Columbia Place Assisted Living

Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a short term change of condition and failed to document weekly progress until the condition resolved for 2 of 6 sampled residents (#s 2 and 4) who experienced short term changes of condition requiring monitoring. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 06/2025 with diagnoses including unspecified dementia, cerebral infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease and unsteadiness on feet.

Progress notes from admission to 08/24/25, the resident’s initial and current service plan (updated 07/10/25), incident reports, wound evaluations and the “Task List Report” (which contained updates to the resident’s service plan and instructions for staff for responding to changes of condition) were reviewed during the survey.

Resident 4 had four falls, three of which resulted in minor injuries. The following was identified:

a. On 06/29/25, Resident 4 slid out of his/her wheelchair. The resident sustained a skin tear to the left elbow. Staff were instructed to provide checks at routine intervals, observe for increased confusion, drowsiness, headache, dizziness, personality changes, changes in ability to transfer or ambulate, bruising and pain. There was no documented evidence the facility monitored the resident as instructed.

* The facility documented on the progress of the skin tear to the left elbow on 07/10/25, 07/22/25 and 07/31/25. This did not meet the requirement for weekly monitoring. The 07/31/25 note indicated the wound was not resolved. No further monitoring of the wound was documented.

b. On 07/10/25, Resident 4 had two falls, the second of which resulted in a skin tear to the left inner arm. Staff were instructed to document and observe each shift as above and to also note the resident’s level of pain (between 1-10) and any pain meds given. There was one monitoring note dated 07/14/25 that read, “Resident voiced no complaints of discomfort through the shift.” The monitoring instructions were documented as discontinued on 07/16/25 but did not indicate if the change of condition was determined to be resolved.

* The facility documented on the progress of the skin tear to the left inner arm on 07/14/25. The 07/14/25 note indicated the wound was not resolved. No further monitoring of the wound was documented.

c. On 08/02/25 Resident 4 had a fall in his/her room. Staff documented the resident sustained a skin tear to the top of the right hand. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed and failed to document weekly progress of the resident’s mobility and injury until the conditions resolved.

The need to ensure the facility implemented an effective system for responding to resident changes of condition was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director), Staff 12 (Regional Director of Operations) and Staff 13 (ED in Training) on 08/27/25. They acknowledged the findings. No additional documentation was provided.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including atrial fibrillation and congestive heart failure.

The resident’s progress notes, dated 05/25/25 through 08/25/25, service plan, dated 07/20/25, and service plan addendums were reviewed. The following was identified:

Review of the service plan indicated the resident was able to manage transfers and walking independently as of 07/20/25.

On 08/01/25, staff documented the resident was sent to the hospital due to lethargy and weakness. In an interview on 08/26/25, Staff 2 (RN/Health Services Director) indicated the resident was treated at the hospital for excess carbon dioxide levels.

The resident returned home on 08/05/25 and was placed on alert monitoring for “return from hospital.” Staff documented the resident needed assistance with walking after the hospital return. There was no documented evidence the facility determined actions or interventions related to the increased need for ADL assistance or communicated any actions or interventions to staff. Staff documented on 08/10/25 the resident still needed assistance with daily tasks. No further monitoring of the resident’s lethargy and weakness was documented, nor was there documentation of resolution of the short-term change of condition.

In an interview on 08/26/25, Staff 2 stated the resident had returned to baseline status with ADLs, lethargy, and weakness.

The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed and documented weekly progress to resolution following a short-term change of condition was discussed with Staff 1 (ED), Staff 2, Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 3 of 6 sampled residents (#s 1, 4 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 05/2025 with diagnoses including stroke and type 2 diabetes.

Review of Resident 6’s MAR, dated 08/01/25 through 08/25/25, and current physician's orders, dated 07/29/25, identified the following:

a. Glipizide was ordered to be administered one tablet in the morning for diabetes, give 30 minutes before meal, skip if pre-meal CBG was less than 100.

The MAR indicated there were four occasions the pre-meal CBG was less than 100, and the medication was administered.

b. Carvedilol was ordered to give one tablet two times a day for hypertension, hold for systolic blood pressure less than 100 or heart rate less than 60.

The MAR lacked documented evidence the resident’s blood pressure and/or heart rate were taken prior to the medication being administered 49 times from 08/01/25 to 08/25/25.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 2 (RN/Health Services Director), Staff 1 (ED), Staff 12 (Regional Director of Operations), and Staff 13 (ED in training) on 08/26/25 and 08/27/25. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 07/2025 with diagnoses which included hypertension and dementia.

Review of the MARS, from 07/22/25 through 08/25/25 revealed the resident did not receive the following medications because they were unavailable:

* Sertraline HCL 25 mg two tablets daily for dementia was not administered on 15 occasions;
* Sodium Chloride tablet twice a day for hyponatremia was not given on 55 occasions;
* Cyanocobalamin 1000 mcg once daily for supplement was not given on 32 occasions;
* Ergocalciferol capsule once every Friday for supplement was not given on three occasions;
* Fiber oral packet once in the morning for constipation was not given on 16 occasions; and
* Mirtazapine 15mg one at bedtime for sleep aid was not given on one occasion.

In an interview on 08/26/25 at 2:45 pm, Staff 2 (RN/Health Services Director) and Staff 3 (HSD Assistant) verified the medications had not been given as prescribed. Staff 2 stated that all medications, except for cyanocobalamin (facility working with family to provide the medication) were available as of the survey and being given as ordered.

The need to ensure medications were available and administered as prescribed was reviewed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 06/2025 with diagnoses including unspecified dementia, cerebral infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease and unsteadiness on feet.

Resident 4’s current signed orders and the 08/01/25 through 08/24/25 MAR were reviewed during the survey. The following deficiencies were identified:

a. The resident was prescribed fluticasone-salmeterol aerosol powder (an inhaler to treat COPD and asthma), inhale 1 puff into the lungs BID.

The MAR indicated the resident was not administered the inhaler as ordered on 08/10/25 (both am and pm doses), 08/16/25 (am dose), 08/17/25 (both am and pm doses), 08/19/25 (pm dose) and 08/20/25 (pm dose). The MT documented “med not available.”

b. The resident was prescribed dabigatran etexilate mesylate (an anticoagulant to prevent blood clots) 150 mg capsule, take 1 capsule BID.

The MAR indicated the resident was not administered the medication as ordered on 08/01/25 (am dose), 08/03/25 (am dose) and 08/04/25 (am dose). MTs documented “no medication,” “medication not in cart,’ and “medication on order.”

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director), Staff 12 (Regional Director of Operations) and Staff 13 (ED in Training) on 08/27/25. They acknowledged the findings. No additional documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications for 1 of 6 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2025 with diagnoses which included hypertension and dementia.

