monitored consistent with his or her evaluated needs and service plan was discussed with Staff 1 (Director of Operations) and Staff 22 (Health and Wellness Coordinator) on 08/15/24. They acknowledged the findings. No additional information was received.
Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition were monitored consistent with the resident's evaluated needs and service plan, and documented with weekly progress noted until the condition resolved for 5 of 6 sampled residents (#s 7, 8, 9, 10, and 11) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 10 admitted to the facility in 04/2024 with diagnoses including transient cerebral ischemic attack and atrial fibrillation.The resident's MARs, dated 07/01/24 through 08/14/24, progress notes, dated 07/06/24 through 08/06/24, and a Care Plan (temporary service plan) dated 07/17/24, were reviewed, and staff were interviewed.Staff 22 (Health and Wellness Coordinator) stated Witness 1 (Consultant RN) placed parameters on the MAR directing staff to, "Check blood pressure, pulse day and evening shift, report to physician if blood pressure greater than 130/80."The following days were noted when Resident 10 had a blood pressure reading greater than 130/80:* 07/24/24 - 165/83;* 07/25/24 - 184/85;* 07/31/24 - 146/92; and* 08/10/24 - 174/84.Staff 22 confirmed there was no documented evidence staff notified the resident's physician.The need to ensure the resident was monitored consistent with his or her evaluated needs and service plan was discussed with Staff 23 (Health and Wellness Coordinator) and Staff 25 (General Manager) on 08/15/24. They acknowledged the findings.2. Resident 11 was admitted to the facility in 04/2024 with diagnoses including type two diabetes mellitus, chronic kidney disease, and hypertension.The resident's MARs, dated 07/01/24 through 08/14/24, an RN assessment dated 07/17/24, and progress notes, dated 07/17/24 through 08/08/24, were reviewed, and staff were interviewed. Witness 1 (Consultant RN) stated the facility's offsite RN placed parameters on the MAR directing staff to, "Check and record CBGs, if CBGs are greater than 350, call RN for instruction. If RN is unavailable, call 911." The following days were noted when Resident 11 had a CBG reading greater than 350:* 07/22/24 - 500;* 07/29/24 - 413;* 08/01/24 - 364; and* 08/03/24 - 352.Witness 1 confirmed there was no documented evidence staff notified the RN or called 911.The need to ensure the resident was monitored consistent with his or her evaluated needs and service plan was discussed with Staff 23 (Health and Wellness Coordinator) and Staff 25 (General Manager) on 08/15/24. They acknowledged the findings.

2. Resident 13 moved into the facility in 01/2024 with diagnoses including type 2 diabetes.A review of the resident's 11/01/24 through 02/04/25 progress notes and 11/01/24 through 01/05/25 service plan showed the following:* 11/05/24: Holding Plavix, a heart attack prevention medication, for 12 days;* 11/08/24: Oral surgery;* 11/22/24: Non-injury fall;* 11/24/24: Non-injury fall;* 12/17/24: Injury from a fall with a big bump and bruise around the right eye;* 12/17/24: Antibiotic treatment for a urinary tract infection;* 12/24/24: " ...went to the hospital and got stitches...";* 01/01/25: Fall requiring an emergency visit;* 01/05/25: Two falls, with one requiring an emergency visit;* 01/07/25: Rash in the groin area;* 01/20/25: A fall with emergency visit;* 01/27/25: Two falls, with one leading to a skin cut on the right arm and required an emergency visit; * 01/27/25: Began taking scheduled pain medication; and* 01/28/25: Decreased dosage of Zoloft, an antidepressant.There was no documented evidence the facility evaluated the resident's short term change in condition to determine what action or interventions was needed, communicated the actions or interventions to staff on each shift, and monitored the resident's condition with progress noted at least weekly until resolved. The need to ensure residents' short-term changes in condition were evaluated, actions determined, communicated to staff and conditions monitored at least weekly until resolved was discussed with Staff 23 (Health and Wellness Coordinator) and Staff 26 (Health and Wellness Director/RN) on 02/06/25 at 3:00 pm. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and documented progress until the condition resolved for 2 of of 2 sampled residents (#s 13 and 14) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 14 was admitted to the facility in 01/2025 with diagnoses including neuromuscular dysfunction of bladder and long-term use of anticoagulants.Review of clinical records, including the service plans dated 01/08/25, 01/23/25, and 01/26/25, progress notes from 01/01/25 through 02/02/25, and interviews with facility staff were conducted.The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:* 01/07/25: Admission to the facility;* 01/23/25: Unwitnessed fall with injury;* 01/25/25: Emergency Room visit;* 01/26/25: Started new antibiotic for urinary tract infection and new medication for low back pain;* 01/28/25: " ... resident had a hard time getting up this morning, even after given PRN acetaminophen ...;* 01/30/25: "Resident in lots of pain this morning ....describe the pain as "a hot knife just going through my spine."';* 01/30/25: Emergency Room visit;* 01/31/25: Started new medication for muscle spasms; and* 02/02/25: "Resident continues to have extreme back pain. Resident is requiring 1 staff physical assist with getting in and out of bed and to change [his/her] clothes."The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 27 (General Manager), Staff 26 (Health and Wellness Director/RN), and Staff 23 (Health and Wellness Coordinator) on 02/06/25 at 2:30 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place