Morningstar Assisted Living at Laurelhurst

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 04/01/25 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas:

* Freezer on service line – interior bottom shelf – significant amount of food debris; exterior doors with spills/smears;

* Ceiling vents in dishwashing area – build up of dust;

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

* Wall above and behind dishwashing – build up of black matter;

* Exterior of dishwasher – spills/drips;

* Hood vents above cooking equipment and convection ovens – build up of grease/dust;

* Stainless steel wall surrounding deep fat fryer and behind cooking equipment– build up of grease;

* Lids on large food bins – build up of food debris;

* Stainless drawer fronts below microwave – spills/drips;

* Shelf in service area below bulletin board – debris/food crumbs; and

* Blue storage cart containing plates/bowls – debris/food crumbs.

Other areas of concerns included:

* Colored cutting boards – finish worn and significantly scored (potentially uncleanable).

* White cutting boards on service line – significantly stained and scored (potentially uncleanable).

* Lack of hair and beard restraints.

* Freezer on service line – open packages of frozen food products.

The areas of concern were observed and discussed with Staff 1 (Dining Room Supervisor) and discussed with Staff 2 (Executive Chef) on 04/01/25. 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 03/12/24 through 03/15/24, 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 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the initial licensure survey of 03/15/24, conducted 09/03/24 through 09/05/24, 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.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the second revisit to the initial licensure survey of 03/15/24, conducted on 11/21/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure residents' right to be treated with dignity and respect, related to dining services, personal care and medication administration. Findings include, but are not limited to:1. During the survey, the following was noted:a. Review of the previous three months of Food Council meeting minutes indicated recurring complaints from residents about:* Food being served cold;* Menu shortages;* Servers not visible in the dining room;* Long wait times for orders to be taken and for food to be prepared and served;* Dessert options advertised not being available; and* Portion sizes ordered not being honored (half-portions coming out as full orders).Responses from the facility to the complaints noted the facility chef would provide training to the servers on the various concerns and that a chef from another of the company's facilities would also provide training to the kitchen and dining room staff.During a group interview on 03/13/24 with sampled and unsampled residents and two family members, participants confirmed the above issues were still occurring. Several participants reported orders continued to be brought out incorrectly. A participant explained the dining staff often failed to provide condiments for the table or when plates were served. Also, participants reported long wait times for their meal to be prepared and served, and individual plates for the table coming out at separate times (sometimes 10 minutes or more between plates) which disrupted the meal experience.b. During an observation of meal service on 03/14/24 at 10:35 am, after a resident was heard telling the server that s/he had not ordered the toast that had just been served to him/her, the dining staff was observed to say, "Oh, OK" and take the toast off the resident's plate with an ungloved hand and dispose of it.2. Lack of staff training related to incontinent care resulted in Resident 2 not being treated with dignity and respect.Refer to C372 example 2.3. Failure to ensure Resident 2's service plan included specific instructions regarding the need for timely administration of antiparkinson's medications resulted in Resident 2 not being treated with respect and dignity.Refer to C260 example 1b.The need to ensure residents were treated with dignity and respect by ensuring the meal experience provided was satisfactory, staff received proper training, and time-sensitive medications were administered timely was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator) and Staff 3 (MCC Administrator) on 03/15/24. Staff 1 acknowledged the services provided were not adequate and needed to be improved.