Resident 1 had orders for:
* Cyanocobalamin 1000mcg one daily for supplement;
* Fiber oral packet once in the morning for constipation;
* Sertraline HCL 25 mg two tablets daily for dementia; and
* Sodium Chloride tablet twice a day for hyponatremia.

According to the MARs, staff documented on multiple occasions between 07/22/25 through 08/25/25 that the medications were not available. However, there were also multiple occasions that staff initialed that the medications were administered during the same time frame.

The discrepancies on the MAR were reviewed with Staff 2 (RN/Health Services Director) and Staff 3 (HSD Assistant) on 08/26/25 at 2:45 pm. Both confirmed staff documented that the medications had been administered when they were unavailable. They acknowledged the MAR was inaccurate.

The need to ensure MARs were accurate was discussed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update and review the acuity-based staffing tool (ABST) evaluation for each resident no less than quarterly at the same time the resident’s service plan was updated. Findings include, but are not limited to:

The facility used the Department’s Acuity-Based Staffing Tool. The data contained in the ABST was reviewed on 08/26/25. At the time of the survey, there were 70 residents residing in the assisted living facility. The following was identified:

* Twenty-one current residents’ individual ABST evaluations had not been updated within the last 90 days (quarterly).

The need to ensure the facility had a process for updating and reviewing each resident’s ABST evaluation no less than quarterly at the same time the resident’s service plan was updated was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director), Staff 12 (Regional Director of Operations) and Staff 13 (ED in Training) on 08/27/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed prior to beginning job duties for 3 of 4 newly hired staff (#s 6, 8 and 9) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 08/26/25 and the following was identified:

a. There was no documented evidence Staff 6 (MT), hired on 07/08/25, Staff 8 (Housekeeping) hired on 06/06/25, and Staff 9 (CG) hired on 04/10/25, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities:
* Resident rights and values of CBC care;
* Fire safety and emergency procedures;
* Infectious Disease Prevention;
* An approved HCBS course; and
* An approved LGBTQIAS+ course.

b. There was no documented evidence Staff 6 (MT) had completed one or more of the following pre-service dementia care training topics:
* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics;
* Strategies for addressing social needs and engaging them in meaningful activities; and
* Specific aspects of dementia care including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

The need to ensure staff completed all required pre-service orientation trainings and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (ED) on 08/26/25 at 10:55 am. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 6, 7 and 9) whose records were reviewed demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/26/25. The following was identified:

There was no documented evidence Staff 6 (MT) hired 07/08/25, Staff 7 (MT) hired 05/06/25, and Staff 9 (CG) hired 04/10/25, had demonstrated competency in some or all of the following required areas and within 30 days of hire including:

* Role of service plans in providing individualized care;
* Providing assistance with ADL's;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition; and
* Conditions that require assessment, treatment and observation and reporting.

Additionally, there was no documented evidence Staff 6 had completed First Aid certification and abdominal thrust training.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (ED) on 08/26/25 at 10:55 am. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission for 3 of 3 sampled residents (#s 1, 4 and 6), and annually for 2 of 2 sampled residents (#s 2 and 5) whose fire and life safety training records were reviewed. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following was identified:

* There was no documentation of fire and life safety training provided to Residents 1, 4 and 6 within 24 hours of move in; and
* There was no documentation of annual fire and life safety training provided to Residents 2 and 5.

The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed, at least annually, was discussed with Staff 1 (ED) on 08/26/25 at 1:50 pm. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways in good repair and free from drop-offs to mitigate potential tripping hazards. Findings include, but are not limited to:

On 08/05/25 through 08/06/25 the exterior walking paths and courtyard were toured and the following was identified:

* There were multiple uneven concrete seams noted throughout the courtyard and along the walking path surrounding and in front of the building.

The need to ensure pathways and exterior surfaces were maintained in good repair and did not have potential hazards was discussed with Staff 11 (Maintenance Director) during a tour of the exterior grounds on 08/25/25 at 12:00 pm, and reviewed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair. Findings include, but are not limited to:

Observations of the facility on 08/25/25 revealed the following:

a. Facility entry:
* An upholstered chair to the right of the piano had an approximate three-inch tear in the arm rest and discolored stains on the top of the chair back;
* An upholstered chair to the left of the piano had stains on the arm rest and seat cushion;
* Several stains were observed on the carpet;
* Seating benches had scratched/gouged areas on the wooden legs; and
* Two chairs near the fireplace had discolored areas on the upholstery.

b. Dining room:
* Several stains were noted on the carpet throughout;
* Holes, worn, and frayed areas were observed along the carpet border;
* Metal transition strips leading to the courtyard had an accumulation of dirt and debris;
* Pillars had scraped and gouged areas;
* A windowsill (near patio doors) had peeling paint and drywall crumbling on the left side;
* Windowsills had an accumulation of dead bugs and dust; and
* The cabinet underneath the handwash sink had stains and spills on the interior.

c. First floor:
* Room 105 had a scraped door and/or frame; and
* Several carpet stains were observed in the halls.

d. Second floor:
* Room 201 had a scraped door and/or frame; and
* Several carpet stains were observed in the halls.

e. Second floor common sitting area:
* Two brown chairs had worn, cracked areas on seats and arm rests;
* A seating bench near the elevator had scraped areas on the wooden legs; and
* Scraped paint on elevator door frame.

f. Second floor television area:
* Two chairs near the bookshelf had scraped legs; and
* Stains on carpet in front of the vending machine.

g. First floor common bathroom (on left side) had discolored caulking around the toilet base.

h. Exterior smoking area had numerous cigarette butts and trash on the ground.

The surveyor toured the interior and exterior environment with Staff 11 (Maintenance Director) on 08/25/25. He acknowledged the findings.

The need to ensure interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident was kept clean and in good repair was discussed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. The findings were acknowledged.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 07/22/24. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthHS: Hours of sleepLPN: Licensed Practical NurseMT: Medication Technician or Med TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseSP: Service planSPT: Service Planning TeamTAR: Treatment Administration Record

Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:A review of Resident 1's service plan, dated 01/26/24 indicated the following:· Staff would provide assistance with showers per the shower schedule;· Trash removed dailyA review of Resident 1's Point of Care Audit Report for Bathing/Showers on Tuesday & Friday Evenings, dated 05/01/24 - 05/31/24 indicated on 05/07/24, 05/10/24 and 05/28/24 a shower was not recorded as given for Resident 1. No documentation of resident refusals was available or provided.In an interview on 07/22/24, Staff 1 (Executive Director) stated based on the audit reports Resident 1 did not receive showers on three occasions in May 2024.In an interview on 07/22/24, Resident 1 stated s/he has had issues with receiving care at the facility.The facility failed to ensure the implementation of services.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.Verbal Plan of Correction: Re-training of staff on ADLs, how to respond to residents when they refuse care and move care to next shift to be implemented on 08/01/24. Facility leadership to verify plan of Care ADLs sign-off daily, and follow up with staff.Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to ensure the service plan was reflective of the resident's needs for 1 of 1 sampled resident (# 2). Findings include but are not limited to:A review of Resident 2's service plan, dated 05/06/24, indicated under the section ambulation/mobility the following:· Resident 2 ambulated with a four-wheeled walker and had a cane s/he may occasionally use to support the right side of his/her body; and· S/he was able to manage ambulation and mobility independently.Under the section for Transfers, service plan indicated the following:· Resident 2 was able to manage transfers independently.Under the section Risk for Falls, service plan indicated the following:· Falls on 06/16/24, 06/18/24 and 06/20/24;· Resident 2 had a history of falls - s/he had four falls in the past three months on 02/11/24, 02/21/24, 02/26/24 and 03/24/24; and· Resident had multiple falls during times when s/he attempted to get out of bed at around 6:00 am.A review of Resident 2's incident report dated 03/24/24 indicated Resident 2 was found by med tech in the hallway/doorway of his/her room. Resident stated s/he was going to the grocery store when s/he fell.No temporary service plans were available or provided for Resident 2 regarding interventions for falls.In an interview on 07/22/24, Staff 1 (Executive Director) stated there could be some confusion on if all of the recorded falls are actually falls due to how Resident 2 likes to take naps on the floor, but there had not been any interventions put in place for Resident 2's falls.The facility failed to ensure the service plan must reflect the resident's needs.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.Verbal Plan of Correction: Administrator had input interventions on 07/22/24 which included additional housekeeping, encouraging him/her to use his/her walker and have someone help him/her tidy his/her room. Administrator was to involve case manager and behavioral support services. Was to do a root cause analysis for falls by end of week on 07/26/24. Based on observation, interview, and record review, conducted during a site visit on 07/22/24, the facility's failure to ensure the implementation of services for 1 of 1 sampled Resident (# 1) was substantiated. Findings include, but are not limited to:Resident 1 stated s/he struggled with receiving care. The facility was short staffed, and s/he had problems getting showers and with two person transfers.At approximately 11:20 am, Staff 12 (CG) entered Resident 1's room to provide care (toileting assistance) to Resident 1.Resident 1's service plan, dated 01/26/24, indicated:-Staff will provide physical assistance with showers per the shower schedule.-"Staff will provide physical assistance with transferring [Resident 1]. Staff to use transfer board, [Resident 1] is able to bear some weight."The facility's Point of Care Audit Report, dated 08/01/23 through 08/31/23, and 05/01/24 through 05/31/24, indicated physical assistance for Resident 1's with bathing/showers were scheduled for Tuesday and Friday evenings.There was no documented evidence physical assistance was provided for a shower on Tuesday, 05/28/24 as scheduled.The facility's failure to ensure the implementation of services for Resident 1 was substantiated.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Nurse), and Staff 3 (Health Services Director).The facility's plan of correction is to perform retraining of staff on ADLs, how to respond to resident when they refuse care, and moving the ADL to the next shift will commence on August 1, 2024. Plan of care ADLs sign-off will be verified daily and follow up with staff.

Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to develop a service planning team that included the resident for 4 of 5 sampled residents (#s 2, 8, 9, and 12). Findings include, but are not limited to:a. Resident 9In an interview on 07/22/24, Resident 9 stated s/he had not been included in a service planning meeting or consulted about his/her care in about a year. S/He stated if s/he were invited to a service planning meeting s/he would like to attend.A review of the service plan binder indicated Resident 9 did not have a service plan available.b. Resident 8In an interview on 07/22/24, Resident 8 stated s/he had never been to a service planning meeting and had never been invited to attend one. S/He further stated s/he had never seen his/her service plan.A review of the service plan binder indicated Resident 8's service plan, dated 02/13/24, was signed by staff members. The section for resident and family signatures lacked any signatures.c. Resident 2 On 07/22/24 Resident 2 refused an interview.A review of the service plan binder indicated Resident 2's service plan, dated 02/08/24, was signed by staff members. The section for resident and family signatures lacked any signatures.d. Resident 12Resident 12 was unavailable for interview on 07/22/24.A review of the service plan binder indicated Resident 12's service plan, dated 01/17/24, was signed by staff members. The section for resident and family signatures lacked any signatures.The facility failed to develop a service planning team that included the resident.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.Verbal Plan of Correction: Since June when new administrator started residents and families were being included in service plan meetings. The administrator printed out old and new service plans, medications, and demographics and reviewed them all together during the service planning meeting with residents and/or family. Reception scheduled the meeting and sent the invites to administrator, nurse, RCC and family.

Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed. Findings include but are not limited to:A review of Resident 5's 04/01/23 - 05/31/23 MAR's indicated the following:· "Check weight one time a day, Notify PCP if 5 pound weight loss or gain one time a day for monitoring for 30 Days" with a start date of 04/15/23.· On 04/15/23, 04/16/23, 04/26/23, 04/30/23, 05/13/23 no weights were recorded and no indication of why residents weight was not obtained.In an interview on 07/22/24, Staff 1 (Executive Director), Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) acknowledged the lack of consistency with monitoring Resident 5's weight.The facility failed to carry out medication and treatment orders as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 and Staff 3 on 07/22/24.Verbal Plan of Correction: MT meeting to occur by 07/26/24 to review vitals and missed medications. The facility had been working with staff to put medications on cycle-fill. Based on interview and record review, conducted during a site visit on 07/22/24, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled Resident (# 7) was substantiated. Findings include, but are not limited to:Resident 7's physician order summary report, dated 01/31/23, indicated:-Alpha-Lipoic Acid 600 mg (nerve pain), give two capsules by mouth one time a day. May increase to two capsules daily if no improvement, starting 09/06/22;-Ferrous Sulfate 325 mg (anemia), give one tablet by mouth one time a day at bedtime starting 01/02/23;-Omeprazole Delayed Release 20 mg (acid reflux), give one capsule by mouth in the morning starting 01/03/23;-Suboxone Sublingual Film 2-0.5 mg (pain management), give one tablet sublingually three times a day starting 08/08/22; and-Venlafaxine 37.5 mg (depression), give one tablet by mouth one time a day starting 08/09/22.Resident 7's MAR, dated 01/01/23 through 01/31/23 indicated:-Alpha-Lipoic Acid 600 mg was not administered 12 times;-Ferrous Sulfate 325 mg was not administered five times;-Omeprazole Delayed Release 20 mg was not administered 12 times;-Venlafaxine 37.5 mg was not administered four times; and-Suboxone Sublingual Film 2-0.5 mg was not administered 19 times.Staff 1 (Executive Director), stated Resident 7 had moved out of the facility.Resident 7 was no longer at the facility and could not be interviewed or observed.The facility's failure to carry out medication and treatment orders as prescribed for Resident 7 was substantiated.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse), and Staff 3 (Health Services Director).The facility's plan of correction was to hold a MT meeting this week to review vitals and missed medications. The facility has been working with staff to put medications on cycle fill. Administration and their clinical team will create an additional plan of correction.

