Alpine House Assisted Living

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).

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 12/16/25 from 10:15 am until 1:00 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Walls and ceiling by stand-up mixer; * Two exhaust vents/fans over the range; * Bottom shelves of the reach-in refrigerator, reach-in freezer, and cabinets throughout the kitchen; *Exterior and interior of the oven, range top, and grease trap of grill were found with food debris build up and grease; * Top of the microwave; * The window air conditioning unit; * Black mat underneath the range. b. The following areas were in need of repair: * The interior lid of the chest deep freezer was in disrepair and had exposed insulation; * Staff 2 (Cook) reported the heat lamp above the island was no longer functional; * There was a burned out light at entryway of the kitchen; * The light between the range and the stand up freezer was missing a light cover; * There was a cracked light cover over the reach-in freezer; * There were chips in the laminate/covering in two of the four corners of the kitchen island, in front of the microwave, the countertop to the left of the microwave; * There was chipped area of linoleum near the drain by the island; * There were chips observed in the wall near the reach-in freezer, the corner of the wall by the double sink; and * There was no longer a baseboard with area that was not smooth or cleanable underneath the three compartment sink and dish pit. c. The facility lacked a written policy for when kitchen staff are sick. On 12/16/25 at 11:40 am, Staff 1 (Owner/Director), Staff 2, and surveyor toured the kitchen. Staff 2 acknowledged the above findings at exit interview at 1:15 pm.

a. Accumulated minor cleaning needed. Walls/celing, exhaust fans in ceiling above stove, shelvess, top of microwave, window AC unit filter, stove exterior interior, oven, range top and grease trap on side of stove, top of microwave, and black mat beneath stove cleaned. Bottom shelve of refrigerators and freezer. Cabinets throughout the kitchen to be cleaned. Cleaning schedule to be posted and the kitchen manager / or Steve will do periodic walk through to see that clenliness is maintained. b. Repairs needed, Chest freezer remove or replace, Heat lamp continue to use as a shelf, Burned out light at entry of kitchen to be replaced, or if inspecotr ment the one at the back entry to kitchen, between the chest freezer and the refrigerator just turn on the switch they are on a separate circuit, Broken light cover and missing light cover will be replaced, Chips in corners of kitchen island and in front of and on left of the microwave will be filled in hopefully to level because covering them with super glue is not visually acceptible. Linoleum near drain will get patched in, Chip and some calking by the reach in freezer have been scraped filled and painted, Wall at the corner of the double sink near the door has been repaired and painted, Baseboard under the sinks has been replaced, Steve has been whipping the repair guys to get the repairs done, and fixing more things we had planned to do in the future but had not gotten enough data to decide what to do, so we will throw away some money and experiment, Steve will stay on top of the repairs. c. Sick kitchen staff policy, Steve will post one. Our has been verbal, "If you do not feel good do not come to work, we pay sick days" and our staff love and watch out after tenants and do not need a written policy to do common sense things. Increase frequency of cabinet cleaning, Steve will inspect more often. Hired carpenter to address the outside window sheetrock where paint is not smooth, remove some glue left when we recintly replaced a freezer and repaint the wall. The old freezer installers had glued the old freezer to the wall. Either smooth and paint or replace with ruber molding or a board to cover the mopboard area under the sink wash area. WE arehaving an oven and hood cleaning party which will include the ceiling vents and the filter on the window air conditioner. The counter chips were already covered with "Super Glue" but it is clear and hard to see. So I will cover them with something probably unsightly but visible and smooth. I cleaned off the little spill of milk on the bottom of the refrigerator. Longer term plan is to remove the cleaning routine from the 3 ring binder and make it more prominent. And Steve check it more often. Probably have to pay extra to get the hood and ovens cleaned. Cooks already have 10 to 11 hour work days. and Ovens and hoods interfere with cooking and stove use.

Based on interview and record review, it was determined the facility failed to maintain a complete and accurate record for 3 of 3 sampled residents (#s 1, 3 and 4)  and several unsampled residents whose records were reviewed. Findings include, but are not limited to: Resident 1, 3 and 4's records were reviewed during the survey and found to be incomplete and inaccurate in the following areas: 1. The facility documented information and monitoring about multiple residents' daily changes of condition in the "Staff Communication Log." The documentation included information about multiple residents, and was not a confidential document and could not be included in each resident's individual record as required under 411-054-0040(1)(d)(B). 2. Resident 4 was admitted to the facility in 11/2021 with diagnoses including stroke and unsteadiness on his/her feet. During an interview on 02/08/23, Staff 2 (Facility RN) reported Resident 4 had a fall on 02/02/23 and sustained a rug burn on the knee. There was no documentation in the resident's record of the fall and injury that occurred on 02/02/23. 3. During record review, the surveyor noted multiple blanks on the ADL task sheets on multiple non-sampled residents. The failure to ensure complete an accurate records of the resident's status was shared with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records, for 4 of 4 sampled residents (#s 5, 6, 7 and 8), whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. On 08/08/23 the survey team requested incident reports for Resident 6 regarding a burn on the forehead and for an injury of unknown cause for Resident 7. The facility had not completed investigations for these incidents. Refer to C 231, examples 1 and 2. 2. Resident's 6 and 7's records reviewed during the survey identified the following: There was no documented evidence the facility was monitoring the residents per evaluated care needs and changes of condition. On 08/07/23, the surveyor team requested progress notes for both residents. The "observation notes" provided lacked documented evidence the facility evaluated and determined what action or intervention was needed for the residents and lacked monitoring of the conditions, at least weekly until resolved. Refer to C 270, examples 1 and 3. 3. On 08/07/23 through 08/09/23, the survey team requested outside provider notes for Resident's 6, 7 and 8. There was no documented evidence the facility was consistently coordinating care with outside providers and the facility management or facility RN had not consistently reviewed outside provider notes and updated the service plans, as appropriate for Resident's 6, 7 and 8. Refer to C 290, examples 1, 2 and 3. 4. On 08/07/23 the survey team requested quarterly service plan evaluations, quarterly side rail evaluations, self-administration of medications evaluations and quarterly smoking evaluations for Resident's 5, 6, 7 and 8. The facility was not able to provide documentation that evaluations were completed or updated quarterly, as required. Refer to C 252, examples 1, 2 and 3 and C 325, example 1. The need to ensure resident records were complete and accurate was discussed with Staff 1 (Administrator/owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings.

1. Resident 6 and 7's records were reviewed for injuries of unknown cause and determined needed actions. Full chart review completed by consultant to identify injury of unknown cause and identify follow up needed. Resident 6, 7 and 8's outside provider notes reviewed and service plans updated as appropriate. Resident 5, 6, 7 and 8's charts were reviewed and evaluations completed. 2. The consultant is providing training to the community on investigations and reporting for injury of unknown cause. Incident reports will be reviewed daily in the clinical meeting. Consultant to provide training to staff for monitoring requirements needed though resolution of the change of condition. Consultant has provided training and guidance for processing third party notes. Outside service notes will be reviewed in the clinical meeting. Consultant has provided training on completion of quarterly self-med evaluations, assistive devices, and smoking evaluations. Whiteboard has been updated to assist in tracking these evaluations. 3. Daily in the clinical meeting, monthly in QA meeting and quarterly to coincide with quarterly evaluations. 4. Administrator.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The kitchen was toured on 02/08/23 at 9:40 am. The following areas needed cleaning or repair to ensure surfaces could be cleaned and sanitized and to prevent cross-contamination during meal preparation and service: * There was black mold build-up along parts of the caulking surrounding the warewasher counter; * The metal wall shelf above the warewasher counter had sticky debris build-up; * Refrigerator #1 lacked a working thermometer; * The exhaust vent on the ice machine was covered with dust/lint; * A white Kitchen-Aid stand mixer that was stored in the dry storage room was covered with dried debris; * The floor and wall cabinets and countertops had areas where laminate was missing, detached or worn which exposed bare wood that was a porous and uncleanable surface that could harbor germs; * A floor cabinet to the right of the range had chipped or worn paint, exposing bare wood; * The surface of the window sills was worn, exposing bare, unsealed wood; * The window air conditioner did not seal in the window opening properly which could allow pests to enter the building; * Two ceiling vents above the range had dark build-up; * The condensers above the refrigerators had dust/lint build-up; * The floor around the feet of refrigerators #1 - 3 had dark debris build-up; and * There was dried liquid debris on the interior floor of the refrigerator in the dining room. * The facility lacked a schedule for routine cleaning of the ice bin of the ice machine. * The facility did not have test strips for bleach solutions and were not using them to test quaternary or bleach sanitizing solutions. * Multiple garbage cans lacked lids. * The facility did not use pasteurized eggs when preparing egg dishes served with soft yolks. The kitchen was toured with Staff 1 (Administrator/Owner) and Staff 12 (Cook) on 02/09/23 at 11:00 am. The need to ensure the kitchen was maintained and cleaned properly and the facility followed safe food preparation and handling practices was discussed. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The kitchen was toured on 08/07/23 at 2:50 pm. The following areas needed cleaning or repair to ensure surfaces could be cleaned and sanitized and to prevent cross-contamination during meal preparation and service: * The floor and wall cabinets and countertops had areas where laminate was missing, detached or worn which exposed bare wood that was a porous and uncleanable surface that could harbor germs; * A floor cabinet to the right of the range had chipped or worn paint, exposing bare wood; * The floor around the base of freezer #1 and  freezer #2 had multiple holes, approximately 5 cm diameter; * There was dried liquid debris on the inside of the free standing upright freezer in the dining room; * Staff 12 (Cook) used a test strip to check the chlorine sanitation solution. The test strip color remained unchanged. A review of the instructions on the test strip case indicated the color should have changed to green when the proper parts per million (PPM) of chlorine was used; and * Multiple garbage cans lacked lids. The kitchen was toured with Staff 1 (Administrator/Owner) and Staff 12 on 08/07/23 at 3:20 pm and 08/09/23 at 11:20 am. The need to ensure the kitchen was maintained and cleaned properly and the facility followed safe food preparation and handling practices was discussed. They acknowledged the findings.

