Cornell Estates Retirement And Assisted Living Residence

Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:The facility was unable to provide physician orders for Resident 1's Valacyclovir 1mg (antibiotic).An incident report for Resident 1, dated 07/24/24, indicated one dose of Valacyclovir 1mg was remaining in a medication card for Resident 1, despite the order having ended.Resident 1's MAR, dated 07/01/24 through 07/31/24, indicated his/her Valacyclovir had been administered as prescribed.During an interview on 10/14/24, Staff 2 (LPN) stated "there was one pill left over" once the medication regimen should have been completed, and there was "no way to tell which med tech [made the error]."It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Facility had begun to review resident's prescribed antibiotics during clinical meetings.Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:Physician orders, dated 02/02/24, indicated Resident 2 was to receive Clonazepam 0.25mg (anxiety) every morning, as well as Clonazepam 0.5mg at night.Resident 2's MAR, dated 04/01/24 through 04/30/24, indicated Clonazepam 0.5mg had been administered to Resident 22 on the mornings of 04/01/24 through 04/09/24.An incident report, dated 04/14/24, indicated a med tech had marked the medication as given but had not administered the medication to the resident. It further indicated the medication had not been signed out in the facility's narcotics logbook and was accounted for.During an interview on 10/14/24, Staff 2 (LPN) stated s/he remembered the med tech had marked the medication as given and forgot to "pop" the medication from the narcotics drawer.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Med tech responsible no longer employed by the facility.Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:A physician order for Resident 2, dated 02/02/24, indicated s/he was to be administered Propranolol 10mg (anxiety) twice a day, and to hold the medication if systolic blood pressure was below 110 or if the resident's heart rate was lower than 60 beats per minute (bpm).Incident reports, dated 03/10/24 and 03/12/24, indicated Resident 2 had received Propranolol outside of parameters.Resident 2's MAR, dated 03/01/24 through 03/30/24, indicated s/he had received Propranolol on 03/10/24 when his/her blood pressure had been recorded at 57bpm, as well as on 03/12/24 when his/her blood pressure had been recorded at 55bpm.Physician orders for Resident 2, dated 02/02/24, indicated s/he was to receive Clonazepam 0.5mg once a day.An incident report, dated 02/18/24, indicated a med tech had been unable to find Resident 2's Clonazepam.Resident 2's MAR, dated 02/01/24 through 02/29/24, indicated s/he had not received his/her Clonazepam on 02/18/24.It was determined the facility failed to administer medication as prescribed.Staff 2 (LPN) stated the incidents had occurred.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:Physician orders for Resident 4, dated 02/04/24, indicated s/he was to be administered Clonazepam 0.125mg (anxiety) twice a day.An incident report, dated 03/04/24, indicated Resident 4's Clonazepam had been marked off as administered on his/her MAR but had not been administered and had been found in the facility ' s medication cart.Staff 2 (LPN) stated the incident had occurred and the med tech responsible had been terminated.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. Med tech responsible had been terminated. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:An incident report, dated 03/03/24, indicated Resident 5's order had been changed from Losartan 50mg twice a day to Losartan 100mg once a day on 03/01/24, and the facility had not processed the order.Resident 5's MAR, dated 03/01/24 through 03/30/24, indicated s/he had received Losartan 50mg twice a day on 03/03/24.Staff 2 stated med techs were supposed to provide first checks and process orders.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:An incident report, dated 02/04/24, indicated a med tech had filled out the facility's narcotic logbook and not administered the medication, Hydrocodone 5mg (pain management), to Resident 3.Staff 2 (LPN) stated the med tech had been new and had been coached on dispensing the medication prior to filling out the paperwork.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Med tech responsible no longer employed at facility.Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:Physician orders for Resident 3, dated 02/04/24, indicated s/he was to receive Clonazepam 0.5mg (anxiety) once a day.An incident report, dated 02/18/24, indicated a med tech had not known the location of Resident 3's Clonazepam 0.5mg and therefore had not administered it to Resident 3.Resident 3's MAR, dated 02/01/24 through 02/29/24, indicated s/he had not received his/her Clonazepam 0.5mg.Staff 2 (LPN) stated the med tech "didn't know Clonazepam was a narcotic" and didn't look in the narcotics drawer of the med cart.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 2 of 3 sampled residents (#s 6 and 8). Findings include, but are not limited to:An incident report, dated 02/15/24, indicated on 02/13/24 " Med tech popped one of [Resident 6 ' s] oxycodone 5mg thinking it was [Resident 8 ' s] oxycodone 5mg and gave it to [Resident 8] " and " correct med given, but given from [Resident 6 ' s] card instead of from [Resident 8 ' s]. "A quarterly physician order review for for Resident 6, dated 03/22/24, indicated s/he was to receive oxycodone 5mg (pain management) three times daily.Physician orders for Resident 8, dated 12/22/23, indicated s/he was to receive oxycodone 5mg six times a day.During an interview, Staff 2 (LPN) stated the error had occurred.