Based on observation, interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:No posted staffing plan was observed.In an interview on 07/22/24, Resident 1 stated on 07/08/24 there were not enough staff to provide care timely and s/he had to wait over an hour to be assisted out of bed.In an interview on 07/22/24, Staff 1 (Executive Director) stated generally if the facility was short staffed the management team would step on the floor to assist, and s/he recently got approval to use agency staff. S/he stated the posted staffing plan may not have been hung back up after painting the lobby, but the facility staffing plan was as follows:· Day shift: 3 med techs and 3 to 4 caregivers;· Swing shift: 2 med techs and 3 caregivers;· Night shift: 1 med tech and 2 caregivers; and· Housekeepers and dietary staff are scheduled in addition to caregivers and med techs.Documentation to support management had assisted with resident care was requested and was not available or provided.A review of the facility scheduled dated 07/01/24 - 07/31/24 indicated 36 of 65 shifts we staffed below the stated staffing plan. The facility failed to have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.Facility Verbal Plan of Correction: The facility had received approval to use agency staff and would be staffing with agency staff to meet the staffing plan.Based on observation, interview, and record review, conducted during a site visit on 07/22/24, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of residents was substantiated. Findings include, but are not limited to:The facility's Acuity-Based Staffing Tool (ABST) generated staffing hours requiring minimums of six direct care staff on day shift, five direct care staff on swing shift, and two direct care staff on night shift. There were two residents whose care needs were not accounted for in the tool.The facility did not have a posted staffing plan.Staff 1 (Executive Director) stated the facility's staffing plan was three Med Techs (MTs) and three to four Personal Care Assistant (PCA/CG) on day shift, two MTs and three CGs on evening shift, and one MT and two CGs on night shift and on 07/08/24, the facility was short staffed, so Staff 1, Staff 3 (Health Services Director), and Staff 2 (Nurse) all worked the floor. On 07/22/24 there were three CGs and two MTs working the floor on day shift.A facility staff schedule, dated 07/01/24 through 07/22/24, indicated the facility was not staffing according to ABST generated minimum staffing requirements for 21 instances on day shift, ten instances on swing shift, and six instances on night shift.Staff 5 (MT) stated when s/he was working at the facility, the facility was "short" on "in-house" staff.The facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of residents was substantiated.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3.Facility's plan of correction: Facility has since received approval to utilize agency staff and will continue to fill scheduling gaps with agency staff.

Based on observation, interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool for 2 of 4 sampled residents (# s 3 and 14). Findings include, but are not limited to:A. Resident 3A review of facility resident roster and ABST indicated Resident 3 was not entered into the tool. In an interview on 07/22/24, Staff 1 (Executive Director) stated Resident 3 had moved in on 12/31/22.B. Resident 14A review of facility resident roster and ABST indicated Resident 14 was not entered into the tool. In an interview on 07/22/24, Staff 1 stated Resident 14 moved in on 06/17/24.There was no posted staffing plan available.A review of the stated staffing plan and 07/01/24 - 07/31/24 staff schedule indicated the facility was not staffed according to the staffing plan on 36 of 65 shifts.In an interview on 07/22/24, Staff 1 stated the RCC or the RN were responsible for updating the ABST.The facility failed to fully implement and update an acuity-based staffing tool.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.Based on observation, interview and record review, conducted during a site visit on 07/22/24, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 3 of 3 sampled residents (#s 2, 3, and 14). Findings include, but are not limited to:The facility utilized the ODHS ABST. Residents 3 and 14 were not entered into the tool, the facility had no staffing plan posted, and the facility was not consistently staffing to the levels indicated by the tool.The facility's ABST generated staffing hours requiring minimums of six direct care staff on day shift, five direct care staff on swing shift, and two direct care staff on night shift.There were three Caregivers (CG) and two Med Techs (MT) working the floor on day shift.Staff 4 (Community Relations Director) stated the facility's census was 68.Staff 1 (Executive Director) stated either the Resident Care Coordinator (RCC) or Staff 3 (Health Services Director) updated the ABST and the staffing plan was three MTs and three to four CGs on day shift, two MTs and three CGs on evening shift, and one MT and two CGs on night shift.A facility staff schedule, dated 07/01/24 through 07/22/24, indicated the facility was not staffing according to the required staffing levels for 21 instances on day shift, ten instances on swing shift, and six instances on night shift.Staff 5 (Med Tech) stated when s/he was working at the facility, the facility was "short" on "in-house" staff.During interviews, Staff 2 (Nurse) and Staff 3 (Health Services Director) stated regarding Resident 2's care needs, Staff brought breakfast, performed safety checks, assisted with dressing, and assisted with bathing three times weekly.Interventions for fall prevention identified in Resident 2's service plan, dated 05/06/24, were not captured in his/her ABST profile.Residents 2, 3, and 14 were unavailable for interview.The facility's failure to fully implement and update an ABST was substantiated.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3.

Based on interview and record review, conducted during a site visit on 07/22/24, the facility's failure to document they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 3 sampled staff (# 15) was substantiated. Findings include, but are not limited to:Staff 1 (Executive Director) stated s/he identified training as an area of the facility that needed improvement.Facility records for Staff 15 indicated s/he did not have a Health/Medication Competency Checklist, and his/her basic Competency Checklist for Passing Medications was incomplete.The facility's failure to document they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised was substantiated for Staff 15.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Nurse), and Staff 3 (Health Services Director).The facility's plan of correction included scheduling several caregiver trainings. Staff 1 will ensure all staff complete the trainings starting August 1, 2024. Staff 1 has completed an audit of the facility's training records to ensure staff have completed all required trainings.