1. All noted areas have been cleaned. The kitchen flooring is being repaired. New liners ordered for under the oven/stove.  The floor cabinet to the right been repaired and painted.  Countertop sealant has been ordered to correct uncleanable surfaces. The freezer shelves have been cleaned. Staff have been trained on proper use of sanitation test strips. 2. An updated kitchen cleaning task was developed and staff will be trained on how to use it for daily, weekly and monthly cleaning tasks. The dining director and administrator will do weekly walkthroughs. Dining director to complete competencies of using test strips properly.   3. Weekly 4. Administrator and Dining Director.

Based on interview and record review, it was determined the facility failed to provide services to assist the residents in activities of daily living in the area of showers for 1 of 3 sampled residents (#4) and multiple unsampled residents who required oversight, cueing, supervision and assistance with ADL's. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2021 with diagnoses including stroke and unsteadiness on his/her feet. Resident 4 was dependent on staff for most of ADL care, including showers. The resident's 09/28/22 service plan indicated s/he required assistance with bathing. A review of the 01/01/23 through 02/07/23 ADL flowsheets showed multiple blanks in the shower assistance without documentation that explained why the care was not provided. 2. Caregiver ADL task sheets, reviewed from 01/01/23 to 02/07/23, revealed the following: * The task sheets showed that there were 10 residents who required oversight, cueing, supervision and assistance with showers. * The 10 residents' ADL task sheets were reviewed during the survey and showed that 6 of 10 residents lacked documented evidence that they received shower assistance from staff as outlined in their service plan. On 02/08/23, the lack of documented evidence of assisting showers as outlined in their service plan was reviewed with Staff 1 (Administrator/Owner) who acknowledged the findings.

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) and the use of assistive devices was evaluated and documented quarterly for 2 of 2 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 10/2022. A review of the resident's move-in evaluation failed to address the following: * Spiritual, cultural preference and traditions; * Cognition, including decision making abilities; * Mental Health issues including effective non-drug interventions; * Personality including how a person copes with change or challenging situations; * Independent activity of daily living including ability to use call system and transportation; * Pain including non-pharmaceutical interventions; * List of treatments; * Indicator of nursing needs including potential for delegated nursing tasks; * Fall risk or history; * Complex medication regimen; * Recent losses; * Unsuccessful prior placements; * Elopement risk or history; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the residents behavior, including but not limited to: noise, lighting and room temperature. The facility's failure to complete all required elements for Resident 2's move-in evaluation was discussed with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2017 with diagnoses including depressive episode, type 2 diabetes mellitus and insomnia. During the acuity interview, Resident 1 was identified as using a side rail on his/her bed. In an interview in the resident's room on 02/08/23 at 3:10 pm, Resident 1 stated s/he used the side rail to hold onto when getting into and out of bed. The side rail was positioned along the upper part of the bed toward the resident's shoulders. Inspection of the side rail revealed that, though it was positioned tight to the mattress to prevent entrapment, the rail was loose and pivoted approximately six inches to the left and right. The surveyor notified Staff 5 (Med Tech/Personal Staff Aide) that the side rail was loose. Staff 5 stated she would follow up to secure it immediately. There was no documented evidence the side rail was evaluated and its use as an assistive device documented in Resident 1's record. The need to ensure assistive devices were evaluated quarterly and their use documented in the resident's record was discussed with Staff 1 (Administrator/Owner) on 02/09/23. He acknowledged no evaluation had been completed. 3. Resident 3 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes mellitus. During observation and interview of Resident 3, a side rail on his/her bed was identified. In an interview in the resident's room on 02/08/23 at 10:30 am, Resident 3 and Witness 1 (family member) stated that the side rail was used to hold onto when getting into and out of bed. The side rail was positioned along the upper part of the bed toward the resident's shoulders. Inspection of the side rail revealed that it was secure and positioned tight to the mattress to prevent entrapment. There was no documented evidence the side rail was evaluated and its use as an assistive device documented in Resident 3's record. The need to ensure assistive devices were evaluated quarterly and their use documented in the resident's record was discussed with Staff 1 (Administrator/Owner) on 02/09/23. He acknowledged no evaluation had been completed.

Based on observation, interview, and record review, it was determined the facility failed to ensure the smoking status and the use of assistive devices were evaluated and documented quarterly for 3 of 3 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 7 moved into the facility in 01/2023 with diagnoses including bipolar mood disorder and type 2 diabetes mellitus. In an interview on 08/08/23 at 9:20 am, Resident 7 stated s/he smoked daily as needed for social activity. There was no documented evidence the resident's smoking status was evaluated in the resident's record. The need to ensure the resident's smoking status was evaluated quarterly and documented in the resident's record was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. They acknowledged no evaluation had been completed. 2. Resident 8 moved into the facility in 03/2021 with diagnoses including pruritus (itchy skin). In an interview on 08/09/23 at 1:45 pm, Resident 8 stated s/he smoked daily as needed. Smoking materials including cigarettes and lighters were observed in his/her room. A facility's "Safe Smoking Assessment", undated, revealed the resident was considered a safety risk and should be supervised at all times when smoking. However, the assessment was the only assessment/evaluation and there was no updated quarterly evaluation as required. The need to ensure the resident's smoking status was evaluated quarterly and documented in the resident's record was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. They acknowledged no quarterly evaluation had been completed. 3. Resident 6 moved into the facility in 12/2020 with diagnoses including Multiple sclerosis. During the acuity interview on 08/07/23, Staff 1 (Administrator/Owner) reported the resident smoked, including the use of a "vape" (vaporizer) pen for marijuana. Observations throughout the survey conducted 08/07/23 through 08/09/23 confirmed the resident smoked daily. There was no documented evidence the resident's smoking status was evaluated in the resident's record. The need to ensure the resident's smoking status was evaluated, updated quarterly and documented in the resident's record was discussed with Staff 1 and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. They acknowledged the findings.

1. Residents 6, 7 and 8 smoking ability was evaluated and placed in the resident record. 2. All residents who smoke will be evaluated to do so safely. Whiteboard has been updated to track evaluations completed. 3. Quarterly. 4. Administrator and nursing.

3 . Resident 4 was admitted to the facility in 11/2021 with diagnoses including cerebral infarction. Interviews with care staff and observation of Resident 4 during the survey revealed s/he was incontinent and dependent on staff for ADL care. Resident 4's current service plan, dated 09/28/22,  revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas. * Refusal of care with interventions; * Ability to use call system; * Preference for shower assistance by male staff only; * Hydration status; and * Risk of weight loss and dehydration status. The need to ensure the service plan provided clear instruction to staff and was reflective of the resident's needs was discussed with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 3 and 4's current service plans were reviewed during the survey. The residents were observed and interviewed and care staff were interviewed. 1. Resident 1 was admitted to the facility in 08/2017 with diagnoses including depressive episode, type 2 diabetes mellitus and insomnia. The current service plan, which was undated, was not reflective of the resident's care needs or lacked clear direction regarding the delivery of care services in the following areas: * The resident required less assistance with dressing than was described in the service plan; * The service plan lacked resident-specific information that the resident wore dentures, cared for them him/herself but needed reminders each morning to wear them; * The resident required less assistance with toileting than was described in the service plan, only needing assistance when incontinent; * The service plan lacked information that the resident used a side rail to assist with self-transferring and lacked instructions for staff regarding the safe use and monitoring of the side rail; and * Though the resident had a behavior support plan written in 2021, the current service plan lacked information about typical signs that the resident was getting agitated and interventions for staff to employ immediately to calm and support the resident. The need to ensure resident service plans were reflective of care needs and included clear direction for providing services was reviewed with Staff 1 (Administrator/Owner) on 02/09/23. He acknowledged the findings. 2. Resident 3 was admitted to the facility 12/2021 with diagnoses including type 2 diabetes mellitus. Interviews with care staff, Resident 3, Witness 1 (family member) and observations of Resident 3 during the survey revealed s/he was at times dependent upon staff for mobility assistance, transferring and toileting. Resident 3's current service plan, dated 10/13/22, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas: * Evacuation; * Transferring; * Toileting; * Siderail; and * C-PAP machine. The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator/Owner) on 02/09/23. The findings were acknowledged.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of resident care needs and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 01/2023 with diagnoses including diabetes and weakness. Observations of the resident, resident and staff interviews and review of the service plan, dated 05/20/23 showed the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas: * Use of a right leg brace; * Use of oxygen; * Smoking status; and * Ambulation status. The need to ensure Resident 7's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23 at 10:00 am. They reviewed the service plan and acknowledged the findings. 2. Resident 8 moved into the facility in 03/2021 with diagnoses including prurites (itchy skin). a. The resident's service plan that was available to staff was dated 10/24/2022. The facility had not updated the service plan quarterly as required. b. Observations of the resident, resident and staff interviews and review of the service plan showed the service plan did not provide clear direction to staff in the following areas: * Use of oxygen including staff instruction for how often the nasal cannula and oxygen tubing needed to be changed. The need to ensure Resident 8's service plan was updated quarterly and provided clear direction to staff was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23 at 10:00 am. They reviewed the service plan and acknowledged the findings.

