Dallas Retirement Village Assisted Living

The findings of the kitchen inspection, conducted 10/24/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities 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 10/24/23, conducted 01/29/24, 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 facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observations made in the kitchen on 10/24/23 from 10:15 am through 1:30 pm identified the following deficiencies:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following:*Handwashing sink;*Water/ice machine;*Floor throughout the kitchen;*Floors in-between and under equipment;*Large can opener;*Inside conventional oven;*Prep space next to stove;*Shelves and door seals of reach-in refrigerator and freezer; and*Fire sprinkler, vents, and light fixtures above the tray line.b. The following areas were found in need of repair:* Black serving trays had visible staining.* Floor with splitting seam * Service carts with visible damage (not smooth and cleanable)c. The staff supervising servers reported the rinse temperature for the dish machine did not need to be 180 degrees Fahrenheit, and she had been told 172 degrees Fahrenheit was acceptable. Dish washer rinse log was reviewed and multiple entries were noted less than the required 180 degrees. Surveyor educated staff on the temperature needed to sanitize dishes in the rinse cycle of the dish machine.d. Kitchen staff was observed to handle RTE (ready to eat) food items with potentially contaminated gloves during meal serve out.e. Kitchen staff did not check the temperature of a hot dog cooked to order on the grill before plating and serving to resident. Large container of pea/cheese/mayo salad was not kept on ice bath during serve out to ensure temperature remained at 41 or below. Findings were reviewed with Staff 2 (Dining Services Manager) on 10/24/23 at 1:00 pm. He acknowledged the findings.The need to ensure all areas of the kitchen were maintained in a sanitary manner and all equipment was in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Manager) on 10/24/23 at 1:00 pm. They acknowledged the findings.

The findings of the on-site investigation, conducted 08/15/23 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

Based on interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 11). Findings include, but are not limited to:A review of Resident 11's July 2023 MAR and an incident investigation dated 07/23/23 revealed the following:*Resident 11 had an order for Clonazepam .5 mg take one tablet by mouth two times a day.*On 07/23/23 Resident 11 did not receive his/her morning dose of Clonazepam medication. During an interview with Resident 11 on 08/15/23 s/he stated remembering not getting the medication a few weeks previously, and had notexperienced any side effects or negative outcomes. The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 08/15/23.The facility failed to carry out medication orders as prescribed.Verbal plan of Correction: The Administrator to confirm that follow up training was completed with MT. LPN began printing reports that showed any holes in the MARs for MT's to review and correct, which was reviewed at clinical meeting on Thursdays. LPN to move medication errors to top of dashboard, review daily, and complete review weekly with the Administrator.

Based on observation, interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to fully implement an ABST for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:A review of the facility's ABST for 08/15/23 revealed the following:*The facility required 66.41 hours of direct care or 8.85 shifts; and *Resident 1 and Resident 2's care needs were not completely entered into the ABST.The facility's posted staffing plan revealed the following: stated:Day shift: 3 MA, 5 Universal workers, not increased to reflect ABST direct care needs.Eight direct care staff were observed working on day shift on 08/15/23.During an interview on 08/15/23, Staff 1 (Administrator) stated the facility staffed nine care staff during the day. She further stated, they are not always able to do that and confirmed there were only eight care staff working that morning.The facility failed to fully implement an ABST.The findings were reviewed with and acknowledged by Staff 1 on 08/15/23.Verbal plan of correction: The Administrator will update the posted staffing plan by end of day on 08/15/23. She will audit ABST by end of week, and will implement a rule that the new move-in checklist must be used and ABST must be completed prior to the resident moving into the facility. The Administrator to meet with the RCC weekly and audit the facility's checklist for compliance.

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 03/16/2023. 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

Based on observation, interview and record review, Compliance Specialist (CS) was unable to confirm that the facility failed visually observe the resident take the medication. Findings include but not limited to:During an unannounced site visit on 03/16/2023, CS completed several walk throughs of the facility and did not see any medications on the floor outside of resident rooms or left in resident rooms. CS observed Staff #4 (S4) pass medications to two residents and S4 observed both residents take their medications.During interview, S4 stated that they are required to observe all residents take their medications and that they have never seen a staff member leave medications at a resident's door.A review of the facility's Medication& Treatment Pass/Administration Policy and Procedure dated 10/22 stated "observe the resident taking the medication/treatment."These findings were reviewed with Staff #6-Staff #7 (S6-S7) on 03/16/2023.