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:An incident report, 02/05/24, indicated on 02/04/24 "[Resident 3] missed her AM dose of oxycodone 5mg."Staff 2 (LPN) confirmed the error had occurred.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:An incident report, dated 03/03/24, indicated Resident 3 had not received his/her Oxycodone 5mg on 03/03/24.Resident 3's MAR, dated 03/01/24 through 03/30/24, indicated s/he had not received his/her oxycodone on 03/03/24.Staff 2 (LPN) stated the pharmacy hadn't sent the medication when ordered, and when they were contacted sent it over immediately.It was determined the facility failed to administer medication as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24.Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.

The findings of the re-licensure survey conducted 09/25/23 through 09/28/23 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 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 09/28/23, conducted 02/14/23 through 02/15/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the second re-visit to the re-licensure survey of 09/28/23, conducted on 05/17/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the third re-visit to the re-licensure survey of 09/28/23, conducted on 09/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the fourth re-visit to the kitchen inspection of 09/28/23, conducted 10/15/24, 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, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 09/25/23 through 09/28/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.Refer to the deficiencies identified in the report.
Based on observation and interview it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the second revisit survey, conducted on 05/17/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations.Refer to C 240 and C 455.
Based on observation and interview it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to:During the third revisit survey, conducted on 09/05/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations.Refer to C 240 and C 455.

Based on observation, interview, and record review, it was determined the facility failed to ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The facility kitchen was toured on 09/26/23 at 9:52 am. a. The following areas were in need of cleaning or repair:* The caulk adjoining the stainless-steel ware washing area and the wall had a build up of black matter and the caulk was deteriorating which caused water to saturate the wall beneath the ware wash counter;* The floor underneath the three compartment sink had a buildup of dirt, food debris and rubbish;* There was a hole in the wall with exposed pipes underneath the sprayer sink in the dishwashing area;* There was a water leak from unknown source in the dishwashing area that was leaking water through the wall and floor to the other side of the kitchen near the food service table (located at the entrance of the kitchen); * Wall baseboard coving was pulling away from the floor and wall near the hand washing sink, near the steam table, food prep area, and wall surrounding the dish washing area;* Laminate veneer on the left corner of the food service table was missing with exposed wood, which created an uncleanable surface;* Walk in freezer door gasket was failing which cased condensation and ice buildup on the freezer door;* The dry food storage area had a build up of food debris underneath shelves, and sticky brown matter on the floor; * Flying insects were observed in the dry food storage area and janitorial closet; and* The kitchen exit door that entered into the assisted living dining room had a door hinge that was disconnected from the door frame. b. Observations of the food preparation and food service identified the following:* Poultry and poultry-based food product temperatures were prepared under the required 165 degrees F.;* Cold food items (milk and fresh cut fruit) plated for food service had temperatures above 41 degrees F.; and* Alcohol wipes were not used to sanitize the food thermometer after each use.c. Observations of sanitation including pots, pans, plates, food service equipment, utensils and knives identified the following:* The ware wash machine was a low temp (120 degrees F.) machine that was equipped with a sanitizer solution. The solution was empty and had not been replaced by the dishwasher. This created a situation in which the food service equipment was not effectively sanitized when using a low temperature ware wash machine. d. Review of employee infection control practices identified the following:* Staff 12 (Cook) failed to ensure his hair and beard were restrained; and* Staff 16 (Prep cook) failed to have a valid Oregon Food Handler card.e. Resident's who chose to dine in their apartments were served their food in styrofoam containers, including styrofoam drinking containers and plastic-ware utensils verses those resident's who dined in the assisted living dining room. The kitchen was toured, and the above areas were discussed with Staff 1 (Administrator), Staff 5 (Dining Services Director), and Staff 6 (Regional Director of Operations) on 09/26/23 at 1:41 pm. They acknowledged the findings. Staff 6 instructed Staff 1 and Staff 5 to immediately contact the facility maintenance, a plumber and the facility's contracted pest control.