Based on observation, interview, and record review, it was determined the facility failed to report an injury of unknown cause to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 1 of 1 sampled resident (#2) with an injury. Findings include, but are not limited to:Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment. During the acuity interview on 03/12/24, care staff reported Resident 2 currently had bruises on his/her shins.During an interview on 03/13/24, Resident 2 was observed with bruising on the left shin. When asked, Resident 2 stated s/he sustained the bruising while staff were transferring the resident out of the bed.There was no documentation in the resident's record regarding the bruising to the shin. In an interview on 04/14/24, Staff 2 (Assisted Living Coordinator) reported no Incident Report had been completed regarding the injury.The bruising to Resident 2's shin represented an incident that should have been reported to the local SPD office or local AAA unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. There was no documented evidence the facility either reported the incident or immediately investigated the incident and ruled out abuse.The incident was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged they were not aware of the injury and had not reported or investigated the incident. The surveyor directed the facility to self-report the incident to the local SPD or AAA office as suspected abuse. Confirmation the facility reported the incident was received on 03/18/24.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment. The resident's new move-in evaluation dated 12/12/23 was reviewed and the following elements were not addressed:* Customary routines including eating and bathing;* Mental health including presence of depression, thought disorders or behavioral or mood problems, and effective non-drug interventions;* Cognition including confusion and decision-making;* Personality, including how the person copes with change or challenging situations;* Communication and Sensory: hearing and the ability to understand and be understood; * Dental status; * Pain including non-pharmaceutical interventions;* Fall risk;* Complex medication regimen;* Recent losses; and* Elopement risk or history.The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 5 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24 at 1:30 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and/or services were implemented for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment. a. Observations of and interviews with the resident, interviews with staff, and review of the 02/09/24 service plan, temporary service plans dated 01/17/24 through 01/24/24, and current evaluations identified Resident 2's service plan was not reflective of his/her needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas:* Resident's ability to self-direct care;* Dressing assistance;* Bathing assistance;* Grooming and hygiene;* Nail care;* Toileting and incontinent care;* Emergency and evacuation;* Short-term memory;* Sleep routine;* Pain and discomfort;* Mobility and transfer assistance;* Transfer devices;* Home health provider information; and* Psychotropic medication monitoring.b. In interviews on 03/12/24 and 03/14/24, Resident 2 and Witness 1 (Spouse) expressed concerns the facility repeatedly failed to administer Resident 2's antiparkinson's medications timely, resulting in Resident 2 having difficulty with movement and causing him/her anxiety. Antiparkinson's medications are considered time-sensitive medications because a delay in their administration can result in loss of symptom control. The facility provided emails initiated by Witness 1 to facility administration, including Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator) and Staff 3 (MCC Administrator) on 01/09/24, 02/03/24, 02/05/23 and 03/09/24, which included Resident 2 and Witness 1's continuing complaints that the resident was being administered the medications late.The facility failed to update the service plan to instruct staff of the importance of timely medication administration of Resident 2's antiparkinson's medications.On 03/15/24 at 1:30 pm, the need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, and the services were implemented was discussed Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 5 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24 at 1:30 pm. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 08/2023 with diagnoses including traumatic brain injury and sleep apnea. The resident's current service plan dated 02/21/24, temporary service plans and progress notes dated 12/08/23 to 03/05/24 were reviewed, interviews were conducted, and observations were made. The resident's service plan was not reflective, implemented, and/or did not provide clear direction to staff in the following areas:* Number of staff for transfers;* Use of gait belt for transfers;* Devices including CPAP;* Number of staff for bathing and toileting; * Personal hygiene; and* Evacuation instructions.The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator), and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what action or intervention was needed for a resident following a change of condition with weekly progress noted until the condition resolved, for 2 of 3 sampled residents (#s 1 and 2) with documented changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 11/2023 with diagnoses including Parkinson's disease, cerebrovascular disease and neurogenic bladder. The resident's record was reviewed and interviews were conducted with the resident and care staff during the survey. The following was identified:* Upon admission, a "Short Term Observation and Temporary Service Plan" (STO/TSP) form was created which instructed staff to document on the resident's adjustment to the facility for 14 days. The last observation note was dated seven days after admission, and there was no documentation the charting was to be discontinued.* On 01/04/24, the resident had a fall and sustained a "small cut" on the knee. The STO/TSP form directed staff to monitor the resident for high blood pressure, drowsiness and to ensure s/he used his/her walker or wheelchair. However, there were no interventions developed for the cut on the knee, and there was no documented monitoring of the resident's knee injury until resolved.* On 02/10/24, the resident fell and sustained a bone fracture in the right wrist. In interviews during the survey, the resident and staff reported the resident had to wear a wrist brace/splint for several weeks following the incident that affected the use of the right hand. Observation notes from staff indicated the resident had difficulty holding onto the walker with the right hand. The STO/TSP form created in response to the change of condition directed staff to ensure the resident used his/her wheelchair or walker at all times, though the use of the walker was not appropriate. The STO/TSP form also directed staff to provide safety checks, but did not specify how frequently they should be provided.The need to ensure the facility determined and documented resident specific interventions for staff in response to a resident change of condition and monitored the resident with weekly progress noted until the condition was determined to be resolved was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.2. Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment.The resident's record was reviewed and interviews were conducted with the resident, Witness 1 (Spouse) and care staff during the survey. The following was identified:* Staff began documenting on how the resident was adjusting to the facility beginning on the resident's date of admission. However, the facility could not provide a copy of the "Short Term Observation and Temporary Service Plan" (STO/TSP) form that instructed staff as to what actions or interventions were to be implemented.* An STO/TSP form was developed on 01/17/24 that directed staff to monitor the resident for symptoms of a possible urinary tract infection (UTI). On 01/21/24, the resident was diagnosed with a UTI and prescribed and antibiotic. However, no new STO/TSP form was developed that instructed staff of the new medication and what actions, interventions or monitoring was required.* An observation note written by a care staff dated 01/21/24 noted: "Resident called Care team due to resident having a mini seizure. Resident expressed to [staff] [Resident 2] froze for a couple minutes and couldn't move their body. Resident expressed afterwards [s/he] was feeling nausea and dizzy." Resident 2 was sent to the hospital for evaluation. The resident returned to the facility later that day. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident and the resident was not monitored for further seizure symptoms.The need to ensure the facility determined and documented appropriate interventions for staff in response to a resident change of condition and monitored the resident with weekly progress noted until the condition was determined to be resolved was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.