The findings of the re-licensure survey, conducted 10/24/22 through 10/26/22, 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 Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 10/26/22, conducted 03/21/23 through 03/22/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse, and reported to the local Seniors and People with Disabilities Office (SPD) for 2 of 2 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 08/2022, with diagnoses including cerebral infarction and hemiplegia/hemiparalysis affecting the dominant side.Interviews with staff and review of Resident 3's clinical records, including incident reports, progress notes dated 08/02/22 - 10/25/22, service plans, temporary service plans, evaluations, and hospital discharge records, revealed the following:* On 08/14/22, an incident report noted staff found Resident 3 on the floor near the foot of his/her bed. The resident stated s/he fell trying to move his/her wheelchair and reported hitting his/her head. The resident was sent to the hospital and was diagnosed with a "closed head injury." The facility's investigation lacked information as to whether or not staff had been following the service plan. There was no documented evidence abuse or suspected abuse had been ruled out, there was no documented evidence of an Administrator's review, and that the facility reported the incident to the local SPD office.* On 08/22/22, a progress note indicated staff discovered a bruise on Resident's 3 right shoulder. There was no documented evidence the Administrator reviewed the incident.* On 10/14/22, an incident report noted Resident 3 "stated [s/he] fell twice" and staff noted a bruise on the right side of Resident 3's face. A progress note dated 10/15/22 noted the resident stated s/he fell twice and did not notify staff immediately. The resident stated s/he fell trying to walk from the bed to his/her electric scooter and hit his/her face on the scooter, and the second fall occurred when s/he was trying to walk to his/her scooter and fell on his/her tailbone. The facility's investigation lacked information as to whether or not staff had been following the service plan. There was no documented evidence abuse or suspected abuse had been ruled out, there was no documented evidence of an Administrator's review, and that the facility reported the incident to the local SPD office. There was no documented evidence of an Administrator's review of the investigation until 10/21/22The need to ensure incidents of abuse, suspected abuse, and injuries of unknown cause were promptly investigated and reviewed by the Administrator and incidents were immediately reported to the local Senior and People with Disabilities Office (SPD) if abuse or suspected abuse could not be ruled out was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/25/22 and 10/26/22. They acknowledged the findings and reported the required incidents to the local SPD office per the survey team's request; confirmation was provided.2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including rheumatoid arthritis and congestive heart failure. The resident's service plan, dated 10/07/22, observations of the resident, and interviews with care staff indicated the resident required assistance to transfer and ambulate using a walker for short distances. Review of incident investigations and progress notes from 07/24/21 through 10/24/22 showed the following: A incident report dated 08/05/22 indicated the resident had paged for assistance at 3:00 am and was found on the floor in the bathroom with bleeding from both sides of his/her head, a skin tear on the left hand, and bleeding from the neck. The resident reported using the bathroom, but did not remember anything after that statement. The incident report indicated the resident was not wearing slippers or non-skid socks and the room was dark. Resident 2 was transported to the emergency room, admitted for an infection, and returned to the facility on 08/08/22.The facility failed to complete an investigation of the unwitnessed fall with injuries to rule out abuse and neglect and did not report the incident to the local SPD. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and to report to the local SPD when indicated was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/25/22. The staff acknowledged the findings. At the request of the surveyor, the facility reported the incident to the local SPD on 10/25/22 and provided the Surveyor a copy of the submitted report.