to ensure outside service providers left written information in the facility that addressed on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care, and updated the service plan as appropriate for 1 of 1 sampled residents (# 2) whose records were reviewed. Findings include, but are not limited to:Resident 2 was discharged from skilled nursing and moved into the facility in 12/2023 with diagnoses including elevated blood pressure reading without diagnosis of hypertension, a right rib fracture, and Alzheimer's disease.Review of clinical records, including the service plan dated 12/04/23, progress notes from 12/19/23 through 02/19/24, temporary care plans for the same time period, and outside care provider communication notes were completed during the survey. a. On 01/30/24 a HHPT evaluation was completed and included a plan to visit the resident two times per week. There was a total of two outside provider notes in the resident's record. b. On 02/20/24, a fax from HHOT indicated the resident would be discharged from OT services. There was no documented evidence the OT provider left written information in the facility that addressed the on-site services provided to the resident from previous OT visits. The facility failed to consistently have a system in place to ensure that outside service providers left written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care. c. On 02/14/24 an outside provider note left the recommendation to "monitor vitals closely (BP), please report to PCP [physician]- for any symptoms (BP) [and] pain." There was no documented evidence the facility updated the service plan with the recommendations from the outside provider and monitored the resident's blood pressure and pain and reported to the physician. The need to ensure the facility consistently had a system in place to ensure that outside service providers left written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care, and to ensure the service plan was updated as appropriate was discussed with Staff 1 (General Manager) and Staff 2 (Health & Wellness Director/RN) on 02/28/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication and treatment administration system. Findings include, but are not limited to:Refer to C302, C303, C304, C305, C310, and C372 (1).

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#2) whose record was reviewed. Findings include, but are not limited to:Resident 2 moved into the facility in 12/2023 with diagnoses including osteoporosis and Alzheimer's disease.Resident 2 had signed physician orders for Oxycodone, two tablets by mouth every four hours as needed for pain. Resident 2's 12/18/23 through 02/26/24 MARs and the Controlled Substance Disposition Log were reviewed and identified the following: The Controlled Substance Disposition log showed the oxycodone was administered on 27 occasions between 12/19/23 through 02/26/24; however, the MAR was initialed as administered on 22 occasions.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 02/28/24 with Staff 1 (General Manager) and Staff 2 (Health & Wellness Director/RN). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 2 sampled residents (# 7) whose MARs and Controlled Substance Disposition logs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 7 moved into the facility in 07/2024 with diagnoses including malignant neoplasm of prostate.During the acuity interview on 08/14/24, the resident was identified to receive hospice services and was administered pain medication as needed.a. Resident 7 had signed physician orders for Morphine ER (extended release) 30 mg three times daily for pain.The resident's 07/12/24 through 08/14/24 MARs and Controlled Substance Disposition Log were reviewed and identified the following:* The Controlled Substance Disposition log showed the Morphine was administered on 57 occasions; however, the MAR was initialed as administered on 51 occasions.b. Resident 7 had signed physician orders for Morphine IR (immediate release) 30 mg every four hours as needed for pain.* The MAR and Controlled Substance Disposition log showed multiple discrepancies.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (Director of Operations) and Witness 1 (Consultant RN) on 08/15/24. They reviewed the documentation and acknowledged the discrepancies.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to:Resident 2 moved into the facility in 12/2023 with diagnoses including osteoporosis and Alzheimer's disease. Resident 2's MARs, dated 12/19/23 through 02/26/24, corresponding progress notes, and signed prescriber orders dated 12/12/23 were reviewed and identified the following orders were not carried out as prescribed:* Monitor pain every shift;* Monitor sleep;* Weekly weights;* Sertraline (for anxiety) once daily was not administered from 12/29/23 through 02/26/24. * Tylenol three times per day (for pain) was not administered on 13 occasions from 12/19/23 through 02/26/24;* Calcium-Vitamin D3 (oyst Cal-D) four times per day was not administered on 32 occasions from 12/19/23-12/31/23 and was not administered from 01/01/24 through 02/26/24;* Lidoderm Patch (for pain) on six occasions; and* MultiVitamin (for supplement) once daily, on six occasions.During an interview with Staff 2 (Health and Wellness Director/RN) on 02/27/24, she confirmed the facility did not have discontinuation orders for any of the medications and the facility was having a hard time getting signed orders from the physician. She acknowledged the most current signed orders from a physician were the skilled nursing discharge orders dated 12/12/23. The need to ensure the facility had a system in place to ensure prescriber orders were carried out as prescribed was discussed with Staff 1 (General Manager) and Staff 2 on 02/28/24. They acknowledged the findings.