2. Resident 6 moved into the facility in 04/2024 with diagnoses including type 2 diabetes mellitus, repeated falls, and hypertension (high blood pressure).The current service plan dated 08/19/24, "Short Term Observation" documents, and observation notes dated 07/02/24 through 09/01/24 were reviewed. Interviews with staff were completed between 09/03/24 and 09/05/24.The facility failed to determine action or intervention needed for the resident, communicate the resident-specific action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:* 07/02/24 - Fall;* 07/02/24 - Bruise from fall;* 07/12/24 - Fall with tailbone pain;* 08/17/24 - Skin tear from fall;* 08/17/24 - Return from hospital; and* 08/28/24 - Blood on second toes of each foot.The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, communicated the resident-specific interventions to staff on all shifts, and monitored the changes of condition, at least weekly, through resolution was discussed with Staff 1 (ED) on 09/05/24 at 11:17 am. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved for 2 of 3 sampled residents (#s 6 and 7) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 moved into the facility in 06/2024 with diagnoses including Alzheimer's dementia and coronary artery disease.The current evaluation, dated 07/29/24, "Short Term Observation" documents, and observation notes dated 07/01/24 through 09/03/24 were reviewed. Interviews with staff were completed between 09/03/24 and 09/05/24. The facility failed to determine what action or intervention was needed for the resident and communicate the action or intervention to staff on each shift for the following conditions:* 07/22/24 - Resident to resident verbal altercation; and* 08/29/24 - Low blood pressure. The need to ensure the facility determined and documented action or interventions needed for changes of condition, and the interventions were communicated to staff on all shifts was discussed with Staff 1 (ED) on 09/05/24 at 10:55 am. She acknowledged the findings, and no additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#1), who experienced a significant change of condition related to a fracture. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2023 with diagnoses including Parkinson's disease, cerebrovascular disease and neurogenic bladder.Review of the resident's record and an interview with Resident 1 on 03/14/24, indicated the resident fell on 02/10/24 and was diagnosed on 02/11/24 with a "closed chip fracture of triquetrum of right wrist" - a bone in the base of the palm. "Observation notes" and an interview with Staff 9 (Care Manager Assisted Living) on 03/15/24 indicated the resident wore a wrist brace/splint following the injury which impacted his/her ability to easily complete all ADLs independently and to hold onto his/her walker handle properly.Resident 1's wrist fracture and change in ADL status represented a significant change of condition for which an RN assessment was required. There was no documented evidence a facility RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN assessment was completed for all residents with a significant change of condition was reviewed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility administration or nurse failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 2 sampled residents (#2) who received home health services. Findings include, but are not limited to: Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment. The resident was receiving PT, OT and speech therapy services.The resident's outside provider visit notes, service plan dated 02/09/24, temporary service plans, "Observation" notes dated 01/14/24 through 03/11/24 were reviewed, and a home health provider visit was observed. The following recommendations were made by home health providers: * "Needs transfer pole placed at right side of bed for patient to use for transfers"; * "Suggested that a transfer assist disc may be beneficial";* "...to work on safety with transfers, ADL, strength and fall prevention...";* "[Patient] with a lot of [Parkinson's] symptoms making mobility very challenging. Weaker in [right upper extremity] than when [occupational therapy] saw last in Nov[ember] 2023"; and* "Will trial a [bed side commode] over toilet as this worked well in the past."Observations indicated a transfer pole had been installed next to the bed, and a transfer assist disc and bedside commode had been provided. Interviews with staff indicated they were not using the transfer pole or transfer assist disc with Resident 2. There was no documented evidence multiple home health visit notes containing these interventions were reviewed by the facility, the service plan was adjusted and staff were informed of the new interventions.The need to ensure on-going coordination of care was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 5 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24 at 1:30 pm. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 11/2023 with diagnoses including Parkinson's disease, cerebrovascular disease and neurogenic bladder. The resident's 03/01/24 to 03/11/24 MARs and signed physician orders dated 11/22/23 were reviewed. The following was identified:* The facility was administering sertraline (an antidepressant medication) - 2 tablets every day. The facility did not have a written, signed physician order documented in the resident's facility record.* The facility was administering azelastine nasal spray (for symptoms of rhinitis) - 2 sprays twice daily. The current physician order in the resident's record, dated 11/22/23, directed the facility to administer 2 sprays once daily. The facility did not have a written, signed physician order for the increased dosage documented in the resident's facility record. The need to ensure the facility had written, signed physician orders documented in the resident's facility record was reviewed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.3. Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment. The resident's 02/01/24 to 03/11/24 MARs and physician orders dated 01/05/24 and subsequent orders were reviewed. The following was identified:a. The 01/05/24 physician order list the facility obtained at Resident 2's admission was not signed by an authorized prescriber. Therefore, the facility had no signed physician orders to administer any of the medications it was administering to Resident 2 between 01/04/24 and 03/11/24.b. The facility lacked orders for the following additional medications being administered by the facility:* Cranberry PAC (for urinary tract health) 36 mg capsules - 1 capsule daily;* Estrace cream (for symptoms of menopause) - apply 3 times weekly;* Preservision gel (for eye health) - 1 gel daily;* Acetaminophen 325 mg tablet - 2 tablets every 4 hours as needed for pain; and* Melatonin 3 mg tablet - 1 tablet nightly as needed for insomnia.c. Between 02/01/24 and 03/11/24, the following medications were not administered as prescribed due to the "medication not available":* Baclofen TID (to relieve muscle spasms and tightness) all three times on 03/05/24;* Cultrelle once daily (for digestive health) on 03/01/24, 03/02/24 and 03/03/24;* Ezetimide once daily (for high cholesterol) on 02/29/24, 03/01/24, 03/02/24, 03/03/24, 03/07/24 and 03/08/24;* Modafinil once daily (to treat excessive daytime sleepiness) on 02/21/24;* Preservision gels once daily (for eye health) on 02/06/24 through 02/11/24 and 02/12/24 through 02/17/24; and* Vitamin D3 once every other day (supplement for calcium and phosphate absorption) on 03/01/24 and 03/03/24.The need to ensure the facility had written, signed physician orders documented in the resident's facility record and all medication orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible for administering for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 08/2023 with diagnoses including Type 2 diabetes and hypertension. The resident's 02/01/24 to 03/11/24 MARs and physician orders dated 07/19/23 were reviewed, and the following was identified:a. The resident's MAR indicated the following medications were not administered:* Metformin (for Type 2 diabetes) on 03/02/24; and* Losartan (for hypertension) on 03/03/24 and 03/05/24.During an interview at 3:42 pm on 03/13/24, Staff 12 (MT) confirmed Med Techs were supposed to reorder medications, and that the above medications had not been reordered timely.b. The resident had an order for polyethylene glycol, take 17 grams by mouth daily for bowel care. Review of the MAR revealed the medication was listed as a PRN. During an interview at 3:42 pm on 03/13/24, Staff 12 confirmed the medication was not being administered daily.c. The following medications that were being administered by the facility lacked signed physician or other legally recognized practitioner orders:* Naproxen PRN (for pain);* Hydrocodone acetaminophen PRN (for pain);* Benzonatate PRN (for cough); and* Fexofendine (for allergies).The need to ensure orders were carried out as prescribed and written signed physician or other legally recognized practitioner orders were documented in the resident's record was discussed on 03/15/24 with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator), and Staff 16 (Wellness Director). 