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:A survey of the first-floor kitchen was completed by Nursing Facility surveyors on 07/01/22.The second-floor kitchen was toured on 10/24/22 and showed the following: * Brown build-up on floor at the baseboard juncture throughout kitchen;* Dust build-up on kitchen fans, including fan above clean dishes exiting ware washer;* Black debris on full length of windowsill;* Gouges on walls in multiple areas exposing drywall, creating an uncleanable surface;* Paper signs throughout kitchen, creating an uncleanable surface; and* Garbage cans throughout kitchen did not have lids.These findings were reviewed with Staff 9 (Kitchen Manager) and Staff 10 (Dining and Food Services Director) on 10/25/22 and with Staff 1 (Administrator) on 10/26/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements, were updated with changes as needed within 30 days of move-in for 1 of 4 sampled residents (#3) whose evaluations were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 08/2022, with diagnoses including cerebral infarction, hemiplegia/hemiparalysis affecting the dominant side, anxiety disorder, and major depressive disorder Resident 3's move-in evaluation did not include the following information:* Non-pharmacological interventions for reported pain and did not include information related to the resident's mental health diagnoses of major depressive disorder and anxiety disorder, including past treatments and non-pharmacological interventions; and* The resident was a fall risk and required frequent safety checks and staff escorts with mobility in his/her electric scooter. There was no documented evidence Resident 3's evaluation was updated when the resident experienced multiple unwitnessed falls within 30 days of move-in.The need to ensure move-in evaluations addressed all required elements, were updated as needed within 30 days of move-in was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were updated following quarterly evaluations and provided clear direction to staff regarding the delivery of services for 1 of 4 sampled residents (#4) whose service plan was reviewed. Findings include, but are not limited to:Resident 4's service plan was reviewed during the survey. The following deficiencies were identified:* The resident's most current service plan was dated 04/11/22. In an interview on 10/25/22, Staff 3 (Resident Care Coordinator) confirmed Resident 4's service plan had not been updated quarterly as required.* The resident's service plan lacked clear direction to staff regarding catheter care, including when, how, and how often assistance was to be provided.The need to ensure service plans were updated following quarterly evaluations and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including rheumatoid arthritis and congestive heart failure.Observations of Resident 2 during the survey revealed s/he had very fragile, translucent-appearing skin and wore protective arm sleeves. The resident was observed to have a bandage on his/her upper right arm.Resident 2's record revealed the following:An assessment, written by Staff 2 (RN) on 09/21/22 after a hospital return indicated the resident had "several small bruises throughout."There was no further information about the bruising documented, including the location of the bruising or monitoring progress weekly through resolution.Staff 8 (LPN) was interviewed on 10/25/22 at 11:35 am. She reported she had been monitoring the bruises, although had not completed any documentation.The need to ensure changes of condition, including skin injuries, were evaluated and monitored at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 on 10/25/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes in residents' conditions were evaluated to determine resident-specific interventions and conditions were monitored, including the effectiveness of interventions, at least weekly through condition resolution for 2 of 4 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Resident 3 experienced multiple unwitnessed falls, two of which resulted in injury.1, Resident 3 was admitted to the facility in 08/2022, with diagnoses including cerebral infarction, hemiplegia/hemiparalysis affecting dominant side, diabetes, and anxiety.Observations, interviews, and review of Resident 3's clinical records, including incident reports, progress notes dated 08/02/22 - 10/25/22, service plans, temporary service plans, task records, evaluations, and hospital discharge records, revealed the following:Resident 3's move-in evaluation, Level of Care evaluation, and service plan noted the resident was alert and oriented and able to make his/her needs known and required staff assistance with transfers, dressing, bathing, and toileting. Resident 3 was noted to be a fall risk related to right-sided weakness and required frequent safety checks, staff escorts with mobility in his/her wheelchair, and encouragement to use the call light for assistance.Review of Resident 3's clinical records revealed the resident experienced eight unwitnessed falls between 08/02/22 and 10/25/22:a. On 08/04/22, staff found Resident 3 on the floor in his/her room. The resident stated s/he fell when trying to get a shirt from the closet. No injury was noted. There was no documented evidence the facility developed fall interventions, or evaluated the interventions in place for effectiveness.b. On 08/12/22, staff found Resident 3 the on floor next to the entryway door. The resident stated s/he got up from the electric scooter to try to plug it in. There was no documented evidence the facility developed fall interventions or monitored the service plan interventions for effectiveness.c. On 08/14/22, staff found Resident 3 on the floor near the end of his/her bed. The resident stated s/he was eating lunch at the end of the bed and attempted to transfer self to move the wheelchair. The resident reported hitting his/her head and was sent to the hospital via emergency medical services (EMS), then diagnosed with a "closed head injury."