2. Resident 7 was admitted to the facility in 07/2024 with diagnoses including malignant neoplasm of prostate.The resident had a physician's order, dated 07/12/24, to administer Morphine IR (immediate release, breakthrough pain medication) 30 mgs, every four hours as needed for pain.Resident 7's 07/12/24 through 08/14/22 MAR and Controlled Substance Disposition log revealed staff administered 30 mgs of Morphine ER (extended release) on four occasions, instead of 30 mgs of Morphine IR (immediate release).The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Director of Operations) and Witness 1 (Consultant RN) on 08/15/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 5 sampled residents (#s 7 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 02/2024 with diagnoses including early stage Alzheimer's disease and anxiety.The resident's 05/01/24 through 08/14/24 MARs and progress notes, dated 05/15/24 through 08/12/24, were reviewed, and staff were interviewed.a. The following medications were not administered per physician's orders:* Buspirone (for anxiety) - 23 times;* Multivitamin (for supplement) - four times;* Psyllium fiber (for constipation) - three times;* Sertraline (for mood) - four times;* Vitamin B complex (for supplement) - four times;* Donepezil - six times; and* Quetiapine (for dementia) - 18 times.b. There were blanks on the MARs without indication if the medication was administered on:* 07/18/24 - Buspirone; and* 05/11/24 - Donepezil and quetiapine.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Director of Operations) and Staff 22 (Health and Wellness Coordinator) on 08/15/24. They acknowledged the findings. No additional information was received.

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered to residents by the facility, at least every 90 days for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to:During the survey, the team requested documented evidence that a registered pharmacist or registered nurse reviewed all medications and treatments administered to residents by the facility for Residents 2 and 3.On 02/28/24, during the survey, Staff 1 (General Manager) and Staff 2 (Health & Wellness Director/RN) confirmed there was no pharmacy auditing service and the medication and treatment orders were not reviewed by a registered pharmacist or registered nurse every 90 days. The need to ensure a pharmacist or an RN reviewed medication and treatments administered by the facility at least every 90 days was discussed with Staff 1 and Staff 2 on 02/28/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order for 1 of 1 sampled resident (# 2) who was reviewed with medication and treatment refusals. Findings include, but are not limited to:Resident 2 moved into the facility in 12/2023 with diagnoses including Alzheimer's disease and osteoporosis. Resident 2's MARs from 12/19/23 through 02/26/24 and progress notes for the same time period were reviewed. * A progress note on 12/19/23 noted "refusing all medications, but took [his/her] anxiety medication."; and* A progress note on 02/18/24 indicated the resident refused scheduled lidoderm patch (for pain).There was no documented evidence the facility notified the prescriber of the resident's medication or treatment refusals.The facility's failure to notify the physician when Resident 2 refused an ordered medication or treatment and to ensure a system was in place for subsequent medication or treatment refusals, as requested by the prescriber, was reviewed with Staff 1 (General Manager) and Staff 2 (Health and Wellness Director/RN) on 02/28/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept, including medication pass times, reason for use and resident-specific parameters and instructions for PRN medications for 1 of 2 sampled residents (#2) whose records were reviewed. Findings include, but are not limited to:Resident 2 moved into the facility in 12/2023 with diagnoses including osteoporosis and Alzheimer's disease. The resident's clinical record including MAR's dated 12/19/23 through 02/26/24, progress notes from the same timeframe, and signed prescriber orders dated 12/12/23 were reviewed.a. The 12/2023 MAR had the following inaccuracies:* Missing reason for use for miconazole powder, multi vitamin tablet, melatonin 3 mg tablet, polyethylene glycol, enema, milk