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 2 sampled residents (#s 5 and 6) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 moved into the facility in 04/2024 with diagnoses including type 2 diabetes mellitus and hypertension (high blood pressure).The resident's MAR dated 08/01/24 through 09/02/24 and current physician's orders were reviewed.The resident had physician orders for the following medications dated 05/07/24:* Aspirin 81 mg - Chew one tablet by oral route everyday (for stroke prevention);* Atorvastatin 40 mg - Take one tablet by mouth daily (for high cholesterol);* Lisinopril-HCTZ 20-12.5 mg - Take one tablet by mouth twice a day (for high cholesterol); and* Metformin 1000 mg - Take one tablet by mouth twice a day with morning and evening meals (for diabetes).a. Resident 6's once daily aspirin was not included on the MAR and was not administered as prescribed between 08/01/24 and 09/02/24. On 09/04/24 at 10:27 am, Staff 24 (Med Care Manager) confirmed there was not a discontinuation order for this medication; therefore, the medication was not administered as ordered.b. Resident 6's MAR was blank on the following occasions;* 08/05/24 - the evening doses of atorvastatin, lisinopril, and metformin;* 08/10/24 - the evening doses of atorvastatin, lisinopril, and metformin;* 08/13/24 - the evening doses of atorvastatin, lisinopril, and metformin; and* 08/28/24 - the evening doses of atorvastatin, lisinopril, and metformin.On 09/03/24 at 3:42 pm, Staff 24 and this surveyor reviewed Resident 6's medication supply and MAR for all blanks. Staff 24 was unable to verify if the orders were followed as prescribed.c. Resident 6's prescription for metformin directed staff to give the medication with morning and evening meals. According to the resident's MAR, the medication was administered at 9:00 am and 9:30 pm daily. On 09/03/24, Staff 24 at 3:15 pm and the resident at 12:26 pm confirmed the evening meal is consumed between 4:00 pm and 6:00 pm. Therefore, the resident's metformin was not being administered as prescribed.The need to ensure all medications were carried out as prescribed was reviewed with Staff 1 (ED) on 09/05/24 at 11:17 am. She acknowledged the findings.
2. Resident 5 was admitted to the facility in 12/2023 with diagnoses including including Parkinson's disease.Resident 5's 08/01/24 through 09/03/24 MARs, corresponding observation notes, and current physician's orders were reviewed.The resident had physician orders for the following medications dated 04/07/24:* Atorvastatin 40 mg - Take one tablet by mouth daily (for high cholesterol);* Remove lidocaine 4% patch from left hip at 8:00 pm (for pain); * Melatonin 3 mg - Take one tablet by mouth daily at bedtime (for sleep);* Rytary 36.25 mg/145 mg capsule - Take one capsule by mouth three times daily (for Parkinson's disease); and* Rytary 61.25 mg/245 mg capsule - Take one capsule by mouth three times daily (for Parkinson's disease). Records revealed the following medications were marked as "not recorded" on the following dates: * 08/10/24 - removal of lidocaine patch;* 08/13/24 - melatonin; * 08/17/24 - atorvastatin, melatonin, Rytary 36.25/145 mg and Rytary ER 61.25 mg/245 mg for 8:00 pm doses;* 08/23/24 - removal of lidocaine patch;* 09/01/24 - removal of lidocaine patch; and * 09/01/24 - Rytary 36.25 mg/145 mg and Rytary 61.25 mg/245 mg for 8:00 pm doses. During an interview on 09/04/24 at 1:25 pm, Staff 19 (Chief of Wellness) was unable to confirm if the medications had been administered. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) on 09/04/24 at 3:00 pm. The findings were acknowledged.
OAR 411-054-0055 (1) (f-h) Systems: Treatment OrdersRESIDENT 6:1. Actions taken to correct rule violations include:a) Received discontinue aspirin order. b) Ordered is followed as prescribed for atorvastain, lisinopril and metformin and MAR is initialed.c) Metformin is being administered as prescribed and MAR is initialed.2. System will be corrected so that the violation will not occur again by:o Medication Order and Administration Reviews: a) Daily, Weekly, and Monthly Audits: The facility will implement a process for daily, weekly, and monthly reviews of medication orders to ensure medications are administered exactly as prescribed. These reviews will verify that the Medication Administration Record (MAR) is initialed by the administering staff member immediately after each administration. Any discrepancies in MAR documentation will be addressed in real-time, with corrective actions