1. Service plans for Resident 7 and 8 have been updated with consultant assistance. Clear direction is available to staff on how to use a leg brace and the use of oxygen. Training was provided by consultant. All resident services plans will be reviewed and updated. 2. Consultant is providing instruction on service plan development with clinical team as well as providing a checklist to ensure service plans are updated with all required service planning elements. Service plans will be reviewed after completion for content requirements. A service plan schedule will be developed and reviewed weekly. 3. Weekly and quarterly. 4. Administrator, Nurse and Resident Care Manager.

3. Resident 4 was admitted to the facility 11/2021 with diagnoses including cerebral infarction. Resident 4's progress notes, 11/22/22 through 02/07/23, facility Staff Communication Log notes, 02/01/23 - 02/08/23 MAR and incident reports were reviewed and revealed the following: * Received COVID vaccine on 12/13/22; * A fall on 02/02/23; * Hospital stay, 02/02/23 to 02/04/23; and * Use of antibiotic, beginning 02/05/23, for 5 days. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident following each change of condition, communicated the actions or interventions to staff on each shift and documented on the progress of the condition at least weekly until resolved. The need to implement a system for responding to resident changes of condition which included determining and documenting what actions were needed for the resident and documenting on the status of the condition at least weekly until resolved in a way that the documentation could be made part of the resident's record was discussed with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2017 with diagnoses including depressive episode, type 2 diabetes mellitus and insomnia. The resident's progress notes, facility Communication Log notes, and incident reports were reviewed to identify resident changes of condition that occurred between 11/07/22 and 02/07/23. The following were identified: a. Between 12/26/22 and 01/08/23 and, again, between 01/13/23 and 01/23/23 staff documented in the Communication Log notes that the resident was "feeling under the weather," "sick" or "not feeling well." * The facility failed to determine and document what actions or interventions were needed for the resident and, because the entries in the Communication Log included reference to other residents, the documentation of the facility's monitoring of Resident 1 could not be made part of his/her record as required in the rule. b. On 01/26/23 Resident 1 was prescribed an antibiotic for his/her cough. * The facility failed to determine and document what actions or interventions were needed for the resident and failed to document on the status of the resident's condition at least weekly until resolved. c. The facility documented Resident 1 fell or was found on the floor on 11/11/22, 11/12/22, 01/15/22 and 02/07/23. * The facility failed to determine and document what actions or interventions were needed for the resident and failed to document on the status of the resident's condition at least weekly until resolved. The need to implement a system for responding to resident changes of condition which included determining and documenting what actions were needed for the resident and documenting on the status of the condition at least weekly until resolved in a way that the documentation could be made part of the resident's record was discussed with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. They 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 the resident following a change of condition, communicate the actions or interventions to staff on each shift, document on the progress of the condition at least weekly until resolved and ensure documentation was made part of the resident record, for 3 of 3 sampled residents (#s 1, 3 and 4) who were reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility 12/2021 with diagnoses including type 2 diabetes mellitus. Resident 3's progress notes and facility records dated 10/20/22 through 02/07/23 were reviewed and revealed the following changes of condition: * Falls on: 11/12/22, 12/08/22, 12/18,22, 01/08/23, 01/26/23, 01/28/23 and 02/08/23; and * The resident started two antibiotic medications on 01/19/23. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident following each change of condition, communicated the actions/interventions to staff and documented on the progress of the condition at least weekly until resolved. In an interview on 02/08/23 at 12:45 pm, Staff 1 (Administrator/Owner) stated that for the changes of condition noted, the facility did not have a process in place in which to implement actions and interventions needed and monitor the resident. Staff 1 stated that they were "keeping an eye" on Resident 3 because the staff "know they need to." The need to implement a system for responding to resident changes of condition which included determining and documenting what actions were needed for the resident and documenting on the status of the condition at least weekly until resolved in a way that the documentation could be made part of the resident's record was discussed with Staff 1 and Staff 2 (Facility RN) on 02/08/23. They 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 the resident following a change of condition, document on the progress of the condition at least weekly until resolved, and monitor residents' per evaluated care needs for 3 of 3 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 7 moved into the facility 01/2023 with diagnoses including type 2 diabetes and weakness. Resident 7's facility observation notes dated, 04/13/23 through 08/05/23 and incident reports, dated 04/20/23 through 08/04/23 were reviewed and revealed the following: * 04/20/23: Fall with rug burn and sent out to emergency room due to swollen "very bad" left knee; * 04/22/23: Returned from two days hospital stay; * 05/17/23: A fall; * 07/16/23: Complaint of being heavier on the right foot; * 07/20/23: A fall; and * 08/04/23: A fall with rug burn. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident following each change of condition and documented on the progress of the condition at least weekly until resolved. The need to implement a system for responding to resident changes of condition which included determining and documenting what actions were needed for the resident and documenting on the status of the condition at least weekly until resolved in a way that the documentation could be made part of the resident's record was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23 at 10:00 am. They acknowledged the findings. 2. Resident 8 moved into the facility 03/2021 with diagnoses including pruritus (itchy skin). Resident 8's facility observation notes dated, 05/16/23 through 08/04/23 was reviewed and revealed the following: * 05/16/23: A fall * 06/13/23: "feeling dizzy and woozy" and went to the hospital; * 06/24/23: Urinary track infection with antibiotic treatment; * 06/25/23: A fall with "rib pain" and emergency room visit; * 07/09/23: Emergency room visit for "not being able to breathe"; and * 07/24/23: Complaint of "chest compressed, shakiness, feels tight...". There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident following each change of condition and documented on the progress of the condition at least weekly until resolved. The need to implement a system for responding to resident changes of condition which included determining and documenting what actions were needed for the resident and documenting on the status of the condition at least weekly until resolved in a way that the documentation could be made part of the resident's record was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23 at 10:00 am. They acknowledged the findings. 3. Resident 6 moved into the facility 12/2020 with diagnoses including Multiple sclerosis. Review of the facility's observation notes dated, 04/10/23 through 08/02/23, and quarterly evaluation dated 06/2023, identified the following monitoring per evaluated care needs and changes of condition: a. The current evaluation instructed staff to document daily bowel monitoring, as needed. There was no documented evidence the facility was monitoring the resident's bowel movements, per the evaluation. During an interview on 08/08/23, Staff 5 (Lead MT/Personal Staff Aid), confirmed the facility staff were not documenting bowel monitoring. b. The following short term changes of condition were identified: * On 04/29/23 - pain in left foot cased by hitting /his/her foot on another residents cart; * On 06/10/23 - burn on forehead; * On 06/14/23 - behavior expression; * On 06/15/23 - behavior expression; * On 06/30/23 - Emesis; * On 07/04/23 - behavior expression; and * On 07/05/23 - Edema and feet slightly blue. There was no documented evidence the facility evaluated the resident's changes in condition, determined and documented what actions or interventions were needed for the resident following each change of condition and documented on the progress of the condition at least weekly until resolved. The need to implement a system to ensure monitoring per residents' evaluated care needs and to ensure resident changes of condition which included determining and documenting what actions were needed for the resident and documenting on the status of the condition at least weekly until resolved was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. They acknowledged the findings.

1. Residents 7 and 8 are being evaluated for fall risk and current interventions are being evaluated and new interventions developed and communicated to staff to reduce future falls. Resident 6 service plan is being updated to include information on how to reduce future injury related to behavior expression or bodily injury related to her MS; there is a plan in place to monitor bowel status and response. A full electronic documentation review is being done by consultant to identify changes of condition. Another RN has been hired. Consultant is training both RNs on how to identify, respond to change of condition and document. 2. Clinical meetings for review of change of condition will occur multiple times per week. ISPs and alert charting will be reviewed in the clinical meeting. The clinical team will be trained by the consultant in how to recognize, respond, monitor, and document changes of condition. Med techs will be trained on identifying and responding to changes of condition. 3. Daily, weekly 4. Administrator and Nursing.