Based on observation and interview, it was determined the facility failed to ensure proper food preparation and food service, proper employee infection control and failed to ensure the kitchen was clean and maintained 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 facility kitchen was toured on 02/14/24 at 9:40 am. a. The following areas were in need of cleaning or repair:* Walk-in freezer door gasket was secured with tape; and* A large can opener had build-up of black residue on the blade and surrounding housing.b. Observations of the dry storage, food preparation and food service identified the following:* Alcohol wipes were not used or available to sanitize the food thermometer after each use; * A package of pancake mix in the dry storage area was unsealed and had a scoop stored in the mixture; and* Multiple bags of dry foods in the dry storage area were unsealed or uncovered; and* Observations of three kitchen staff who were preparing food failed to have hair restrained. c. The ware washer was not installed at the time of the re-visit survey and there was repair work in process for the surrounding walls.The kitchen was toured and the above areas were discussed with Staff 1 (Administrator) on 02/14/24 at 2:30 pm. Staff 1 reported the repairs to the kitchen walls and ware washing station were expected to be completed soon and acknowledged the findings.


Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained 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 facility kitchen was toured on 05/17/24 at 9:40 am. a. The following areas were in need of repair:* Walk-in freezer door gasket was secured with tape;* Walk-in refrigerator door was damaged and in need of repair;* There was one-to-three inches of ice buildup in various areas of the walk-in freezer, including ice on food product, pipes and floor;* The ware washer area floor had multiple areas of cracked tile and/or missing tile grout;* There was a two inch diameter hole in the floor next to the grease trap (Located in the dish washing area);* The tile and grout surrounding the grease trap was damaged and deteriorating;* There was a hole in the wall surrounding the pipes in the dish washing area which allowed for the entry of pests;* The garbage disposal was not operable;* The janitor's closet had two areas approximately 14 inches long that were missing coved baseboards;* The floor and wall surrounding the dish washing area (facing the prep table and tray line) had missing coved baseboards;* There was missing floor tile between the tray line and the chef refrigerator and at the end of the tray line;* There was missing baseboards on the front of the tray line, which had exposed wood rendering the surface uncleanable; and* The entry door and threshold to the kitchen had been removed. The need to ensure the kitchen was maintained in good repair and in accordance with Food Sanitation Rules was discussed with Staff 6 (Regional Director of Operations), Staff 24 (Dining Services Director) and Staff 25 (Interim Designee) on 05/17/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained 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 facility kitchen was toured on 09/05/24 at 10:45 am with Staff 24 (Dining Services Director) and Staff 25 (Administrator).a. The following areas were in need of repair:* Ice accumulation was observed in two locations of the walk-in freezer and were up to six inches in length and three-four inches in width. The ice was hanging from the pipes that were connected to the freezer condenser and blower mechanism;* The tile and/or grout surrounding the grease trap was damaged and deteriorating;* The metal cover of the grease trap was rusted and deteriorating creating a whole in the back right corner and the perimeter of the grease trap cover was not flush to the floor creating an approximate 1/4 inch gap around the perimeter of the grease trap and the surrounding floor; * The garbage disposal was not operable;* The wall and coved baseboards facing the prep table and tray line were pulling away from the wall and surrounding floor creating a gap between the wall and baseboard which continued to allow dirt, debris and potential insects to harbor;* The floor thresholds to the two entry doors of the kitchen had been removed, creating a gap between the dining room flooring and the kitchen flooring; and* Upon entering the walk-in refrigerator, near the floor on the right side (roughly ankle height) was a piece of rusted metal refrigeration wall that was pulled away from the surrounding wall and protruding out on a sharp angle.The need to ensure the kitchen was maintained in good repair and in accordance with Food Sanitation Rules was discussed with Staff 24 and