The findings of the kitchen inspection, conducted 04/16/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first re-visit to the kitchen inspection of 04/16/24, conducted 06/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 04/16/24 at 11:05 am, the facility was observed to need cleaning in the following areas: a. Food spills, splatters, debris, grease, dirt, dust and/or black/brown/yellow matter was observed on, underneath or behind the following: * Floor under and behind stove/grill;* Exterior oven doors;* Hood vents above grill/stove:* Sides of steamer, grill and oven:* Shelf beneath microwave;* Ceiling air vents above coffee maker; and * Flooring throughout the kitchen was cracked and stained, including corners and base coving.The areas of concern were observed and discussed with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 04/16/24. The findings were acknowledged.
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 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 06/26/24 at 10:10 am, observations of the facility main kitchen identified the following: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:* Floor underneath and behind stoves/grill,* Exterior oven doors, sides, and knobs;* Caulking and wall plastic strip in dish machine area;* Flooring beside ice machine;* Floor drain under steam table;* Pipes underneath counter and along wall in food prep area; and* Rungs of rolling bread rack in food prep area.b. The following areas were in need of repair: * Flooring throughout the kitchen was cracked and stained; and* Entry door jambs had scraped paint in multiple areas.The areas that required cleaning and repair were observed and discussed with Staff 1 (Dietary Manager) on 6/26/24 at 10:40 am, and with Staff 3 (Executive Director) during the exit interview. The findings were acknowledged.
C240 - The kitchen staff will throughly clean behind and under the stove and grill, exterior oven door, sides and knobs removing all food spills, Splatter, Debris, dirt and/or black matter. To prevent unsanitary areas behind, under and around stove and grill, exterior oven door the kitchen staff will clean up all easy to remove spills, splatters and debris on a daily basis. A deeper clean will be done on a weekly basis. All sanitation activites will be tracked on a checklist available to all kitchen staff. Dining Services Director of chef on duty will provide direct oversight in all cleaning tasked assigned to kitchen staff to ensure the tasks were completed.C240 - The community will have the current caulking and wall plastic strips in the dishwashing area removed, the area cleaned and the caulking and plactic strips replaced.Once repaired, the kitchen stafff will clean and sanitize dishwashing area to remove and spills, splatters and debris that may be present. Dining service director or chief on duty will provide direct oversight and all cleaning tasks assigned to kitchen staff to ensure the tasks are completed.C240 - kitchen flooring beside ice machine and throughout the entire kitchen to include under the stove and grill will be resurfaced to repair all damages, to include cracks, chips significant discolorations and possible uncleanable surfaces.To make sure the floors stay clean and in good repair the kitchen staff will sweep and mop floor daily and will track by using cleaning check list. The director of Enviormental Services Director will inspect the floor for cracks, chips and any other damages on a quarterly basis.C240 - All floor drains and pipes underneath the counter and along wall in prep area and Rungs on all rollling racks with be cleaned both as needed and will be on a monthly routinue cleaning schedule to be track on a cleaning tracking form.C240 - Dining Services Manager will coordinate with Enviromental Services to repaint entry door jams and side of kitchen oven. Enviromental Services will ensure alll painted surfaces in kitchen area are kept in good repair a all times by completing monthly kitchen repair audits.

Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.

The findings of the kitchen inspection, conducted 05/09/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Faculties for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 05/09/23, conducted 07/18/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure appropriate glove use and handwashing were in accordance with the Food Sanitation Rules OAR 333-150-0000. Finding include, but are not limited to: On 05/09/23 at 11:05 am, during the facility kitchen tour the following concerns were observed: * Staff preparing sandwiches and special orders during the noon meal service demonstrated improper glove use: - The same gloves were used to retrieve fresh salad greens from walk in refrigerator and were placed at the station for sandwich prep; - Used same gloves to handle a wet sanitation cloth, opened the microwave and wiped it out; - With same gloves wiped face; and - Handled multiple food products to prepare sandwiches. * Staff serving meal from steam table changed gloves twice without handwashing. * The dishwasher handled clean dishes after handling dirty dishes without handwashing. The areas of concern related to glove use and lack of handwashing were observed and discussed with Staff 1 (Dietary Services Manager), Staff 2 (Central Support Staff) and Staff 3 (Administrator) on 05/09/23. The findings were acknowledged.