of magnesia 400 mg/5ml suspension, aspirin, bisacodyl 10 mg suppository, tylenol 500 mg, senna 8.6 mg tablet, aspirin EC 81 mg tablet, atorvastatin 40 mg tablet, oyst-cal D 250mg/125 IU tablet, and loperamide 2 mg tablet;* Missing initials for who administered oyst-cal D at 1:00 pm on 12/28/23 and Tylenol on 12/22/23 and 12/23/23;* Lacked medication pass times for miconazole powder, multi vitamin, melatonin, polyethylene glycol, loperamide, enema, milk of magnesia, aspirin, bisacodyl suppository, tylenol, and senna;* Resident-specific parameters and instructions for the following pain medication and treatments: PRN Aspercreme cream, PRN diclofenac gel, PRN oxycodone tablet and scheduled lidocaine patch lacked instructions on the location of pain and where to apply the patch; and* The resident had two orders for Oxycodone 5 mg tablet, give two tablets every 4 hours as needed (for pain) and a second order for Oxycodone 5 mg tablet, give one tablet every 4 hours as needed (for pain). There was no parameters for which order to follow first and/or when to give one tablet verses two tablets.There was no documented evidence the facility contacted the prescriber to clarify which order should be administered. * Medication refusals were noted in a progress note dated 12/19/23; however, there was no indication on the 12/2023 MAR that the resident refused any medications on this day.b. The 01/01/24 through 02/26/24 MARs had the following inaccuracies:* Missing reason for use for aspirin EC 81 mg tablet, atorvastatin 40 mg tablet and oyst-cal D 250mg/125 IU tablet;* Miconazole powder apply topically twice per day only had one pass time at 9:00 am and the treatment was transcribed to the MAR without being on the medication list signed by the prescriber on 12/12/23;* Lidocaine patch lacked instructions on the location of pain and where to apply the patch;* Icy hot as needed topical pain treatment was transcribed to the MAR without being on the medication list signed by the prescriber; * Signed orders for enema, milk of magnesia, bisacodyl suppository, polyethylene glycol, and loperamide were not transcribed on the MARs, and there was no documented evidence the orders had been discontinued; * An order for weekly weights dated 12/12/23 was transcribed to the 02/2024 MAR as monthly vitals and weights; and* Medication refusals were noted in a progress note dated 02/18/24; however, there was no indication on the MAR that the resident refused any medications on this day. The need to ensure accurate MARs were kept and included medication pass times, reason for use, resident-specific parameters and instructions for PRN medications and staff were consistently initialing the MAR when medications were administered was discussed with Staff 1 (General Manager) and Staff 2 (Health and Wellness Director/RN) on 02/28/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident-specific parameters and staff instruction for PRN medications, and included the initials of the person administrating the medication for 3 of 5 sampled residents (#s 6, 7, and 8) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including diabetes and hypertension.The resident's 07/01/24 through 08/14/24 MARs were reviewed and showed the following:* Multiple PRN pain medications lacked clear parameters for when to administer and which one should be given first; and* The resident had an order for PRN Tramadol every six to eight hours. There were no parameters for when to administer the medication in six hours verses eight hours.The need to ensure MARs were accurate and included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Director of Operations) and Witness 1 (Consultant RN) on 08/15/24. They acknowledged the findings.2. Resident 7 was admitted to the facility in 07/2024 with diagnoses including malignant neoplasm of prostate.The resident's 07/12/24 through 08/14/24 MARs were reviewed and showed the following:* Multiple PRN pain medications and multiple PRN nausea/vomiting medications lacked clear parameters for when to administer and in which order the medications should be administered.The need to ensure MARs were accurate and included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Director of Operations) and Witness 1 (Consultant RN) on 08/15/24. They acknowledged the findings.