taken as necessary.b) Verification of Physician Orders: A 3 check system for daily, weekly, and monthly reviews of medication orders will be put in place to ensure that all written and signed physician orders are accurately documented in each resident's record. The facility will maintain up-to-date records of physician orders and perform regular audits to ensure compliance with this requirement.o Medication Administration Practices: a) Change to Bubble Pack Administration Protocol: The facility will revise its medication administration practice by ensuring that Med Techs pop medications from the bubble pack based on the current date, rather than by sequence. This adjustment is intended to reduce the risk of medication errors and ensure that medications are administered in alignment with prescribed dosages and timing as suggested by state surveyors. Staff will be instructed to follow this new procedure starting Oct 10 (next cycle fill), and adherence will be monitored daily. o Staff Training on Medication Administration: a) Med Tech Training via Relias: All Med Techs will undergo mandatory medication administration training via the Relias platform, with a completion deadline of October 15, 2024. This training will cover proper procedures for administering medications, documentation protocols, and strategies for avoiding medication errors. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024.3. Ongoing Evaluation and Monitoring: a) Daily, Weekly, and Monthly Reviews: The effectiveness of these corrections will be evaluated through daily, weekly, and monthly audits conducted by the Administrator, RN, and/or designee. These audits will focus on ensuring that medications are being administered as prescribed, that the MAR is being appropriately updated, and that all physician orders are documented and verified.4. Accountability and Oversight: a) Responsible Party: The Administrator, RN, and/or designated staff will be responsible for ensuring that all corrections are implemented and maintained. Ongoing monitoring will be documented, and any identified issues will be addressed promptly with corrective actions tracked.5. Facility alleges compliance: October 20, 2024. except for: Medication Administration training for Mech Techs through Relias by 10/15/2024 and will provide training documentation to SQ no later than 10/16/2024RESIDENT 5:1. Actions taken to correct rule violations include:a) Lidocain patch is being removed as prescribed and MAR is initialed. b) Melatonin is being adminstered as prescribed and MAR is initialed.c) Atorvastatin is being administered as prescribed and MAR is initialed. 2. System will be corrected so that the violation will not occur again by:o Medication Order and Administration Reviews: a) Daily, Weekly, and Monthly Audits: The facility will implement a process for daily, weekly, and monthly reviews of medication orders to ensure medications are administered exactly as prescribed. These reviews will verify that the Medication Administration Record (MAR) is initialed by the administering staff member immediately after each administration. Any discrepancies in MAR documentation will be addressed in real-time, with corrective actions taken as necessary.o Staff Training on Medication Administration: a) Med Tech Training via Relias: All Med Techs will undergo mandatory medication administration training via the Relias platform, with a completion deadline of October 15, 2024. This training will cover proper procedures for administering medications, documentation protocols, and strategies for avoiding medication errors. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024.3. Ongoing Evaluation and Monitoring: a) Daily, Weekly, and Monthly Reviews: The effectiveness of these corrections will be evaluated through daily, weekly, and monthly audits conducted by the Administrator, RN, and/or designee. These audits will focus on ensuring that medications are being administered as prescribed, that the MAR is being appropriately updated, and that all physician orders are documented and verified.4. Accountability and Oversight: a) Responsible Party: The Administrator, RN, and/or designated staff will be responsible for ensuring that all corrections are implemented and maintained. Ongoing monitoring will be documented, and any identified issues will be addressed promptly with corrective actions tracked.5. Faility Alleges Compliance: October 20, 2024 except for Medication Administration training for Mech Techs through Relias by 10/15/2024 and will provide training documentation to SQ no later than 10/16/2024 .