The findings of the relicensure survey, conducted 01/31/22 through 02/02/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 02/02/22, conducted 05/11/22 through 05/12/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of the resident's current status for 2 of 3 sampled residents (#s 2 and 6) whose quarterly evaluations were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2021. The quarterly evaluation, dated 11/01/21, was reviewed and staff were interviewed. The following inaccuracies were identified: * Call light ability; * Risk of weight loss; * Where the resident took his/her meals; and * Transfer assistance needed. 2. Resident 6 was admitted to the facility in 02/2009. The quarterly evaluation, dated 11/30/21 was reviewed, observations of the resident's unit were made during the resident interview and staff were interviewed. The following inaccuracies were identified: * Transportation assistance needed; * ER visits in the past month; * Where the resident ate his/her meals; * Mobility device; * Mood; and * Behaviors.The need to ensure quarterly evaluations were reflective of the resident's current status was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) 02/02/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 07/2021 with diagnoses including signs and symptoms involving the circulatory and respiratory system and presence of a cardiac pacemaker. Observations of Resident 1, interviews with staff, review of the 01/30/22 service plan and review of the Service Plan Addendums (SPAs) during the survey revealed the following was not reflective of the resident's needs, lacked clear direction and/or was not followed by staff: * Use of oxygen including setting and instruction; and * Fall risks status and interventions.The need for the service plan to be reflective of the resident's needs, provided clear direction and was followed by staff was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 06/2021. The resident's service plan was reviewed and staff were interviewed. The service plan was not accurate or did not provide clear caregiving instruction in the following areas: * The service plan directed staff to be aware of allergies and reactions, but there was no information listed of what the resident's allergic reactions were;* Non-drug interventions for pain; and * Assistance needed with grooming and hygiene. 4. Resident 6 was admitted to the facility in 02/2009. The resident's service plan and task sheet (used by the staff to assist in caring for the resident) were reviewed, observations were made in the resident's unit and Resident 6 and staff were interviewed. The service plan was not accurate or did not provide clear caregiving instruction in the following areas: * Medications the resident self-administers; * Interventions for shower refusals; * Mood and behavior including effective interventions of how to approach the resident, tone of voice, how to gain trust, what to be observant of, how to react if the resident becomes verbally abusive; * Sleep walking; and * Incontinent products used by the resident and interventions for excess use.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) and Staff 2 (Regional RN) 02/02/22. 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's current health status and care needs and lacked clear direction to staff regarding the delivery of services for 4 of 4 sampled residents (#s 1, 2, 3 and 6) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 05/2019 with diagnoses including multiple sclerosis and restless leg syndrome.The resident's service plan dated 12/01/21 and Service Plan Addendums (SPAs) were reviewed during the survey and revealed the service plan lacked clear direction to staff in the following areas:* Use of quarter length side rails and the risks and precautions related to the use of side rails; and* Behaviors and interventions related to alcohol use. The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed ensure changes of condition were evaluated, referred to the facility RN when appropriate, monitored through resolution, and interventions identified and implemented for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) reviewed for changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including signs and symptoms involving the circulatory and respiratory system and presence of a cardiac pacemaker.The resident's clinical records, dated 11/08/21 through 01/31/22, indicated the following:a. Staff documented in a progress note on 12/20/21 that the resident had a fall and stated, " ...bruising noted to right knee with minor swelling and bruising noted to right ankle ..." There was no documented evidence the resident's short-term change of condition related to the skin was monitored and progress documented weekly through resolution.On 02/02/22, the failure to provide on-going monitoring for Resident 1's skin injuries was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN). They acknowledged the findings.b. Review of the facility progress notes, incident reports and Service Plan Addendums (SPAs) during the survey revealed Resident 1 had a fall on 11/16/21, 12/20/21 and 01/06/22. The facility implemented auto generated SPAs, which were reflective of the same interventions for each fall.There was no documented evidence the facility thoroughly reviewed the incident to determine the circumstance of the fall and development of interventions to minimize further falls. The need to ensure short term changes were evaluated, specific resident interventions determined and documented was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 04/2021 with diagnoses including diabetes.Resident 5's weight record was reviewed during the survey and revealed the following:* 10/2021 - 231 pounds;* 12/2021 - 246.8 pounds; and* 01/2022 - 251.1 pounds.From 10/2021 to 12/2021, Resident 5 had gained 15.8 pounds or 6.83 % of his/her body weight and gained an additional 4.3 pounds from 12/2021 to 01/2022, which represented a change of condition. There was no documented evidence the facility thoroughly reviewed the weight changes and determined if action or intervention was required. The need to ensure short term changes were evaluated, specific resident interventions determined and documented was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
4. Resident 2 was admitted to the facility in 06/2021 with diagnoses including abnormal weight loss. The resident's weight record was reviewed during the survey and revealed the following:* 07/2021 - 162.3 pounds;* 08/2021 - 162 pounds; * 10/2021 - 152.1 pounds;* 11/2021 - 108.5 pounds;* 12/2021 - 106.5 pounds; and * 01/2022 - 108.2 pounds.From 10/2021 to 01/2022, Resident 2 had lost 54.1 pounds, or 33.33% of his/her body weight. This represented a severe change of condition in weight.There was no documented evidence the facility thoroughly reviewed the weight changes and developed interventions to address the weight loss. Refer to: C280, example 1.5. Resident 6 was admitted to the facility in 02/2009. The resident's weight record was reviewed during the survey and revealed the following:* 11/2021 - 187 pounds;* 12/2021 - 177.8 pounds; and * 01/2022 - 179 pounds.From 11/2021 to 12/2021, Resident 6 had lost 9.2 pounds, or 4.91% of his/her body weight. This represented a change of condition in weight.There was no documented evidence the facility thoroughly reviewed the weight changes and developed interventions to address the weight loss. The need to ensure short term changes were evaluated, and resident specific interventions were determined and documented was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 05/2019 with diagnoses which included multiple sclerosis, restless leg syndrome and a history of falls. Resident 3's progress notes, reviewed from 12/16/21 through 1/13/22, Service Plan Addendums (SPAs) and weight record revealed the following changes of condition:a. Resident 3's weight record documented the following:* 07/2021- 185.3 pounds;* 10/2021 - 133.7 pounds;* 11/2021 - 169.5 pounds; and* 12/2021 - 169.0 pounds.From 07/02/21 and 10/21/21, Resident 3 lost 51.6 pounds or 27.84% total body weight, within 3 months. This represented a change of condition in weight. There was no documented evidence the facility thoroughly reviewed the weight changes, developed and implemented interventions to address the weight changes, communicated the interventions to staff, and referred the weight changes to the facility RN, when appropriate. b. The following short term changes of condition were not communicated to staff and were not monitored at least weekly through resolution:* 12/21/21 Resident reports a twisted ankle that hurts; and* 12/23/21 MT observed a bruise on the bottom of the left foot. The need to ensure the facility communicated changes of condition to staff, monitored the changes in condition with weekly progress noted until resolution and referred changes of condition to the facility RN when appropriate, was reviewed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.Refer to: C280, example 2.

Based on observation, interview and record review, it was determined the facility failed to conduct a significant change of condition assessment including findings, resident status, and interventions made as a result for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of condition related to weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2021 with diagnosis including abnormal weight loss. The resident's weight records dated 07/02/21 through 02/02/22, and progress notes dated 11/01/21 through 01/26/22, were reviewed, the resident was observed and staff were interviewed. The following was identified: * Between 10/02/21 and 11/22/21, Resident 2 lost 35.7 pounds, or 23.47% total body weight, in a little over one month; and* Between 07/02/21 and 12/16/21, Resident 2 lost 55.8 pounds, or 34.38% total body weight, within six months.This constituted a severe weight loss for Resident 2 which required an RN assessment. On 01/31/22, the surveyor requested the facility obtain a current weight. Resident 2's weight was noted at 108.2 (wheelchair), which was within the range of weights obtained between 11/02/21 and 12/16/21. On 02/02/22 at 1:18 pm, Resident 2 was observed sleeping in his/her recliner. The resident appeared to fit in their clothing well and looked like the picture the facility took for their records in 07/2021.On 02/02/22 at 1:28 pm, Staff 10 (CG) reported Resident 2 ate 100% of breakfast and lunch consistently. He confirmed he has not seen any evidence of weight loss while caring for the resident.There was no documented evidence the facility RN conducted an assessment of the weight loss which included documentation of findings, resident status and interventions made as a result of this assessment. The need to ensure severe weight loss was assessed and documented by the facility RN was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Multiple Sclerosis.Progress notes dated 12/16/21 through 01/13/22, service plan dated 12/01/21, Service Plan Addendums (SPAs) and weight records were reviewed during the survey. The following was identified:* Between 07/02/21 and 10/21/21, Resident 3 lost 51.6 pounds or 27.84% total body weight, within 3 months.This weight loss represented a significant change of condition for Resident 3 for which an RN assessment was required. On 01/31/22, the surveyor requested the facility obtain a current weight. Resident 3's weight was noted at 169.3 (standing), which appeared to stabilize since the 10/21/21 weight loss.There was no documented evidence the facility RN conducted an assessment of the weight loss which included documentation of findings, resident status and interventions made as a result of this assessment. The resident's service plan was not updated and there was no evidence weight loss interventions were developed and implemented.The need to ensure significant changes of condition were assessed and documented by the facility RN, and changes were made to the resident's service plan based on the findings of the assessment, was reviewed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed staff. Findings include, but are not limited to:Delegation records for Resident 5, reviewed on 02/02/22, indicated the facility RN failed to complete the process of delegation and document all required components of delegation in accordance with the OSBN Administrative Rules, including:* Documentation as to how the RN determined the resident's condition was stable and predictable, given Resident 5 was hospitalized during the time period of the assessment.* Transfer delegation was completed on 07/27/21. There was no documented evidence the incoming RN reviewed Resident 5's condition, teaching plan, competence of the staff, written instructions and plan for supervision as outlined by the outgoing RN.* Staff 3's (MT/RCC) initial delegation was completed on 09/15/21 and re-evaluation of the delegation task was completed 12/16/21, more than 90 days from initial delegation. The delegating RN failed to re-evaluate the insulin administration task within 60 days from the initial date of delegation.* Staff 13 (MT) was delegated on 07/09/21 and and was to be re-evaluated in 90 days or before 10/07/21. The re-evaluation of skills was completed on 11/13/21, 37 days after the 90 day period. The requirements for delegation were reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. 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 for 3 of 5 sampled residents (#s 1, 3 and 6). Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including hyperlipidemia, hypothyroidism, cardiac arrhythmia, and signs and symptoms involving the circulatory and respiratory system and presence of a cardiac pacemaker.Resident 1's most recent signed physician orders, 01/2022 MAR and the resident's clinical record were reviewed during the survey and revealed the following:* Resident returned to the facility on 01/27/22; and* The resident was enrolled to hospice services on 01/27/22.The reconciliation of the MAR and the most recent signed physician orders revealed the following medications were not administered to the resident on 01/28/22 without documentation of why or having a signed physician order to discontinue: * Lasix (for heart disease and fluid retention) 20 mg daily; * Synthroid (for hypothyroidism) 150 mcg daily;* Carvedilol (for high blood pressure) 3.125 mg twice daily;* Eliquis (for the reduction of blood clotting) 2.5 mg twice daily; and* MiraLAX (for constipation) 17gm daily. On 02/02/22 at 10:27 am, the findings were reviewed with Staff 1 (Administrator) and Staff 19 (LPN). They acknowledged the findings. No further information was provided.2. Resident 3 was admitted to the facility in 05/2019 with diagnoses including multiple sclerosis. The resident's 01/2022 MAR was reviewed. There was no documented evidence of a signed physician's order in the resident's medical chart. At the request of the surveyor, the facility obtained a current copy of the signed orders during the survey.Refer to: C303, example 1.3. Resident 6 was admitted to the facility in 02/2009. The resident's 01/2022 MAR was reviewed. There was no documented evidence of a signed physician's order in the resident's medical chart. At the request of the surveyor, the facility obtained a current copy of the signed orders during the survey. Refer to: C303, example 5.4. Administrative Oversight of the medication and treatment administration system was also found to be ineffective, based on deficiencies in the following areas:C282: Delegation;C303: System: Medication and Treatment Orders;C305: System: Resident Right to Refuse;C310: System: Medication Administration;C325: System: Self Administration of Medication; andC330: System: PRN Psychotropic Medications.