3. Resident 8 was admitted to the facility in 02/2024 with diagnoses including early stage Alzheimer's disease.The resident's 05/01/24 through 08/14/24 MARs and progress notes, dated 05/15/24 through 08/12/24, were reviewed. The MARs were inaccurate in the following areas:a. There was instruction to staff to obtain Resident 8's vials and weight monthly. There were blanks on the following dates without corresponding documentation as to what occurred on the following dates:* 08/06/24;* 07/05/24; and* 05/06/24.b. There were notes on the MARs documenting that the resident's medications were on hold as s/he was "out with family" on the following dates:* 08/06/24;* 07/18/24;* 06/04/24; and* 06/12/24.However, the medications were documented as administered except for a 3:00 pm dose of buspirone (for anxiety) on 08/06/24.The need to ensure MARs were accurate and included the initials of the person administrating the medication was discussed with Staff 1 (Director of Operations) and Staff 22 (Health and Wellness Coordinator) on 08/15/24. They acknowledged the findings. No additional information was received.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included documentation of less restrictive alternatives prior to use and instruction to caregivers on the correct use and precautions of the device for 1 of 1 sampled resident (# 1) with side rails on their hospital bed. Findings include, but are not limited to:Resident 1 moved into the facility in 02/2024 with diagnoses including orthostatic hypotension and Parkinson's disease.On 02/28/24, Resident 1's bed was observed with two half-length side rails in the up position and secured to the bed. During an interview on 02/28/24, Resident 1 stated s/he used the side rails to help with positioning in bed and transferring in and out of bed. The resident stated s/he wanted the bed rails and considered them "a big help to me."On 02/28/24 documentation of the side rail assessment was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, including documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.On 02/28/24, Staff 2 confirmed she was aware the resident had the side rails; however, she didn't have the time to complete the assessment.On 02/28/24, Staff 2 completed an assessment that included documentation related to less restrictive alternatives attempted prior to use and an interim service plan that included instruction to caregivers on correct use and precautions. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 1 (General Manager) and Staff 2 (Health Services Director/RN). They 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 had a thorough assessment completed by an RN, PT, or OT prior to use which included documentation of less restrictive alternatives prior to use and instruction to caregivers on the correct use and precautions of the device for 1 of 1 sampled resident (# 7) with side rails on their hospital bed. This is a repeat citation. Findings include, but are not limited to:Resident 7 moved into the facility in 07/2024 with diagnoses including malignant neoplasm of prostate.On 08/15/24, the resident's bed was observed with two half-length side rails in the up position and secured to the bed.During an interview on 08/15/24, Resident 7 stated s/he used the side rails to help with positioning in bed and transferring in and out of bed.There was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, including documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements, and was included in the resident's service plan, was discussed with Staff 1 (Director of Operations) and Witness 1 (Consultant RN) on 08/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that addressed all the following activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care. Findings include, but are not limited to:The facility's ABST was reviewed on 02/26/24 at 2:00 pm with Staff 2 (Health & Wellness Director/RN) and found to be deficient in the following areas.* Staff could not confirm all 22 required ADLs contributed to the generated minutes used to create a staffing plan; * ABST data was reviewed for Residents 2, 3, 4 and 5, and the data for Residents 2, 3, 4 and 5 included only 19 of the required 22 ADLs;* Resident 2 had zero minutes added for escorting to dining and activities, repositioning in bed, monitoring skin condition, toileting assistance and transfer assistance per the resident's evaluated needs;* Resident 3 had zero minutes added for monthly vitals checks; however, review of the 02/01/24 through 02/26/24 MAR indicated staff were to measure vital signs monthly; * Resident 4 had zero minutes added for monthly vitals checks and treatments including applying lotion and compression stockings; however review of the 02/01/24 through 02/26/24 MAR indicated staff were to perform monthly vital check and the treatments two times daily. Also, Resident 4 had zero minutes added for dressing and toileting assistance; however, staff reported they provided dressing and toileting assistance per resident request; and* Resident 5 had zero minutes added for responding to call lights.The need to have all required ADLs on the ABST with the amount of staff time needed to provide care was discussed with Staff 1 (General Manager) and Staff 2 on 02/28/24 at 11:00 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that addressed all 22 required elements relating to activities of daily living (ADLs) and other tasks related to care for each resident in order to determine the time needed to meet staffing levels. This is a repeat citation. Findings include, but are not limited to:The facility's ABST was reviewed on 08/15/24 at 1:04 pm with Staff 24 (Opal Manager Memory Care) and was found to be deficient in the following areas:* Staff 24 confirmed that not all of the 22 required elements were addressed for Residents 6, 7, 8, 9, 10, and 11; and* The time needed was not reflective for the required elements that were addressed on the residents' ABST.The need to have all required elements addressed for each resident on the ABST to determine the time needed to meet staffing levels was discussed with Staff 1 (Director of Operations) and Staff 24 on 08/16/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation or written testing, and to maintain written documentation of all training's completed. Findings include, but are not limited to: During a review of staff training records on 02/27/24 at 1:35 pm, Staff 2 (Health & Wellness Director) and Staff 3 (Business Office Manager) were unable to provide documented evidence the sampled newly hired staff had demonstrated competency in all duties they were assigned. Staff 2 further confirmed the facility did not have a process for evaluating competency.The need to maintain written documentation of training completed by each employee and to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 1 (General Manager) on 02/28/24. She acknowledged the findings. Refer to C 372.