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused consent to an order, for 1 of 1 sampled resident (#2) whose MAR was reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment. The resident's 02/01/24 to 03/11/24 MARs and physician orders dated 01/05/24 and subsequent orders were reviewed. The following were identified:The resident was prescribed acetaminophen 500 mg (for pain and fever) - take 2 tablets every 8 hours. Between 02/01/24 and 03/11/24, Resident 2 refused administration of the medication on 55 of 120 occasions. The facility was not notifying the prescribing physician each time Resident 2 refused consent to the order.The need to ensure the facility notified the physician or other practitioner if a resident refused consent to an order, or obtained instructions from the physician as to when s/he wanted to be notified of refusals, was reviewed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 08/2023 with diagnoses including type 2 diabetes, hypertension, depression, and gastroesophageal reflux disease (GERD).The resident's 02/01/24 to 03/11/24 MARs and physician orders dated 07/19/23 were reviewed, and the following was identified:The following orders lacked a reason for use: * Fluoxetine (for depression);* Losartan (for hypertension);* Metformin (for Type 2 diabetes);* Pantoprazole (for GERD);* Polyethylene glycol (for bowel care); and* Vitamin D3 (supplement).The need to ensure an accurate MAR was kept that included minimum requirements was discussed on 03/15/24 with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator), and Staff 16 (Wellness Director). They acknowledged the findings.
2. Resident 1 was admitted to the facility in 11/2023 with diagnoses including Parkinson's disease, cerebrovascular disease and neurogenic bladder. The resident's 03/01/24 to 03/11/24 MARs and physician orders dated 11/22/23 were reviewed. The following were identified:The following orders lacked a reason for use:* Aspirin (for heart health);* Azelastine nasal spray (for symptoms of rhinitis);* Myrbetriq (for overactive bladder);* Rosuvastatin (for high cholesterol); and* Sertraline (an antidepressant medication).The need to ensure an accurate MAR was kept that included minimum requirements was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.3. Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment.The resident's 02/01/24 to 03/11/24 MARs and physician orders dated 01/05/24 and subsequent orders were reviewed. The following deficiencies were identified:The following orders lacked a reason for use:* Acetaminophen (for pain and fever);* Amantadine (to treat symptoms of Parkinson's);* Baclofen (to relieve muscle spasms and tightness);* Carbidopa-levodopa (to treat symptoms of Parkinson's);* Carvedilol (to treat high blood pressure);* Citalopram (an antidepressant medication);* Cranberry PAC (for urinary tract health);* Culturelle (for digestive health);* Estrace cream (for symptoms of menopause);* Ezetimibe (for high cholesterol);* Fish oil capsule (a supplement for heart health);* Losartan (to treat high blood pressure);* Modafinil (to treat excessive daytime sleepiness);* Myrbetriq (for overactive bladder);* Perservision Gels (for eye health);* Pravastatin (for high cholesterol);* Senna (for constipation);* Solifenacin (for overactive bladder);* Tolterodine (for overactive bladder); and* Vitamin D3 (supplement for calcium and phosphate absorption).The need to ensure an accurate MAR was kept that included minimum requirements was discussed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 2 sampled residents (#6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 04/2024 with diagnoses including type 2 diabetes mellitus. Resident 6's MAR dated 08/01/24 through 09/02/24 and corresponding physician orders were reviewed. Interviews with the resident and a review of his/her current evaluation, dated 08/19/24, revealed Resident 6 was alert and oriented.The resident had an order to receive 35 units of Lantus insulin subcutaneously every night for diabetes. The resident's MAR was blank for this medication on 08/10/24, 08/13/24, 08/23/24, 08/28/24, 08/30/24, and 08/31/24. On 09/04/24 at 10:27 am, Staff 24 (Med Care Manager) reported Resident 6 kept a personal log of all insulin injections received which included the date, time, units received, and staff who administered the medication. Resident 6's personal log was reviewed on 09/05/24 at 11:01 am, and it indicated s/he received his/her Lantus as prescribed. It was determined the resident did receive the medication as ordered, and the MAR was not initialed. The need to ensure MARs were accurate was discussed with Staff 1 (ED) on 09/05/24 at 11:17 am. She acknowledged the findings.
OAR 411-054-0055 (2) Systems: Medication AdministrationRESIDENT 6:1. Action taken to correct the rule violation includes:a) Lantus insultin is being administered and MAR is initialed.2. The system will be corrected so that the violation will not occur again by:o Medication Order and Administration Reviews: a) Daily, Weekly, and Monthly Audits: The facility will implement a process for daily, weekly, and monthly reviews of medication orders to ensure medications are administered exactly as prescribed. These reviews will verify that the Medication Administration Record (MAR) is initialed by the administering staff member immediately after each administration. Any discrepancies in MAR documentation will be addressed in real-time, with corrective actions taken as necessary.o Staff Training on Medication Administration: a) Med Tech Training via Relias: All Med Techs will undergo mandatory medication administration training via the Relias platform, with a completion deadline of October 15, 2024. This training will cover proper procedures for administering medications, documentation protocols, and strategies for avoiding medication errors. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024.3. o Ongoing Evaluation and Monitoring: a) Daily, Weekly, and Monthly Reviews: The effectiveness of these corrections will be evaluated through daily, weekly, and monthly audits conducted by the Administrator, RN, and/or designee. These audits will focus on ensuring that medications are being administered as prescribed, that the MAR is being appropriately updated, and that all physician orders are documented and verified.4. Accountability and Oversight: a) Responsible Party: The Administrator, RN, and/or designated staff will be responsible for ensuring that all corrections are implemented and maintained. Ongoing monitoring will be documented, and any identified issues will be addressed promptly with corrective actions tracked.5. Facility Alleges Compliance: October 20, 2024 except for Medication Administration training for Mech Techs through Relias by 10/15/2024 and will provide training documentation to SQ no later than 10/16/2024