Staff 25 on 09/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an initial move-in evaluation included all required elements, for 1 of 1 sampled resident (# 5) who recently moved in. Findings include, but are not limited to:Resident 5 moved into the assisted living community in 09/2023 with diagnoses including pancreatitis and type 2 diabetes mellitus. Resident 5's move-in evaluation, dated 09/22/23, lacked information regarding the following required elements:* Interests, hobbies, social and leisure activities;* Personality: including how the person copes with change or challenging situations; and* Recent losses.The move-in evaluation was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations), and Staff 11 (Director of Health Services, RN) on 09/27/23 at 2:30 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective and provided clear direction regarding the delivery of services for 4 of 5 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including cerebrovascular accident.The service plan dated 09/15/2023, temporary service plans and progress notes dated 07/31/23 through 09/25/23 were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective and failed to provide clear instruction to staff in the following area: * Siderail use and safety.On 09/28/23, the need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including diabetes. The service plan dated 08/03/2023, temporary service plans and progress notes dated 07/23/23 through 09/25/23 were reviewed. Interviews with care staff and Resident 3 were conducted and observations were made. The resident's service plan was not reflective and failed to provide clear instruction to staff in the following area:* Pressure ulcer; and* Discontinuation of walker use.On 09/28/23, the need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN). They acknowledged the findings.
3. Resident 4 moved into the facility in 06/2021 with diagnoses including diabetic neuropathy.Resident 4's service plan, updated 08/16/23, was reviewed during the survey and was not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas: * Use of modified/weighted utensils.The need to ensure service plans were reflective of the resident's needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.
4. Resident 1 was admitted to the facility in 07/2020 with diagnoses including Parkinson's disease, depression and major depressive disorder.The service plan dated 09/20/2023, temporary service plans and progress notes dated 08/01/23 through 09/24/23 were reviewed. Interviews with care staff and Resident 1 were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas: * Communication; * Mental health issues including: presence of depression; and* Siderail use. The need to ensure service plans were reflective of the residents' care needs and provided clear caregiving instruction was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations), Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what action or interventions were needed for a resident, communicate the interventions to staff on each shift, and ensure short-term changes of condition were monitored with weekly progress noted through resolution for 2 of 5 sampled residents (#s 4 and 6) reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 06/2021 with diagnoses including type II diabetes and diabetic neuropathy.Resident 4's 07/27/23 through 09/11/23 facility progress notes and 09/01/23 through 09/25/23 MAR showed the following changes of condition:* 09/01/23 - 09/03/23: On a new anti-biotic medication.The facility initiated short-term monitoring. However, there was no documented evidence the change was monitored at least weekly through resolution. The need to ensure short term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings. No further information was provided.2. Resident 6 moved into the facility in 10/2020 with diagnoses including type II diabetes.Interviews with staff and Resident 6's 07/31/23 through 09/25/23 facility progress notes showed the following changes of condition:* 08/28/23: Received "a shot of left eye"; and * 09/08/23: Experienced a low blood sugar episode.The facility initiated short-term monitoring of the eye injection. However, there was no documented evidence the change was monitored at least weekly through resolution. There was no documented evidence the resident's condition was evaluated to determine what actions or interventions were needed for the resident's low blood sugar episode and communicated to staff on each shift. There was no evidence the resident's change of condition was monitored through resolution. The need to ensure short term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings. No further information was provided.