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics and pre-service dementia training had been completed prior to staff beginning their job duties for 4 of 4 newly-hired staff (#s 9, 14, 15 and 21). Findings include, but are not limited to:The facility's training records were reviewed on 02/27/24 and the following was identified:a. There was no documented evidence Staff 9 (MT), Staff 14 (CG), Staff 15 (CG), and Staff 21 (Receptionist), hired 12/18/23, 01/08/24, 01/08/24, and 01/09/24, respectively, completed the following pre-service orientation topics prior to beginning their job duties:* Resident rights and the values of community-based care;* Abuse and reporting requirements;* Infectious disease prevention training; and* Fire safety and emergency procedures.b. There was no documented evidence Staff 9, 14, and 15 completed the following pre-service dementia training courses prior to providing care to residents:* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to behaviors, including, but not limited to, reducing use of antipsychotic medications;* Strategies for addressing social needs & engaging persons with dementia in meaningful activities; and* Specific aspects of dementia including pain, providing food/fluids, preventing wandering, and the use of a person-centered approach.The requirements for pre-service orientation and training for all employees was reviewed with Staff 1 (General Manager) on 02/28/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to verify and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire. There was no documented evidence appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments), documented they had observed and evaluated unlicensed medication technicians' ability to perform safe medication and treatment administration unsupervised. Findings include, but are not limited to:1. During a review of staff training records on 02/27/24 at 1:35 pm, Staff 2 (Health & Wellness Director/RN) was unable to provide documented evidence that Staff 9 (MT) had demonstrated competency in medication administration. Staff 2 further confirmed the facility did not have a process for evaluating competency and that, currently, no MTs who administered medications (Staff 4, 5, 6, 7, 8, 9, 10, 11, and 12) had verified competency in the task.At 3:15 pm, the survey team met with Staff 1 (General Manager) and explained the deficient practice of not having a process for evaluating staff competency. Staff 1 voluntarily provided and implemented a plan to address staff competency during the survey. 2. Staff 9 (MT), hired 12/18/23, Staff 12 (MT), hired 06/12/23, Staff 14 (CG), hired 01/08/24, and Staff 15 (CG), hired 01/08/24, lacked documented evidence of demonstrated knowledge and performance in the topic of the role of service plans in providing individualized care.3. Staff 14 and 15 lacked documented evidence of demonstrated knowledge and performance in the following topics:* Providing assistance with the activities of daily living;* Changes associated with normal aging;* 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 * General food safety, serving and sanitation.The need to ensure the facility verified and documented that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 and 2 on 02/28/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records, dated between 09/2023 and 02/2024, revealed the following: a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas: * The escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* The number of occupants evacuated.b. Staff 16 (CG) was interviewed on 02/28/24. She was unable to state the designated point of safety as determined by the Fire Authority having jurisdiction.The need to ensure fire drills were conducted according to the OFC was reviewed with Staff 1 (General Manager) on 02/27/24. She acknowledged the findings. No further information was provided.
Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:Fire and life safety records, dated between 05/2024 and 07/2024, revealed the following:The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas:* The escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* The number of occupants evacuated.The need to ensure fire drills were conducted according to the OFC was reviewed with Staff 1 (Director of Operations) on 08/15/24. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:A review of fire and life safety records, dated between 10/2024 and 02/2025, revealed inconsistent documentation of the following required components:* The escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * The evidence alternate routes were used during the fire drills.The need to ensure fire drills were conducted according to the OFC was reviewed with Staff 27 (General Manager) and Staff 28 (Plant Operations Supervisor) on 02/06/25. They acknowledged the findings. No further information was provided.

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 270, C 302, C 303, C 310, C 340, C 361, and C 420.

Based on interview and record review, it was determined the facility failed to ensure their second re-visit survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 270 and C 420.