Based on interview and record review, it was determined the facility failed to ensure implementation of an acuity-based staffing tool (ABST) that included all required ADLs and amount of staff time needed to provide care. Findings include, but are not limited to:The facility's ABST was reviewed with Staff 1 (Administrator) at 10:17 am on 03/13/24. The tool lacked the following:* Evidence that all required ADLs were addressed for each resident; and* The amount of staff time needed to provide care.The need to ensure an ABST was implemented that included all required ADLs for each resident and the amount of staff time needed to provide care was discussed on 03/15/24 with Staff 1, Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator), and Staff 16 (Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 9, 10 and 13) completed all pre-service orientation training requirements prior to beginning their job duties. Findings include, but are not limited to:Staff training records were reviewed at 10:00 am on 03/14/24 with Staff 1 (Administrator). a. There was no documented evidence Staff 9 (CG), hired 12/28/23, Staff 10 (CG), hired 01/28/24, and Staff 13 (MT), hired 09/11/23, completed pre-service orientation training in the following topics:* Resident rights and values of CBC care;* Abuse reporting requirements;* Infectious disease prevention;* Fire safety and emergency procedures; and* Pre-service dementia training.b. There was no documented evidence Staff 7 (Server), hired 02/01/24, completed pre-service orientation training in the following topics:* Resident rights and values of CBC care;* Abuse reporting requirements;* Infectious disease prevention; and* Fire safety and emergency procedures.The need to ensure staff completed all required pre-service orientation training prior to beginning job responsibilities was discussed on 03/15/24 with Staff 1, Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator), and Staff 16 (Wellness Director).They acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease, hemiplegia affecting non-dominant side and memory impairment.The record indicated that when the resident was admitted s/he was using an external catheter device at night to address incontinence. In interviews on 03/12/24 and 03/14/24, Resident 2 and Witness 1 (Spouse) reported continued issues with facility care staff knowing how to use and position the device properly. They reported when the device was positioned improperly and resulted in leakage, it caused Resident 2 agitation and anxiety.Emails initiated by Witness 1 to facility administration, including Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator) and Staff 3 (MCC Administrator) on 01/23/24 and 02/23/24, included Resident 2 and Witness 1's continuing complaints that staff were not positioning the device properly and that staff stated to them they had not been trained on the use of the external catheter. Witness 1 repeatedly asked when training to staff would be provided.In an interview on 03/15/24, Staff 12 (MT) stated she had not received training on the use of the external catheter device. In another interview on 03/15/24, Staff 9 (CG) stated she had recently received training on the use of the device along with other care staff. On 03/15/24, Staff 2 provided a list of eight direct care staff who had received training on the use of the device in a group training on 03/07/24. However, she acknowledged that not all staff who are responsible to assist Resident 2 with the device as part of their job duties had received the training.The need to ensure direct care staff demonstrated satisfactory performance in any duty they were assigned was reviewed with Staff 1, Staff 2, Staff 3 and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 10 and 13) demonstrated satisfactory performance in assigned job duties within 30 days of hire, and verification that direct care staff demonstrated satisfactory performance in any duty they were assigned for 1 of 1 resident (#2) who required catheter care. Findings include, but are not limited to:1. Staff training records were reviewed at 10:00 am on 03/14/24 with Staff 1 (Administrator). There was no documented evidence Staff 10 (CG), hired 01/28/24, and Staff 13 (MT), hired 09/11/23, demonstrated satisfactory performance within 30 days of hire in the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting 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 that direct care staff demonstrated satisfactory performance in any duty they were assigned within 30 days of hire was discussed on 03/15/24 with Staff 1, Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator), and Staff 16 (Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:Facility fire drill records were reviewed on 03/13/24 with Staff 3 (Maintenance Director). In describing the current fire drill process, Staff 3 reported residents were not being relocated during the fire drills. During a group interview conducted on 03/14/24 at 3:00 pm, several sampled and unsampled residents confirmed they were not being included in the fire drills.Because the facility was not relocating residents during fire drills, documentation was lacking or was not reflective for the following required items:* The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and* Number of occupants evacuated.The need to ensure fire drills were conducted according to the OFC was reviewed with Staff 1 (Administrator), Staff 2 (Assisted Living Coordinator), Staff 3 (MCC Administrator) and Staff 16 (Wellness Director) on 03/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their initial licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 270, C 303, and C 310.