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) Division 47 Rules, for 1 of 1 sampled resident (# 6) who was being assisted with insulin injections or CBG readings by unlicensed facility staff. Resident 6 experienced avoidable medical complications related to the lack of training and supervision to ensure safety and accuracy of insulin administration of unlicensed staff. Findings include, but are not limited to: Resident 6 moved into the facility in 10/2020 with diagnoses including type II diabetes.During the acuity interview on 09/25/23, Resident 6 was identified to be administered insulin injections by non-licensed staff. a. The resident's delegation records and clinical records were reviewed and identified the following:* Staff 18 (MT) documented on the MAR she administered Resident 6's insulin injection on multiple occasions; and* There was no documented evidence Staff 18 was delegated to administer Resident 6's insulin.b. Interviews with Staff and the resident's 09/01/23 through 09/25/23 MARs were reviewed and identified the following:* The MAR directed staff to administer insulin to the resident twice a day;* The MAR noted the following instruction "do not administer [the insulin] if blood sugar is below 100.";* The MAR showed the resident's CBG was 74 on 09/08/23 at 7:00 am and staff signed on the MAR that they administered insulin to the resident when the CBG was 74; * During an interview on 09/25/23, Staff 18 confirmed she administered the insulin to the resident when the resident's CBG was "around 70's". She further stated a caregiving staff reported to her that the resident was having "low blood sugar" episode approximately 15 minutes after she had administered the insulin to the resident. Staff 18 reported she checked the resident's blood sugar level and it was "around 40's."; and* The facility investigation noted Staff 18 was "unaware of" the instruction to hold insulin when CBG was below 100.The facility's failure to complete Staff 18's delegation and supervision of special tasks of nursing care put the resident at risk for an insulin administration error and avoidable medical complications. During the survey on 09/27/23, Staff 11 (Health Services Director, RN) reported she completed the delegation of the insulin administration task to Staff 18 on 09/26/23. c. Interviews with staff, review of delegation records and the 09/01/23 through 09/25/23 MAR identified the following:* Staff 9 (MT), Staff 13 (MT) and Staff 19 (MT/CG) initialed the MAR for insulin administration;* Staff 9 and Staff 13, lacked determination of frequency resident should be reassessed, including rationale and determination of frequency the unlicensed staff should be supervised and re-evaluated, including rationale; and * Staff 19 had no documented evidence of the delegation task for Resident 6 had been completed as of 09/25/23. On 09/28/23 at 11:30 am, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules with Staff 1 (Administrator) and Staff 11 was reviewed. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system. The lack of adequate professional oversight for the safe medication system including insulin administration and delegated tasks put Resident 6 at risk. Findings include, but are not limited to:1. Resident 6 moved into the facility in 10/2020.During the acuity interview on 09/25/23, Resident 6 was identified to be administered insulin injections by non-licensed staff.a. The resident's 08/14/23 physician's orders, delegation records and 09/01/23 through 09/25/23 MARs were reviewed.Resident 6 had a physician order to administer Humalog 70/30 (an intermediate-acting insulin combined with the more rapid onset of action) 60 units injection subcutaneously at 7:00 am and 20 units at 3:30 pm and to check CBG four times daily.The MAR showed an instruction "do not administer [the insulin] if blood sugar is below 100." Further review of the MAR showed the resident's CBG was 74 on 09/08/23 at 7:00 am and staff initialed on the MAR that they administered insulin to the resident on 09/08/23 at 7:00 am when CBG was below 100.During an interview on 09/25/23, Staff 18 (MT) confirmed she administered insulin to the resident when the resident's CBG was "around 70's." She further stated a caregiving staff reported to her that the resident was having "low blood sugar" episode approximately 15 minutes after she had administered the insulin to the resident. Staff 18 reported she checked the resident's blood sugar level and it was "around 40's." b. Review