Based on interview and record review, it was determined the facility failed to have policies to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care, and that the facility nurse reviewed the resident's health-related service plan changes made as a result of outside provider services, for 2 of 2 sampled residents (#s 1 and 3) who received home health on-site services. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2017 with diagnoses including depressive episode, type 2 diabetes mellitus and insomnia. The record indicated, and interviews with staff confirmed, Resident 1 received regular on-site visits from a mental health counselor. The facility was unable to provide evidence the mental health provider left written documentation regarding the services being provided and any instructions for the facility regarding supplemental care. The need to ensure the facility had policies to ensure outside providers left documentation regarding the services being provided was discussed with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes mellitus. Review of the progress notes from 10/20/22 through 02/07/23, staff communication log notes dated 01/04/23 through 02/07/23 and interviews with staff confirmed, Resident 3 received regular on-site visits from a home health RN. In an interview on 02/08/23, Staff 5 (Med Tech/Personal Staff Aide) stated the home health RN visited the resident on 02/06/23 and discovered a bruise on Resident 3's back. Per Staff 5, the home health RN communicated this information to her verbally. The facility was unable to provide evidence the home health RN left written documentation regarding the services that were provided and any instructions for the facility regarding supplemental care. The need to ensure the facility had policies to ensure outside providers left documentation regarding the services being provided was discussed with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. They acknowledged the findings.

2. Resident 7 moved into the facility in 01/2023 with diagnosis of type II diabetes and weakness. During the acuity interview on 08/07/23, the resident was identified to receive HHPT services from an outside provider. Resident 7's clinical records, including recommendations, revealed the following: * 07/26/23: "PT [physical therapy] eval [evaluation] due to drop foot " ... AFO (ankle-foot orthoses, to support lower leg) on the right leg; and * 08/01/23: "Please help [Resident 7] with brace if [s/he] can't manage." 08/08/23, the resident was observed to wear a brace on the right leg during the interview and the resident reported the brace supported his/her leg. There was no documented evidence the facility coordinated care with HHPT and updated the service plan as necessary. The need to ensure the facility was reviewing outside service provider notes that were left in the facility and coordinated care with the onsite HHPT was reviewed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. They acknowledged the findings. 3. Resident 8 moved into the facility in 03/2021 with diagnosis of pruritus. During the acuity interview on 08/07/23, the resident was identified to receive behavior support services from an outside service provider. Resident 8's 02/09/23 behavior support services visit note showed the following: * Track behaviors in a way that was realistic for staff; and * Provide a smoking log or "work" to reduce boredom. The facility initiated "Behavior Data Tracking" on 03/09/23 for smoking in his/her unit and refusal of care, however, the tracking was stopped on 04/08/23 without coordination of care with the behavior support services. The need to ensure the facility was reviewing outside service provider notes that were left in the facility and implemented recommendations as part of coordinated care with outside behavior support services was reviewed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care, and the facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff were informed of new interventions, and that the service plan was adjusted, if necessary, for 3 of 3 sampled resident's (#s 6, 7 and 8) who received on-site services from outside service providers. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 12/2020 with diagnosis of Multiple Sclerosis. During the acuity interview on 08/07/23 it was reported the resident received services from a visiting nurse and a behavior support specialist. Review of "Tenant progress notes" dated 04/10/23 through 07/11/23 indicated the resident had nursing orders for Calmoseptine to be applied with hygiene care. There was no documented evidence the service plan or MAR was updated to include the skin treatment. Additionally, there was no evidence the note was reviewed by facility management or RN coordinated care to ensure the provider left a signed written order for the treatment. Review of the facility's observation notes from 04/10/23 through 08/02/23 indicated on three separate occasions the resident experienced behavioral symptoms. There was no documented evidence the facility coordinated care with the behavior support specialist and updated the service plan as necessary. The need to ensure the facility was reviewing outside service provider notes that were left in the facility and coordinated care with the off-site behavior support specialists was reviewed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings.

1. Resident 6, 7 and 8 charts were reviewed. Outside provider notes reviewed and summarized. Service plans were updated to reflect all current needs and coordination with outside services. 2. Provider notes will be reviewed in clinical meetings to ensure follow-up and documentation are in place. Med techs will be trained to review outside service notes and notify licensed nurses of changes. 3. Daily, weekly. 4. Licensed nurses.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirement as prescribed in OAR 333-019-1011. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011 (6), (8) and (10), persons employed in an assisted living or residential care facility (including a Memory Care Community) are required to wear a face mask while they are in the facility except when employee is alone in a closed room. * Observation of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose and mouth. * Staff 13 (Personal Staff Aide) was the designated Infection Control Specialist for the facility. Review of Infection Control Specialist training revealed Staff 13 had not completed the required specialized Department-approved training in infection prevention and control protocols for a Residential Care Facility infection control specialist. The need to ensure staff consistently wore a face mask and the Infection Control Specialist completed all required training was reviewed with Staff 1 (Administrator/Owner) and Staff 2 (Facility RN) on 02/08/23. 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 system. Findings include, but are not limited to: Refer to C 301, C 303, C 305, C 310 and C 325.

Based on observation, interview, and record review, it was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 03/2021. The resident was prescribed oxygen 2 L /minute as needed for oxygen saturation level under 92 %. Observations on 08/08/23 and 08/09/23 identified the oxygen concentrator was set at 3 L /minute, tubing was filled with sediment and had dirt on the inside and outside of the tubing and cannula. A portable cylinder oxygen tank was missing oxygen tubing. The tubing connected to the regulator and the valve was filled with a brown colored substance and the oxygen tank was not operable. In an interview, on 08/09/23, Resident 8 stated s/he used the oxygen concentrator every other day by nasal cannula, as needed. Resident 8 reported the facility staff didn't check on the oxygen concentrator and tubing condition. The resident reported s/he was unsure if the setting of the oxygen was correct. Resident 8's oxygen management was not being managed by the resident or facility staff. 2. Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas: C 303 : Systems: Treatment Orders; C 310 : Systems: Medication Administration; and C 325 : Systems: Self-Administration of Medications. The requirement to ensure adequate professional oversight of the medication and treatment administration system was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings.

See C303, C310, and C325.

Based on observation, interview and record review, it was determined the facility failed to ensure the staff person who administered medications visually observed the resident take the medications, for 1 of 1 sampled resident (#3) and multiple unsampled residents who were administered medications by facility staff. Findings include, but are not limited to: 1. On 02/08/23 at approximately 12:30 pm, an unsampled resident was sitting at the dining table for lunch. Staff 4 (Med Tech) was observed to put a small medication cup on the dining table in front of the unsampled resident. Staff 4 then walked away from the area and did not observe the resident take the medications. The resident took the medication after finished his/her lunch at approximately 1:00 pm. 2. 02/09/23 at approximately 8:10 am, Staff 4 (Med Tech) was observed passing medications to the residents who were in the dining room. There were approximately 10 residents in the dining room who received a cup of pills, inhalers, a nasal spray and eye drops.  Staff 4 walked away from the area and did not observe the residents take the medications. The need to ensure Med Techs visually observed residents take their medications was discussed with Staff 1 (Administrator/Owner) on 02/09/23 at 1:30 pm. He acknowledged the findings. 3. On 02/08/23 at 8:52 am, an unsampled resident was observed sitting on a bench in the lobby outside the dining room. The resident had a glass of water and a small pill cup with several pills in it. The resident proceeded to take the medications out one at a time and swallow them. There was no Med Tech present to observe the resident take his/her pills. The need to ensure Med Techs visually observed residents take their medications was discussed with Staff 1 (Administrator/Owner) on 02/09/23 at 1:30 pm. He acknowledged the findings. 4. Resident 3 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes mellitus. In an interview on 02/08/23 at 10:30 am, Witness 1 (family member) stated s/he had observed pill cups left in Resident 3's room while visiting the resident. Witness 1 also stated that when family had come to visit Resident 3 there had been pills found on the floor of his/her room. The need to ensure Med Techs visually observed residents take their medications was discussed with Staff 1 (Administrator/Owner) on 02/09/23 at 1:30 pm. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#3) whose orders were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes mellitus. The resident's 01/01/2023 through 02/07/23 MARs and physician's orders were reviewed and revealed the following orders were not followed: * Florastor (a probiotic) 250 mg capsule twice daily was not administered on 31 occasions because the facility was "waiting on medication to arrive;" and * Culturelle (a probiotic) 10B cell-caps twice daily was not administered on 20 occasions because the facility was "waiting on medication to arrive." The need to ensure the facility followed physician orders was discussed with Staff 1 (Administrator/Owner) on 02/09/23. The findings were acknowledged.

Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 6 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 03/2021 with diagnoses including pruritus. The resident's 08/01/2023 through 08/09/23 MAR and physician's orders were reviewed and revealed the following orders were not followed: A physician order, dated 04/04/23, indicated to administer oxygen 2 L/minute as needed for oxygen saturation under 92 %. a. The MAR revealed there was no documented evidence the facility was measuring the resident's oxygen saturation level to determine if the resident needed the oxygen treatment. b. Observation of the resident's room on 08/09/23 showed there was a oxygen concentrator with a pre-setting rate of 3 L/minute, not 2 L/minute as prescribed. The resident stated s/he used the pre-setting of oxygen concentrator approximately every other day. The need to ensure the facility followed physician orders was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. The findings were acknowledged. 2. Resident 6 moved into the facility in 12/2020 with diagnoses including Multiple Sclerosis. The resident's 07/01/2023 through 08/09/23 MARs and physician orders were reviewed and identified the following orders were not followed: A physician order, dated 03/08/23, indicated to administer Milk of Magnesia 15 ml by mouth every day, as needed, for constipation and Polyethylene glycol, every day, as needed for constipation. During an interview on 08/08/23 at 9:18 am with Staff 5 (Lead MT/Personal Staff Aid), it was reported the resident had "real bad constipation and usually only had a bowel movement every week to week and a half. When the resident did have a bowel movement facility staff had to assist the resident to have a bowel movement by pushing down on the resident's lower stomach area." Review of the MAR from 07/01/23 through 08/09/23 identified the resident was administered one dose of Milk of Magnesia on 07/14/23 in which the medication provided "some relief." During an interview on 08/09/23, with Staff 17 (Lead MT/Resident Care Manager), it was reported the resident would often say s/he didn't want it. There was no documented evidence the facility attempted to follow the orders and the resident refused the medication orders. The need to ensure the facility followed physician orders as prescribed or  attempted to follow the orders and document the residents refusal to consent to the order on the MAR was discussed with Staff 1 (Administrator/Owner) and Staff 17 on 08/09/23. The findings were acknowledged.

1. Resident 8's Oxygen concentrator has been set to 2LPM as ordered with staff verifying when resident is using it. Oxygen saturation is being obtained every shift to assess need to encourage Resident to use oxygen as needed for oxygen saturation less than 92%. Training on concentrator reading and use added to all staff agenda scheduled for 9/21 as well as ongoing 1:1 training with staff done by Consultant, LN and RCMs. Resident 6 has been put on Bowel monitoring as well as other Residents will be assessed for appropriateness of adding bowel monitoring to their POC and daily tasks. Staff instructed to administer bowel medications as indicated and preferences clarified with Resident 6. 2. New orders will be reviewed in clinical meeting for appropriateness and MAR Accuracy. MAR report to be reviewed in the clinical meeting to review out of range vitals and holes in the MAR. 3. Daily and Weekly. 4. Licensed Nurses and Administrator.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#3) who had documented medication refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes mellitus. The resident's 01/01/23 through 02/08/23 MARs revealed the resident refused to consent to orders for the following medications: * Doxycycline hyclate (a medication to treat bacterial infections) on one occasion; and * Amoxicillin (a medication to treat bacterial infections) on 19 occasions. In an interview on 02/09/23 at 9:39 am, Staff 4 (MT/Personal Staff Aide) acknowledged there was no documented evidence the facility had notified the physician of the refusals nor did the facility have a process in place to do so. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (Administrator/Owner) on 02/09/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure an accurate Medication Administration Record (MAR) was kept for all medications that were ordered by a legally-recognized prescriber and administered by the facility, for 3 of 3 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2017 with diagnoses including depressive episode, type 2 diabetes mellitus and insomnia. Review of Resident 1's MAR from 01/01/23 through 02/08/23 indicated the following inaccuracies: * Multiple medications lacked a reason for use; * Multiple PRN medications prescribed for "pain" lacked parameters as to when to administer each medication; * Multiple PRN medications prescribed for "constipation" lacked parameters as to when to administer each medication; and * Staff were not consistently documenting on the MAR why a medication was held. The need to ensure an accurate MAR was maintained was reviewed with Staff 1 (Administrator/Owner) on 02/09/23. He acknowledged the findings. 3. Resident 3 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes mellitus. Resident 3's MARs were reviewed from 01/01/23 through 02/08/23 and the following was noted: * Multiple medications lacked a reason for use. On 02/09/23 at 9:40 am, the surveyor and Staff 4 (MT/ Personal Staff Aide) reviewed the electronic MAR and confirmed no additional information was included on the computer MAR vs the printed MAR. The need to ensure the facility maintained accurate MARs was discussed with Staff 1 (Administrator/Owner) on 02/09/23. The findings were acknowledged. 2. Resident 4 was admitted to the facility in 11/2021 with diagnoses including cerebral infarction. Review of Resident 4's MAR from 01/01/23 through 02/08/23 indicated the following inaccuracies: * Multiple medications lacked a reason for use; and * Multiple PRN medications prescribed for "constipation" lacked parameters as to when to administer each medication. The need to ensure an accurate MAR was maintained was reviewed with Staff 1 (Administrator/Owner) on 02/09/23. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters, and staff instruction for 3 of 3 sampled residents (#s 6, 7 and 8) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 01/2023 with diagnoses including type 2 diabetes mellitus. Review of Resident 7's MAR from 08/01/23 through 08/07/23 indicated the following inaccuracies: * Multiple PRN medications prescribed for "pain" lacked parameters as to when to administer each medication. The need to ensure an accurate MAR was maintained was reviewed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. They acknowledged the findings. 2. Resident 8 moved into the facility in 03/2021 with diagnoses including pruritus (itchy skin). Review of Resident 8's MAR from 08/01/23 through 08/09/23 indicated the following inaccuracies: * The MAR directed staff to apply Triamcinolone 0.1 % (to treat skin condition including itching) twice daily as needed. The MAR lacked reason for use for the treatment; and * The MAR lacked indication of location for the treatment use. The need to ensure an accurate MAR was maintained was reviewed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. They acknowledged the findings. Surveyor: Sievers, Sara 3. Resident 6 admitted to the facility in 12/2020 with diagnoses including Multiple Sclerosis. Resident 6's 05/01/23 MAR, 07/01/23 through 08/07/23 MAR's, "tenant progress notes" and facility observation notes were reviewed during the survey. a. The following medications lacked parameters which indicated which medication to administer first or second. * PRN Milk of Magnesia and PRN Polyethylene glycol; and * PRN ibuprofen 200 mg, every six hours, as needed, for pain and PRN Tylenol 500 mg capsule, four times daily, as needed for pain. b. Facility observation notes and "tenant progress notes" identified the following topical medications were not documented on the MAR: * 05/31/23 facility observation note indicated "this caregiver reapplied calmoseptine." * 07/11/23 tenant progress note from the visiting nurse stated "continue with calmoseptine [with] hygiene care." The resident's 05/2023 electronic MAR was reviewed on Staff 5's (Lead MT/Personal Staff Aid) computer and review of the 07/2023 MAR identified the topical cream was not transcribed on the MAR and the facility staff were not signing the MAR after the treatment was administered. The need to ensure MAR's were accurate to include all medications and treatments the facility was responsible to administer, and to include parameters for multiple PRN medications used to treat the same condition was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings.

1. Resident 7 PRN pain medication orders were clarified with PCP, and MAR has been reviewed for holes in the MAR. Resident 8 now has orders for topical barrier cream and education provided to RN about need for orders and additional directions for OTC meds including topicals in CBC setting. Resident 6 medication orders and MAR were reviewed; the MAR was updated and staff trained in how to transcribe and review orders; med techs were trained in how to document medications with administration. Consultant reviewed with RNs the process for ensuring medication orders are transcribed accuately and the MAR reviewed for accuracy and documentation. Consultant will complete a full medical order to MAR audit. 2. New orders will be reviewed in the clinical meeting for MAR accuracy. MAR report to be reviewed in the clinical meeting to review out of range vitals and holes in the MAR. Med tech training by consultant. 3. Daily and weekly. 4. Licensed Nurses and Administrator

Based on interview and record review, it was determined the facility failed to ensure residents had a physician's or other legally-recognized practitioner's order of approval for self-administration of prescription medications and failed to evaluate a resident's ability to safely self-administer medications, for 1 of 1 sampled resident (#2) who self-administered their medications. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2022 with diagnoses including hypertension. An evaluation, dated 10/06/22, indicated Resident 2 self-administered all his/her medications. This was confirmed by facility staff. A review of Resident 2's clinical record revealed the following: * There was no documented evidence of an order from a physician indicating approval for the resident to self-administer his/her prescription medications; and * There was no documented evidence the facility evaluated Resident 2's ability to safely self-administered the medications. An interview on 02/08/23 at 9:55 am, Staff 2 (Facility RN) confirmed there was no physician order indicating approval for the resident to self-administer his/her prescription medications and no evaluation related to self-administration of his/her medications. The lack of signed orders indicating a physician's approval for Residents 2 to self-administer their medications and evaluation of the resident's ability to self-administer medications was reviewed with Staff 1 (Administrator/Owner) and Staff 2 on 02/08/23. No additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure residents had a physician's or other legally-recognized practitioner's order of approval for self-administration of prescription medications, and failed to evaluate a resident's ability to safely self-administer medications, for 1 of 1 sampled resident (#5) who self-administered their medications. This is a repeat citation. Findings include, but are not limited to: Resident 5 was admitted to the facility in 05/2023 with diagnoses including hypertension. During the acuity interview on 08/07/23, the resident was identified to manage his/her own medications. During an interview on 08/08/23 at 10:25 am, multiple medication bottles and pill boxes were observed in the resident's room. Resident 5 stated s/he managed his/her own medications. A review of Resident 5's clinical record revealed the following: * There was no documented evidence of an order from a physician indicating approval for the resident to self-administer his/her prescription medications; and * There was no documented evidence the facility evaluated Resident 5's ability to safely self-administer the medications. The lack of signed orders indicating a physician's approval for Resident 5 to self-administer their medications and evaluation of the resident's ability to self-administer medications was reviewed with Staff 1 (Administrator/Owner) and Staff 17 (Resident Care Manager/Lead MT) on 08/09/23. No additional information was provided.