2. Resident 1 was admitted to the facility in 07/2021 with diagnoses including cardiac arrhythmia and had a cardiac pacemaker.Resident 1 had a physician's order, dated 01/28/22, to apply Lidocaine patch daily.Resident 1's 01/2022 MAR revealed there was no indication the order was transcribed.On 02/02/22, the physician orders and current MARs were reviewed with Staff 1 (Administrator), Staff 2 (Regional RN) and Staff 19 (LPN). They acknowledged the findings.3. Resident 5 was admitted to the facility in 04/2021 with diagnoses including hypertension (high blood pressure).Resident 5 had a physician's order to administer Metoprolol 150 mg daily for hypertension and hold for blood pressure less than 100 or heart rate less than 50 per minute, which was also reflected on the MAR.Resident 5's 01/2022 MAR revealed seven occasions there was no documented evidence the facility was taking the resident's blood pressure and heart rate prior to administering the medication to determine if the mediation needed to be held.On 02/02/22, the physician orders and current MAR were reviewed with Staff 1 (Administrator), Staff 2 (Regional RN) and Staff 19 (LPN). They acknowledged the findings.
4. Resident 2 was admitted to the facility in 06/2021 with diagnoses including macular degeneration and glaucoma. The resident's 01/2022 MAR and physician orders were reviewed. The below medications were not administered per physician's orders on the following dates:* 01/02/22 - GenTeal Tears (for dry eye) was not administered as the medication had not been received;* 01/03/22 - Brimonidine tartrate solution (for glaucoma), cyclosporine emulsion (for glaucoma), dorzolamide HCI-timolol mal solution (for glaucoma), erythromycin ointment (for dry eye), and systane solution (for dry eye) were not administered as the resident was sleeping;* 01/07/22 - GenTeal Tears was not administered as the resident was sleeping;* 01/21/22 - GenTeal Tears and diclo gel (for pain management) was not administered as the resident was sleeping; and* 01/30/22 - Artificial eye ointment (for dry eye) was not administered as the medication had not been received. 5. Resident 6 was admitted to the facility in 02/2009. The resident's 01/2022 MAR, physician orders and service plan were reviewed. The resident's room was observed and the resident and staff were interviewed. a. There was no documented evidence of signed physician's orders in the resident's medical chart. b. Resident 6 had an order for levothyroxine with the parameters specifying to administer the medication "30 minutes before first meal and medications." The MAR reflected staff was to administer the medication at midnight.An interview with Staff 9 (MT) on 02/01/22 at 10:04 am confirmed the resident went to sleep late and woke up between 9:30 am and 12:00 pm.The need to ensure physician's orders were followed as prescribed and current signed physician's orders were available in the resident's chart for all medications and treatments administered by the facility was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose physician orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Multiple Sclerosis. The resident's 01/2022 MAR and physician's orders were reviewed. There was no documented evidence of a signed physician's order in the resident's medical chart for the following medications and treatments:* Amlodipine (for hypertension);* Docusate Sodium (for bowel care);* Gabapentin 1.5 tablets (for pain);* Gabapentin 1 tablet (for pain);* Lisinopril (for hypertension);* Rosuvastatin Calcium (for hyperlipidemia);* Vitamin D3 (supplement);* Carbamazepine (for nerve pain);* Baclofen (for skin);* PRN Tylenol (for pain);* PRN Albuteral (for shortness of breath);* PRN Ibuprofen (for pain); * PRN Lidocaine Cream (for pain);* PRN Lidocaine Ointment (for pain); * PRN Nicotine Patch (for smoking cessation);* PRN Polyethylene Glycol powder (for bowel care); and* PRN Voltran Gel (for pain).On 01/31/22, Staff 1 (Administrator) and Staff 2 (Regional RN), reported they were sending faxes out to physician's to obtain signed orders but were having difficulty getting the physician's to send signed orders back. The need to ensure current signed physician's orders were available in the resident's chart for all medications and treatments administered by the facility was discussed on 02/02/22, with Staff 1 and Staff 2. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 04/2021 with diagnoses including diabetes.Resident 5's 01/2022 MAR was reviewed during the survey and revealed the following:* Staff documented Resident 5 refused a treatment, Clindamycin gel for infection, 11 occasions; and* Staff documented Resident 5 refused a treatment, Clotrimazole-Betamethasone cream twice daily for skin care, on 34 occasions.There was no documented evidence the facility notified Resident 5's physician of the refusals.The need to ensure the facility notified physicians or practitioners of treatment refusals was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
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 2 of 2 sampled residents (#s 2 and 5) who had documented medication and treatment refusals. Findings include, but are not limited to:Resident 2's 01/2022 MAR, progress notes and medical chart were reviewed and the following medications were noted as "spit out" or "refused:"* Ascorbic acid (supplement);* B complex vitamin (supplement); and * Diclo Gel (for pain management).There was no documented evidence the facility notified the prescriber each time the resident refused to consent to the orders. The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 07/2021. The resident's 01/2022 MAR was reviewed during the survey and revealed the following treatment lacked indication of location/area for treatment:* Tacrolimus ointment twice daily; and* Hibiciens Liquid 4 % as needed for skin care.The need for resident specific parameters and clear administrative instruction to unlicensed staff was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were complete and accurate for 2 of 5 sampled residents (#s 2 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2021. The resident's 01/2022 MAR was reviewed and the following medications were missing a reason for use:* Latanoprost solution;* Brimonidine tartrate solution;* Dorzolamide solution; and * Carboxymethylcellulose solution.The need to ensure MARs were accurate and all medications had documentation of the reason for use was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