of the delegation records revealed there was no documented evidence Staff 18 was delegated to administer Resident 6's insulin.The facility investigation noted Staff 18 was "unaware of" the instruction to hold insulin when CBG was below 100.The facility's failure to provide professional oversight of the medication administration system including following a special instruction on the MAR and the lack of documented evidence that the delegation and supervision of special tasks of nursing care had been completed, put the resident at risk for an insulin administration error and avoidable medical complications.On 09/28/23 at 11:30 am, the above findings were shared with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC) and Staff 11 (Director of Health Services, RN). They acknowledged the findings. Refer to C282
2. Resident 7 moved into the assisted living community in 02/2023 with diagnoses including anxiety, Bi-polar mood disorder, posttraumatic stress disorder (PTSD), and schizoaffective disorder. During the acuity interview on 09/25/23, Resident 7 was identified to be administered an as needed psychotropic medication. The resident's 09/01/23 through 09/25/23 MAR, physician orders, and 08/28/23 through 09/25/23 progress notes were reviewed during the survey.Resident 7 was prescribed prochlorperazine (for PTSD), one tablet every day, as needed.On 09/10/23, unlicensed staff (MT) administered the as needed medication twice, for a total of two tablets. During an interview on 09/26/23 at 3:10 pm, Staff 4 (LPN), reported the physician orders were entered into the electronic MAR (EMAR) by the pharmacy. The pharmacy entered the order incorrectly which failed to alert the MT that the medication had already been given and was too soon to administer another dose. The facility staff failed to review the order that was entered into the EMAR by the pharmacy which resulted in the medication administration error. The need to ensure the facility had effective oversight of the medication system was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Coordinator), Staff 4 (LPN), Staff 6 (Regional Director of Operations), and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings. 3. During the re-licensure survey, conducted 09/25/23 through 09/28/23, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:* C 282: Systems: RN Delegation;* C 302: Systems: Tracking Controlled Substances;* C 310: Systems: Medication Administration;* C 325: Systems: Self Administration of Medications; and* C 330: Systems: Psychotropic Medication.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 4 moved into the facility in 06/2021 and had diagnoses including chronic neck and back pain.Resident 4 had an order for hydrocodone-acetaminophen 5/325 mg, one tablet every six hours as needed for pain.Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 09/01/23 through 09/25/23, revealed 29 occasions when staff signed on the drug disposition log that the hydrocodone-acetaminophen was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Administrator), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) during the survey. They reviewed the documentation and acknowledged the discrepancies.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident specific parameters, and instructions for PRN medications for 4 of 5 sampled residents (#s 2, 3, 4 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including cerebrovascular accident.The resident's current physician's orders and the MAR dated 09/01/23 through 09/25/23 were reviewed and revealed the following:The following medications did not include clear parameters for unlicensed staff to follow:* PRN Vicodin (for pain); and* PRN Morphine (for pain).The need to ensure MARs included clear parameters was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of health Services, RN). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including diabetes.The resident's current physician's orders directed staff to obtain pulse and BP prior to administration of Coreg (for high blood pressure). The MAR dated 09/01/23 through 09/25/23 was reviewed and revealed the following multiple blanks for the following:* Pulse; and* Blood pressure.During an interview with Staff 4 (LPN), she stated the resident had been refusing daily vitals and staff had not always been documenting the refusals on the MAR.The need to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 and Staff 11 (Director of Health Services, RN). They acknowledged the findings.