1. Self-medication evaluation completed for resident 5 and physician order obtained approving the self-administration of medications. An audit of all residents for self-medication was completed. A whiteboard is in place to note self-med status and date of evaluation. The consultant is assisting with self-med evaluations. 2. A list of residents with self-med evaluations and the last date of the evaluation will be available on the whiteboard and updated with changes. The RN and LPN will be trained in how to complete a self-med evaluation. Self-med evaluations will be scheduled with the quarterly service plan updates or sooner if necessary. 3. Monthly, quarterly. 4. Licensed Nurses and Administrator.

Based on interview and record review, it was determined the facility failed to implement an acuity based staffing tool (ABST) that met the regulation. Findings include, but are not limited to: 1. During a review of the facility's ABST on 02/08/23, it was determined the tool failed to include all of the 22 required ADL components to include: * Personal hygiene; * Repositioning in bed or chair; * Medication administration, passing out medications; * Providing non-drug interventions for pain management; * Cueing or redirecting due to cognitive impairment or dementia; * Ensuring non-drug interventions for behaviors * Monitoring physical leisure activities; * Monitoring physical conditions or symptoms; and * Assisting with communication, assistive devices for hearing, vision, speech. 2. Review of three sampled residents' records (#s 1, 3 and 4) revealed the following: a . Resident 4 was admitted to the facility 11/2021 with diagnoses including cerebral infarction. During the acuity interview on 02/07/23, it was reported that Resident 4 required assistance in most of ADLs. Reviews of Resident 4's service plan, 09/28/22, 11/22/22 through 02/07/23 progress notes and 24-hours communication notes and interview with multiple care staff noted the ABST failed to accurately reflective the time spent for Resident 4's current ADL care needs in the following areas: * Transferring in or out of bed or chair; * Cueing and supporting while eating; * Safety checks; * Completing resident specific housekeeping or laundry services; * Monitoring behavioral conditions or symptoms; * Medication administration; and * Ensuring non-drug interventions for behaviors. The ABST tool was reviewed and discussed with Staff 1 (Administrator/Owner) on 02/08/23. Staff acknowledged the findings. b. Resident 1 was admitted to the facility in 08/2017 with diagnoses including depressive episode, type 2 diabetes mellitus and insomnia. Resident 1's record was reviewed, observations were made of the resident, and interviews were conducted with the resident and facility care staff. The time spent for the following ADL activities that staff had to provide for Resident 1 were not included on the resident's ABST: * Medication administration; and * Ensuring non-drug interventions for behaviors. The ABST tool was reviewed and discussed with Staff 1 (Administrator/Owner) on 02/08/23. He acknowledged the findings. c. Resident 3 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes mellitus. Resident 3's record was reviewed, observations were made of the resident and interviews were conducted with the resident, Witness 1 (family member), and facility care staff. The time spent for the following ADL activities that staff provided for Resident 3 were not included on the resident's ABST: * Bowel and bladder management; * Transferring in or out of bed or a chair; * Dressing and undressing; * Ambulation; and * Medication administration. The ABST tool was reviewed and discussed with Staff 1 (Administrator/Owner) on 02/08/23. He acknowledged the findings.

Based on interview and record review it was determined the facility failed to ensure the licensee updated the acuity-based staffing tool (ABST) to compensate for the evaluated care and service needs of residents at move-in and no less than quarterly. This is a repeat citation. Findings include, but are not limited to: On 08/09/23, the ABST was reviewed with Staff 1 (Administrator/Owner) and identified the following: * Three unsampled residents, including one "respite care" resident for whom the facility provided care were not entered into the ABST; * Three unsampled residents ABST's were not updated quarterly; and * The ABST reflected one resident who was no longer residing in the facility. The need to ensure the facility's ABST was updated when residents move in or out, when the facility was providing respite care, and no less than quarterly was reviewed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) during the exit interview on 08/09/23. They acknowledged the findings.

1. Administrator has been trained on completion of ABST. 2. The ABST will be updated with each admission, quarterly update, significant change of condition. 3. Weekly. 4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation training and pre-service dementia training had been completed for 4 of 4 newly-hired staff (#s 3, 6, 7 and 8). Findings include, but are not limited to: Staff training records were reviewed on 02/08/23. 1.  Staff 3 (Lead Cook) was hired on 09/01/22, Staff 6 (Personal Staff Aide) was hired on 05/25/21, Staff 7 (Personal Staff Aide) was hired on 04/29/22, and Staff 8 (Maintenance) was hired on 12/21/21. Staff 3, 6, 7 and 8's training records lacked documented evidence of completing orientation training, prior to beginning job responsibilities, in the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention; * Fire safety and emergency procedures; and * Written job description. 2. Staff 7's training records lacked documented evidence of pre-service dementia training with certification, prior to beginning job responsibilities, in the following areas: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communication and responses to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach. The training program and requirements were discussed with Staff 1 (Administrator/Owner) on 02/08/23. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure pre-service orientation training and pre-service dementia training had been completed for 4 of 4 newly-hired staff (#s 14, 15, 16 and 19) and pre-service infectious disease prevention training for 1 of 1 long term direct care staff  (#12) was completed by 07/01/22, as required. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 08/08/23. Staff 14 Personal Staff Aide (PSA) was hired on 05/01/23, Staff 15 (MT/PSA) was hired on 03/06/23, Staff 16 (PSA) was hired on 08/03/23, and Staff 19 (Housekeeper) was hired on 07/31/23. 1. Staff 14, 16 and 19's training records lacked documented evidence of completing pre-service orientation training, prior to beginning job responsibilities, in the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention; * Fire safety and emergency procedures; and * Written job description. 2. Staff 15's training records lacked documented evidence of completing pre-service orientation training, prior to beginning job responsibilities, in the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; and * Written job description. 3. Staff 14 and 16's training records lacked documented evidence of pre-service dementia training with certification, prior to beginning job responsibilities, in the following areas: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communication and responses to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach. During an interview on 08/08/23,with Staff 5 (MT/PSA) and Staff 16, it was confirmed Staff 16 assisted a resident with ADL incontinent care. Later that same day, Staff 16 was observed taking required pre-service orientation and pre-service dementia training courses. 4. Staff 12 (Lead Cook), hired on 08/03/03, lacked documented evidence pre-service infectious disease prevention training was completed by 07/01/22, as required. The lack of training records, requirement to complete pre-service orientation prior to beginning their job responsibilities, and requirement to complete pre-service dementia training prior to providing care to residents were discussed with Staff 1 (Administrator/Owner) on 08/08/23. He acknowledged the findings.

1. Full training audit completed to identify employees who have not completed pre-service training requirements. 2. Training tracking system placed to ensure all staff are completing necessary training requirements. 3. Weekly and monthly audits. 4. Administrator and Resident Care Manager.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired direct care staff (#6) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 02/08/23. Staff 6 (Personal Staff Aide) hired 05/25/21, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents 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 of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and abdominal thrust training. The requirement to demonstrate competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (Administrator/Owner) on 02/09/23. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#'s 14 and 15) had documented demonstration of competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 08/08/23. Staff 14 Personal Staff Aide (PSA), hired 05/01/23, and Staff 15 (MT/PSA) failed to have documented evidence of competency demonstrated in some or all assigned job duties prior to working independently with residents 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 of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Other duties as applicable (Medication and treatment pass); and * First Aid and abdominal thrust training. Staff 15 (MT) was not on the schedule during the survey. During an interview with Staff 1 (Administrator/Owner) on 08/08/23 at 2:00 pm, the requirement for Staff 15 to demonstrate medication competency before passing medications was discussed. On 08/08/23, Staff 1 acknowledged the findings and ensured the survey team that all MT's would have demonstrated competency documented before passing medications, and newly hired staff had documented demonstration of competency in all required areas within 30 days of hire.

1. Full training audit completed to identify employees who have not completed training requirements within the first 30 days of hire. 2. Training tracking system placed to ensure all staff are completing necessary training requirements. 3. Monthly audits. 4. Administrator and RCM.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long-term staff (#s 10, 11, 12 and 13) completed the required minimum 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours of training on dementia. Findings include, but are not limited to: Staff 10 (Med Tech/Personal Staff Aide) was hired 03/2019. Staff 11 (Med Tech/Personal Staff Aide) was hired 11/2019. Staff 12 (Med Tech/Personal Staff Aide) was hired 08/2003. Staff 13 (Personal Staff Aide) was hired 09/2018. * There was no documented evidence Staff 10, 11, 12 and 13 completed 12 hours of annual in-service training, reviewed from their anniversary date of hire. The need to ensure 12 hours of annual in-service training was completed for long term staff was reviewed with Staff 1 (Administrator/Owner) on 02/09/23. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 5, 9, and 17) completed the required minimum 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, which included six hours of training on dementia. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 08/08/23. * Staff 5 (MT/Personal Staff Aide), was hired 08/07/20. Training records were reviewed from 08/07/22 through 08/07/23. * Staff 9 (MT/Personal Staff Aide), was hired 06/07/19. Training records were reviewed from 06/17/22 through 06/17/23. * Staff 17 (Lead MT/Resident Care Manager), was hired 05/06/19. Training records were reviewed from 05/06/22 through 05/06/23. * There was no documented evidence Staff 5, 9, and 17 completed 12 hours of annual in-service training, which included at least six hours of dementia care topics. During an interview with Staff 1 (Administrator/Owner) on 08/08/23 at 2:00 pm, it was reported, "I tried getting them [staff] to complete the training's. I even offered a [financial] bonus if they [staff] would complete the training [courses]. I just can't get them to do it." The need to ensure 12 hours of annual in-service training was completed for long term direct care staff was reviewed with Staff 1 on 08/08/23. He acknowledged the findings.