2. Resident 5's 01/2022 MAR indicated and staff documented the resident self-administered Clobetasol Pro cream twice daily for wound care. There was no documented evidence the facility had a physician's written order of approval for the resident to self-administer the treatment. There was also no documented evidence Resident 5's ability to safely self-administer the treatment was evaluated.The failure to obtain physician's orders and to complete the evaluation of the resident's ability to self-administer medications and treatment was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. No further information was received.
3. Resident 6 was admitted to the facility in 02/2009. The 01/2022 MAR, physician orders dated 01/31/22 and self medication evaluation dated 11/30/21 were reviewed. The resident's unit was observed while s/he was interviewed.The physician order specified the resident was not to self administer any medications with the exception of "APAP and creams." The MAR and self medication evaluation reflected the resident self administered triamcinolone acetonide aerosol (for allergies). In an interview with Resident 6 on 02/01/22 at 10:14 am, an observation was made of two nasal spray containers located on the resident's shelf by his/her bed. When asked if s/he administered their own nasal spray, the resident confirmed s/he did.The need to ensure resident's had physician's orders to self administer medications was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to evaluate a residents' ability to safely self-administer medication and failed to have physician or other legally recognized practitioner's written order of approval for self- administration of medication for 3 of 4 sampled resident (#s 3, 5 and 6) who self-administered medications. Findings include, but are not limited to:1. Resident 3 was admitted to the facility 05/2019 with diagnoses including multiple sclerosis.The resident's record confirmed s/he was self-administering some medications and treatments. There was no documented evidence the facility had physician's orders for the resident to self-administer the following medications and treatments:* PRN Albuterol (for shortness of breath);* PRN Tylenol (for pain);* PRN Ibuprofen (for pain);* PRN Lidocaine Cream (for pain);* PRN Lidocaine Ointment (for pain); and* PRN Voltaren Gel (for pain).The need to ensure signed physician orders were available in the residents' chart for all medications and treatments the resident self-administered was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 01/31/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 1) who was administered PRN psychoactive medication. Findings include, but are not limited to:Resident 1 was admitted to the facility in 07/2021 with diagnoses including cardiac arrhythmia.Resident 1's 01/2022 MAR, 01/28/22 signed physician orders and clinical records were reviewed during the survey and revealed the following:* Resident 1 had orders for PRN Ativan for "anxiety or restlessness";* The PRN Ativan was administered to the resident on 01/28/22, 01/29/22 and 01/30/22;* There was no documented evidence medical parameters had been identified for the administration of the PRN medication; * There was no listing of non-drug interventions on the MAR; and* There was no documented evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.On 02/02/22, Resident 1's record was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required areas was completed prior to beginning job duties for 3 of 3 newly hired staff (#s 8, 14 and 15). Findings include, but are not limited to:The facility training records were reviewed with Staff 4 (Office Manager) on 01/31/2022 at 1:00 pm and revealed the following:* Staff 8 (CG), Staff 14 (MT) and Staff 15 (MT), hired on 12/16/21, 11/22/21 and 12/10/21 respectively, lacked documented evidence of pre-service orientation in standard precautions for infection control and fire safety and emergency procedures. * Staff 14 lacked documented evidence of completion of required pre-service dementia training. The need to ensure newly hired staff completed pre-service training in all required areas was discussed with Staff 1 (Administrator) and Staff 4 during the survey. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 14 and 15) had demonstrated competency in all required areas within 30 days of hire and 2 of 3 staff (#s 8 and 15) completed abdominal thrust and First Aid training. Findings include, but are not limited to:Staff training records were reviewed with Staff 4 (Office Manager) on 01/31/22 at 1:00 pm and revealed the following:* Staff 14 (MT) and Staff 15 (MT) hired on 11/22/21 and 12/10/21 respectively, lacked documented evidence of demonstration of competency in all required areas was completed within 30 days of hire. * Staff 8 (CG), hired on 12/16/21 and Staff 15 lacked documented evidence of abdominal thrust and First Aid training. The need to ensure staff had documentation of demonstrated competency in all required areas within 30 days of hire and completed abdominal thrust and First Aid training was discussed with Staff 1 (Administrator) and Staff 4 during the survey. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 11, 17 and 18) completed the minimum required 12 hours of annual in-service training which included six hours of training on dementia care topics. Findings include, but are not limited to: Annual facility training records were reviewed with Staff 3 (RCC) on 02/01/22 at 11:00 am and revealed the following:Staff 11 (MT), Staff 17 (MT) and Staff 18 (CG), hired on 01/19/20, 01/31/13 and 01/19/20 respectively, lacked documented evidence of 12 hours of annual training which included six hours of training on dementia care topics. The need to ensure all direct care staff completed 12 hours of annual in-service training which included six hours of training in dementia care topics was discussed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternating months from fire drills. Findings include, but are not limited to:Fire drill and fire and life safety training records from 11/01/2021 to 01/31/22 were reviewed on 01/31/2022. There was no documented evidence the facility provided fire and life safety instruction to staff on alternating months from the fire drills. The need to ensure the facility provided fire and life safety instruction to staff on alternating months from the fire drills was discussed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and located above the first floor. Findings include, but are not limited to:The interior of the facility was toured with Staff 6 (Maintenance Assistant) on 01/31/2022 at 12:00 pm. The windows in rooms 218, 220, and 229, located above the first- floor level, had sill heights that measured lower than 36 inches. The windows opened to full capacity and lacked a locking mechanism to prevent accidental falls.Staff 6 stated that windows above the first-floor level had not been checked and confirmed all the windows above the first level did not have a locking mechanism to prevent accidental falls. The need to ensure windows above the first floor were designed to prevent accidental falls was discussed with Staff 1 (Administrator) and Staff 6 during the survey. They acknowledged the findings.