3. Resident 4 moved into the facility in 06/2021 with diagnoses including irritable bowel syndrome. Resident 4's 09/01/23 through 09/25/23 MAR was reviewed and the following was identified: * PRN polyethylene powder and PRN Senna 8.6 mg were both prescribed to treat constipation and lacked clear parameters for the sequence of administration. The need to ensure MARs included clear parameters for multiple PRN medications prescribed to treat the same condition was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.4. Resident 6 moved into the facility in 10/2020 with diagnoses including type II diabetes.Resident 6's 09/01/23 through 09/25/23 MAR was reviewed and the following was identified:* A PRN glucose medication for low blood sugar lacked clear parameters for administration; and* A PRN milk of magnesium for constipation lacked clear parameters for administration.The need to ensure MARs included clear parameters for PRN medications use was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer a specific medication for 1 of 1 sampled resident (#4) who self-administered an insulin injection. Findings include, but are not limited to:Resident 4 moved into the facility in 06/2021 with diagnoses including type II diabetes. On 09/27/23 at 9:40 am, diabetic supplies and a sharp container was observed in the resident's room. Resident 4 confirmed s/he self administered his/her insulin injection.During the survey, an evaluation of the resident's ability to safely administer the insulin was requested. Reviewed the facility's "Medication Self Administration Assessment Results" which showed "DNA" on the administer subcutaneous injections. There was no other information on the form related to the resident's ability to safely self-administer subcutaneous insulin injections. On 09/27/23 at 10:20 am, evaluating Resident 4's ability to safely self-administer medications was review with Staff 1 (Administrator), Staff 4 and Staff 11 (Director of Health Services, RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, resident-specific parameters and non-pharmacological interventions were attempted and documented to have ineffective results, prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (#7), whose records were reviewed. Findings include, but are not limited to:Resident 7 moved into the assisted living community in 02/2023 with diagnoses including anxiety, bipolar mood disorder, posttraumatic stress disorder (PTSD), and schizoaffective disorder. The resident's 09/01/23 through 09/25/23 MAR and 08/28/23 through 09/25/23 progress notes were reviewed during the survey.Resident 7 was prescribed prochlorperazine (for PTSD), one tablet every day, as needed.Between 09/07/23 and 09/12/23, Resident 7 was administered six doses of the PRN prochlorperazine. There was no documented evidence unlicensed staff (MTs) documented non-pharmacological interventions were attempted with ineffective results prior to administering the PRN medication. During an interview on 09/26/23 at 3:10 pm, Staff 4 (LPN) confirmed there were no resident specific parameters or non-pharmacological interventions on the MAR and staff were not documenting non pharmacological interventions were attempted prior to administering the medication. The need to ensure the MAR included resident specific parameters and staff documented non-pharmacological interventions were attempted prior to administering a PRN psychotropic was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 4, Staff 6 (Regional Director of Operations), and Staff 11 (Health Services Director, RN) on 09/27/23 at 2:30 pm. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including diabetes. On 09/26/23, during an interview with the resident in his/her apartment, half-bilateral side rails were observed on the bed in the up position, and securely fastened to the bed. Review of Resident 3's record revealed there was no documented evidence an assessment of the side rails had been completed by an RN, PT or OT nor were the devices with restraining qualities included on the resident's service plan including the use and precautions. The lack of assessment and service planning for devices with restraining qualities was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of health Services, RN). They acknowledged the findings.