1. Full training audit completed to identify employees who have not met annual training requirements. 2. Tracking system was placed to ensure all staff are completing necessary training requirements.  Monthly in-service to address training topics. 3. Monthly audits. 4. Administrator and RCC.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided and documented on alternate months and that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records from 06/2022 through 12/2022 were reviewed and revealed the following: 1. The facility failed to provide fire and life safety training to staff on alternating months. 2. Fire drill documentation lacked the following required information: * Location of simulated fire origin; * Escape route used; * Evacuation time-period needed; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. The need to ensure the facility provided and documented fire and life safety instruction every other month and documented fire drills according to the OFC was discussed with Staff 1 (Administrator/Owner) on 02/09/23.  The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided and documented on alternate months of fire drills and failed to conduct and document all required components of the fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: Fire and life safety records from 04/18/23 through 06/30/23 were reviewed and identified the following: 1. The facility failed to provide fire and life safety training to staff on alternating months of the fire drills. 2. Fire drill documentation lacked the following required information: * Escape route used; and * Evidence alternate routes were used during fire drills. The need to ensure the facility provided and documented fire and life safety instruction every other month and documented fire drills according to the OFC was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. The findings were acknowledged.

1. Consultant provided a new form for fire drill documentation. Consultant will assist with next fire drill. 2. The Administrator and Maintenance person will be trained in how to run, debrief, and document a fire drill including escape route used and evidence of alternate routes used. 3. Monthly. 4. Administrator and Resident Care Managers.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 and 120 degrees Fahrenheit. Findings, include, but are not limited to: On 02/08/23, the surveyor measured water temperatures in non-occupied resident units, including Room 127 and a common bathroom in the facility. Water temperatures ranged from 127 to 131.2 F degrees Fahrenheit. On 02/08/23 at 3:50 pm, the surveyor informed Staff 1 (Administrator/Owner) of the high-water temperatures. Staff 1 stated the facility had one hot water tank which circled the entire facility and would be the same hot water temperatures in all resident's rooms. Staff 1 acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 and 120 degrees Fahrenheit. This is a repeat citation. Findings, include, but are not limited to: During the survey, 08/07/23 through 08/09/23, the surveyor measured water temperatures in occupied and non-occupied resident units, including rooms 103, 104, 125 and a common bathroom in the facility. Water temperatures ranged from 101.1 to 126.5 F degrees Fahrenheit. On 08/09/23 at 10:30 am, the surveyor informed Staff 1 (Administrator/Owner) of the variable water temperatures. Staff 1 stated the facility purchased new water valves that should address the water temperature issues however, the facility had not installed the new water valves yet. Staff 1 acknowledged the findings.

1. Maintenance Director has purchased a new water valve to ensure water temperatures stay within safe range. 2. Maintenance Director will be completing scheduled audits of the system and utilize form for tracking rooms checked. 3. Weekly and monthly. 4. Administrator and Maintenance Manager.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable systems for security purposes and to alert staff when residents exited the building. Findings, include, but are not limited to: During the survey, the facility was identified to have three doors that exited to the community and two doors that exited into the facility's inner courtyard. On 02/08/23, a tour of the facility with Staff 1 (Administrator/Owner) revealed the doors failed to have a working alarm device to alert staff when residents exited the facility. On 02/08/23, the lack of alarms or other acceptable system was shared with Staff 1. He confirmed there was no system to alert staff when residents exited the facility.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable systems for security purposes and to alert staff when residents exited the building. This is a repeat citation. Findings include, but are not limited to: During the survey, the facility was identified to have three doors that exited to the community and two doors that exited into the facility's inner courtyard. On 08/07/23 at 3:15 pm, a tour of the facility with Staff 1 (Administrator/Owner) revealed the doors failed to have a working alarm device to alert staff when residents exited the facility. On 08/07/23, the lack of alarms or other acceptable system was shared with Staff 1. He confirmed there was no system to alert staff when residents exited the facility.

1. New door alarms will be purchased and will be installed. Training to be given to all staff on utilizing the new system when installed. Staff are monitoring residents entry and exit to the courtyard until new system placed. 2. The Administrator and Maintenance Director will do weekly walk throughs to ensure all door alarms are functional. Staff will be trained to be aware of door alarm functionality. 3. Weekly. 4. Administrator and Maintenance Director.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the first revisit to the re-licensure survey of 02/09/23, conducted 08/07/23 through 08/09/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. 1. A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following areas: OAR 411-054-0025 (8) Facility Administration Records OAR 411-054-0027 (1) Resident Rights and Protection OAR 411-054-0025 (4) Reasonable Precautions The facility put an immediate plan of correction in place during the survey and the situations were abated. 2. Refer to deficiencies in the report.

1. Consultant met with the administor and RN to review survey findings and develop a plan of correction. See C155, C160, and C200. 2. The administrator will attend and participate in the clinical meeting and be on-site 40 hours per week. The consultant will work with the adminstrator to review and strengthen systems. 3. Daily 4. Administrator.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the revisit survey, conducted 08/07/23 through 08/09/23, quality improvement and oversight to ensure adequate resident care, services and satisfaction was found to be ineffective based on the number of repeat citations and the number of new citations during the revisit survey. During an interview on 08/09/23 with Staff 1 (Administrator/Owner) at 5:05 pm Staff 1 reported the facility did not have a QI program to evaluate services, resident outcomes and satisfaction. Refer to the deficiencies in the report. The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction was discussed during the exit interview with Staff 1 and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings.

1. Quality Improvement program to be initiated end of September with monthly meetings. Consultant will provide QI meeting agenda and process materials.                           2. Consultant provided forms related to running and managing a quality improvement program. QI program meeting to occur monthly and be led by the Administrator. Consultant will attend in September.                                                          3. Monthly. 4. Administrator.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of multiple unsampled residents and 1 of 1 sampled resident (#8) who was prescribed oxygen and was smoking in his/her room. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to: 1. Observations of Resident 8's room, were made on 08/08/23 and 08/09/23 and the following concerns related to reasonable precautions were identified: * Strong smoking odor in Resident 8's room; * Oxygen concentrator, setting of 3 L/min and a portable oxygen tank; * Multiple lighters on the floor and on the resident's mattress; * Empty cigarette pack and matchbox; * A coffee cup with an unidentified liquid and three cigarette butts inside the coffee cup; and * Multiple burn marks in the mattress and carpeted floor. 2. Interview with Resident 8 on 08/08/23 and 08/09/23 identified the following: * S/he smoked in the unit; * S/he reported s/he smoked multiple cigarettes a week; * The resident had no intention of smoking in the designated area, outside of the facility; and * The resident reported s/he used the oxygen concentrator every other day. 3. Record review of the resident's clinical records identified the following: * Signed physician orders dated 04/04/23, indicated the resident was prescribed 2 L/minute, as needed, for oxygen saturation under 92%. There was no documented evidence the facility was managing the resident's oxygen treatment; and * Observation notes dated 05/16/23 through 08/04/23 identified the resident was found smoking in his/her room on multiple occasions. This constituted a condition that could threaten the health, safety, or welfare of residents and required an immediate plan of correction. An immediate plan of correction was requested by the survey team and was received on 08/09/23 at 4:45 pm. The situation was abated. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23.

1. Administrator met with resident 8 regarding safety concern of smoking in the apartment.  A risk agreement process has been initiated. 2. Routine walkthroughs by administrator to check for unsafe smoking in the community. All residents who smoke will be evaluated for their ability to smoke safely in the designated smoking areas, and the evaluations will be updated quarterly. 3. Daily, weekly and quarterly. 4. Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#8) was treated with dignity and respect, was free from neglect and had a safe and homelike environment. The facility failed to consistently provide Resident 8's service planned housekeeping and laundry services. This represented a lack of dignity and respect and was considered neglect of care. Findings include, but are not limited to: Resident 8 was admitted to the facility in in 03/2021 with diagnoses including prurites (itchy skin). Review of the resident's service plan dated 10/24/22 identified the following care needs: * Daily housekeeping including all room care needs and physical assistance; and * Daily laundry service including running the washers as needed. During an interview with Resident 8 and observations made of the resident's unit on 08/08/23, it was determined the facility failed to provide daily housekeeping and laundry services. There was evidence of food particles, dust, cat litter and feces on the carpeted floor, black matter buildup on the bathroom floor, buildup of black and brown matter inside and outside of the toilet. The resident's bed lacked linens and had a soiled incontinent pad laying directly on the mattress. This represented a situation that placed the resident in an unsafe environment and required an immediate plan of correction. On 08/09/23 at 4:45 pm the facility provided an immediate plan of correction and the situation was abated. The need to ensure residents' were treated with dignity and respect, were free from neglect and had a safe and homelike environment was discussed with Staff 1 (Administrator/Owner) and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings.