2. Resident 4 moved into the facility in 06/2021 with diagnoses including congestive heart failure.During an interview on 09/27/23, Resident 4's hospital bed was observed to have bilateral half-length siderails on the bed. The siderails were in the up position and securely fastened to the bed. In an interview with Staff 4 (LPN) on 09/27/23, siderail assessment documentation was requested. On 09/28/23 at 9:32 am, Staff 1 (Administrator) reported no siderail assessment had been completed for Resident 4. The resident's 08/16/23 service plan showed there were no instructions to caregivers on the correct use of the siderails and precautions related to use of the device. The need to ensure supportive devices with potentially restraining qualities were assessed and service planned prior to use was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device, and failed to include the use of the supportive device in the service plan and evaluated on a quarterly basis for 3 of 3 sampled residents (#s 1, 3, and 4) who used a supportive device with restraining qualities. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 07/2020 with diagnoses including Parkinson's disease.During an interview on 09/25/23, Resident 1's hospital bed was observed to have a quarter-length siderail on the right side of the bed. The siderail was in the up position and securely fastened to the bed. Review of Resident 1's service plan dated, 09/20/23, revealed there was no documentation of the use of supportive devices with restraining qualities included in the resident service plan.In an interview with Staff 4 (LPN) on 09/25/23, siderail assessment documentation was requested. Staff 4 was unaware that siderails were present and stated that a siderail assessment had not been completed for Resident 1. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and documentation of the use of supportive devices with restraining qualities was included in the resident service plan was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director), Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 8, 14 and 17) completed the required minimum 12 hours of in-service training annually which included six hours of dementia care training. Findings include, but are not limited to:Staff training records were reviewed on 09/26/23.There was no documented evidence Staff 8 (CG), Staff 14 (CG) and Staff 17 (MT) hired 07/14/06, 10/07/21 and 07/16/20 respectively, had completed the required minimum 12 hours of in-service training annually, based on hire dates, related to the provision of care which also included six hours of dementia care training.The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented all required components in accordance with Oregon Fire Code every other month, and Life Safety instruction was provided to staff on alternating months. Findings include, but are not limited to:Review of Fire and Life safety records for 03/2023 through 09/2023 and an interview with Staff 1 (Administrator) on 09/26/23 at 9:15 am revealed the facility lacked documentation of the following:* Fire and life safety instruction to staff on alternate months; and* Fire drills conducted and recorded every other month according to the Oregon Fire Code.On 09/26/23, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drills included required components according to the Oregon Fire Code was reviewed with Staff 1, Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations) and Staff 11 (Director of Health Services, RN). They acknowledged the findings.

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

Based on observation and interview, it was determined the facility failed to ensure their second revisit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 240.

Based on observation and interview, it was determined the facility failed to ensure their third revisit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 150 and C 240.

Based on observation and interview, it was determined the facility failed to ensure exterior surfaces were maintained in good repair. Findings include, but are not limited to:Observations of facility pathways outside courtyards and seating areas on 09/27/23 identified the following: * Multiple drop-offs of four to five inches were noted along pathway edges around the perimeter of outside courtyards and seating areas. The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (Administrator) on 09/27/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:During a tour of the facility on 09/25/23 and 09/26/23, the following was observed:* Multiple benches in the common areas had stains on seating area and had chips and gouges on legs;* Carpet throughout the common areas and hallways had black spots, stains and blackened areas;* Handrails throughout the facility had gouges; * Multiple doors including Room 161, 189, 253, 281 and 290 had scuffs and scratches; * Ventilation covers and filters, near the first floor nursing station, were covered with layers of dust;* Room 154, the cabinet and kitchenette sink areas were gouged and not cleanable surfaces; and* The laundry room linoleum floor was ripped, torn, chipped and had accumulated dust in the corner and behind washers and dryers.The environment was toured on 09/27/23 at 10:45 am with Staff 1 (Administrator). He acknowledged the above areas needed to be cleaned and repaired.

Based on observation and interview, it was determined the facility failed to ensure residents had keys to a lockable storage space (e.g., drawer, cabinet, or closet) for the safekeeping of their small valuable items and funds. Findings include, but are not limited to:On 09/26/23 at 1:00 pm, eight non-sampled residents attended a group interview. All residents interviewed confirmed that although they had a lockable storage space in their apartments, they did not have a key to the space.The need to ensure residents had a key to their lockable storage space was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:The building was toured on 09/27/23 with Staff 1 (Administrator). Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.On 09/27/23, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1. He acknowledged the findings.

The findings of the on-site investigation, conducted 08/10/23/2023 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 12/06/2022. 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day