1. Resident 8's room was cleaned and plan of care was reviewed to ensure appropriate instructions for daily and weekly cleaning. 2. Full walkthrough of the community is being completed to ensure all resident rooms are cleaned. Housekeeping schedule is being updated to ensure all rooms are cleaned per plan of care.  Administrator to complete daily and weekly walk throughs to ensure completion and identify further concerns. Another housekeeper has been hired. 3. Daily and weekly. 4. Administrator and housekeeping.

Based on interview and record review, it was determined the facility failed to promptly investigate injuries of unknown cause to rule out abuse or suspected abuse, failed to report the incident to the local Seniors and People with Disabilities (SPD) office if abuse or suspected abuse could not be ruled out and failed to take measures necessary to prevent the reoccurrence of suspected abuse for 2 of 2 sampled residents (#s 6 and 7) who experienced a burn and an injury of unknown cause. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 01/2023 with diagnoses including type 2 diabetes and weakness. Resident 7's clinical records and incident reports dated 04/05/23 through 08/01/23 indicated the following: On 04/05/23: Physical therapy note indicated the resident reported a bruise on the left breast. On 08/08/23 at 1:10 pm, Staff 5 (Lead MT/Personal Staff Aid) stated there was no incident report or documented evidence the facility investigated the cause of the bruise to rule out abuse or suspected abuse. During an interview on 08/09/23, Staff 17 (Resident Care Manager/Lead MT) stated there was no documented evidence the facility reported the incident to the local SPD office. The need to ensure injuries of unknown cause were promptly investigated and reported to the local SPD office if abuse or suspected abuse could not be ruled out was discussed with Staff 1 (Administrator/Owner) and Staff 17 on 08/09/23. They acknowledged the findings and reported the incident to the local SPD office per the survey team's request. The facility provided confirmation of the report prior to exit. 2. Resident 6 moved into the facility in 12/2020 with diagnoses including Multiple sclerosis. Resident 6's clinical records and incident reports dated 04/05/23 through 08/05/23 indicated the following: On 06/10/23 - a facility observation note documented a burn on the resident's forehead. [The resident] reported "someone was curling [the resident's] hair and [s/he] got a little burn." On 08/08/23 at 10:30 am, Staff 5 (Lead MT/Personal Staff Aid), stated there was not an incident report or documented evidence the facility completed a prompt investigation of the burn to rule out abuse or suspected abuse and take measures necessary to protect the residents and prevent the reoccurrence of suspected abuse. During an interview on 08/09/23, Staff 17 (Resident Care Manager/Lead MT) stated there was no documented evidence the facility reported the incident to the local SPD office. The facility reported the incident to the local SPD office on 08/09/23. Verification was received prior to exit. The need to ensure injuries were promptly investigated and reported to the local SPD office if abuse or suspected abuse could not be ruled out was discussed with Staff 1 (Administrator/Owner) and Staff 17 on 08/09/23. They acknowledged the findings.

1. Resident 6 and 7's injuries of unknown cause reported to APS. Training done by consultant on how to complete and document an investigation. 2. The consultant will provide training to the management team on how to investigate incidents. All incident reports will be reviewed by the administrator in the clinical meeting. The consultant team will be reviewing incident reports and providing feedback. All staff will be trained on abuse and neglect identification and reporting. 3. Daily in the clinical meeting. Monthly. 4. Administrator.

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: Review of the posted activity calendar for August 2023 identified the following: * Activities were scheduled from 8:00 am until 2:00 pm; * Coffee Social at 8:00 am; * Exercise, Church or bible reading (on alternating days) at 10:00 am; * BINGO three days per week at 2:00 pm; and * Coffee social at 8:00 am on Saturday and Sundays. There were no other activities scheduled on the weekends. On 08/07/23 and 08/09/23, residents were observed to organize and lead their own BINGO activity which occurred at alternate times after lunch. Coffee social, church, bible reading and exercise were not observed to occur during the survey. During an interview on 08/09/23, with Staff 17 (Lead MT/Resident Care Manager), it was reported "we [staff] paint the residents nails and do other things with the residents, as time permits. These activities are not included on the calendar because if time doesn't allow, then it doesn't happen." The lack of a daily program of social and recreational activities was discussed with Staff 1 (Administrator/Owner) and Staff 17 on 08/09/23. They acknowledged the findings.

1. September calendar has been posted. A designated acitivities person will be appointed and is responsible for ensuring activities happen at scheduled times. 2. Residents are being evaluated for activities of choice. The calendar is being updated to include evening and weekend activities. 3. Daily. 4. Administrator.

Based on observation, interview, and record review it was determined the facility failed to ensure an acuity based staffing tool (ABST) was used to ensure a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, increased staffing levels to maintain adequate resident care and services when utilizing universal workers, and ensured new staff were trained prior to providing care to residents. Findings include, but are not limited to: 1. During the entrance conference and acuity interview on 08/07/23 the following was identified: * The facility had a licensed occupancy of 36 beds and had a current census of 27 residents; * Two residents required two person assist for transfers and/or incontinence care; * Four residents required heavy care needs, including assist with a lift device and full assistance with all or most ADL's; * The facility employed universal workers whose duties included other tasks (e.g., laundry, food service, activities, and medication management) in addition to direct resident care. Observations on 08/07/23 and 08/08/23 during the day and evening shifts from 8:30 am until 6:00 pm, Staff 5 (Personal Staff Aid (PSA)/ MT) was the only direct care staff on duty. On 08/08/23, Staff 16 (PSA), who was at the facility to complete new hire paperwork including pre-service orientation and pre-service dementia training was observed to assist Staff 5 with an unsampled resident who required two person assist with ADL incontinent care. Staff 16 provided care to the resident prior to completing pre-service training, as required. On 08/08/23, Staff 1 (Administrator/Owner) arrived at the facility at 10:50 am. Staff 5 informed the Administrator that someone called off and s/he was working alone. Staff 1 was not able to assist with care due to administrative duties. During an interview on 08/07/23, Staff 5 confirmed there was usually two caregivers on day and evening shifts and one caregiver who was a MT during the night shift. 2. The facility used an ABST (Acuity Based Staffing Tool) which would determine the 24 hour staffing plan. However, the facility failed to enter three residents into the staffing tool, including a new respite care resident who required increased supervision for which the facility was responsible to meet their service needs. Additionally, three resident' ABSTs were not updated quarterly. The ABST was not reflective of all residents who required care from the facility staff and was not being used to generate an accurate staffing plan. The need to ensure the licensee updated the ABST to compensate for the evaluated care and service needs of residents at move-in and the facility used the ABST to ensure staff sufficient in number were scheduled to meet the 24-hour scheduled and unscheduled needs of each resident, increased staffing levels to maintain adequate resident care and services when utilizing universal workers, and ensured new staff were trained prior to providing care to residents was discussed with Staff 1 and Staff 17 (Lead MT/Resident Care Manager) on 08/09/23. They acknowledged the findings. Refer to C 361.

1. Administrator has been trained on completion of ABST to determine appropriate staffing levels based care needs. Consultant has reviewed need that staff complete pre-service training before being scheduled to train on the floor. 2. Resident Care Manager will ensure that appropriate staffing levels are met and utilize agency to assist as needed in meeting staffing levels. Administrator and RCC to work together on ensuring only staff that have completed pre-service are working on the floor. 3. Weekly. 4. Administrator and resident Care Manager.

Based on observation, interview and record review, it was determined the facility failed to ensure a plan of correction for their re-licensure survey conducted on 02/09/23, was submitted within ten days of receipt of the inspection report, and the facility failed to ensure a plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: a. The facility failed to submit a plan of correction, within ten days of receipt of the inspection report, that satisfied the Department. b. Additionally, the facility had numerous repeat citations. Refer to: C 155, C 240, C 252, C 260, C 270, C 290, C 300, C 303, C 310, C 325, C 361, C 370, C 372, C 374, C 420, C 645, and C 655.

Refer to: C 155, C 240, C 252, C 260, C 270, C 290, C 300, C 303, C 310, C 325, C 361, C 370, C 372, C 374, C 420, C 645, and C 655.

The findings of the relicensure survey conducted 02/07/23 through 02/09/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 02/09/23, conducted 08/07/23 through 08/09/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas: OAR 411-054-0025 (8) Facility Administration Records OAR 411-054-0025 (4) Reasonable Precautions OAR 411-054-0027 (1) Resident Rights and Protection The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the second re-visit to the re-licensure survey of 02/09/23, conducted 11/06/23 through 11/09/23, 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 observations and interviews it was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include: During tour of facility on 05/22/2022, Compliance Specialist observed multiple staff in the facility not wearing face masks. Interview with Staff # 1 on 05/22/2022, who acknowledged that multiple staff were not wearing their masks.