* A temporary service plan related to falls was developed 08/15/22 and instructed staff to encourage Resident 3 to eat in the dining room and staff to place meal trays on the table in his/her room and assist him/her to the table. A progress note dated 08/15/22 indicated the facility contacted Resident 3's family to request lowering the resident's bed.*There was no documented evidence the facility monitored the effectiveness of previous interventions for staff to assist with transfers and encourage the resident to use the call light prior to the fall on 08/14/22. d. On 08/22/22, staff found Resident 3 on the floor in his/her room after the resident tried to transfer from the couch to the electric scooter. No injury was noted. A temporary service plan was developed but did not include new fall prevention interventions, and there was no documented evidence previous interventions were monitored for effectiveness. e. On 09/04/22, staff found Resident 3 on the floor after s/he slipped out of bed. A temporary service plan was developed and instructed staff to ensure adequate lighting in the resident's room and ensure the light near the bathroom sink was on. There was no through investigation of the previous service-planned interventions for effectiveness, and the resident continued to fall.f. On 10/03/22, a home health staff member reported the resident had reported s/he fell on 09/30/22. No injury was noted when the facility evaluated the resident. The staff task record was updated with instructions for staff to provide safety checks four times per shift.g. On 10/14/2022, an incident reported noted Resident 3 "stated [s/he] fell twice" and staff noted a bruise on the right side of Resident 3's face. A progress note dated 10/15/22 noted the resident stated s/he fell twice and did not notify staff immediately. The resident stated s/he fell trying to walk from the bed to electric scooter and hit his/her face on the scooter and the second fall s/he was trying to walk to the electric scooter and fell on his/her tailbone. The facility called EMS who recommended further evaluation at the hospital, but the resident declined transport.There was no documented evidence the facility monitored the effectiveness of previous interventions for safety checks four times per shift, and the task record, dated 10/03/22 through 10/23/22, showed multiple days with inconsistent documentation.During an interview on 10/26/22, Staff 17 (CG) stated Resident 3 was supposed to have stand-by assistance from staff for most ADLs, but s/he never used the call light for assistance and staff checked on her multiple times a day.During an interview on 10/25/22, Resident 3 stated s/he was able to transfer self and get around walking in his/her room but "needed to be more careful, so [s/he] didn't fall". Resident 3 stated "the one time I fell, staff came right away when I pressed the call button for help."The facility failed to develop new fall prevention interventions and monitor previous interventions for effectiveness when Resident 3 experienced unwitnessed falls on 08/04/22 and 08/12/22. The resident experienced a third unwitnessed fall on 08/14/22, which resulted in a closed head injury. The resident continued to experience multiple unwitnessed falls, new fall interventions were not consistently developed and/or monitored for effectiveness, and on 10/14/22 the resident reported falls and sustained a bruise to his/her face and reported pain on his/her tail bone.The need to ensure short-term changes of condition were evaluated to determine resident-specific interventions and conditions were monitored, including the effectiveness of interventions, at least weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/25/22. They 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 were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed staff. Findings include, but are not limited to:Delegation records for Resident 3, reviewed on 10/25/22, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 11 (MT), Staff 20 (MT), and Staff 21 (MT) to include:* Nursing assessment and condition of the client to determine if the client's condition was stable and predictable;* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; * Frequency the client should be reassessed, including rationale; and* Re-evaluation of the condition of the resident and skill of the delegated staff within 60 days of initial delegation.The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 4 sampled residents (# 3) whose MARs and orders were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 08/2022, with a diagnosis of diabetes.Interviews with staff and review of Resident 3's physician orders and 10/01/22 through 10/24/22 MAR/TAR revealed the following orders were not carried out as prescribed:* An order for insulin detmir solution (for type 2 diabetes), inject 9 units at bedtime, was not administered on 10/01/22, 10/05/22, and 10/08/22; and* An order to check CBG two times per day was not carried out on 10/01/22, 10/05/22, and 10/08/22.The need ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters were included on the MAR and staff documented which non-pharmacological interventions were attempted without success prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (#6) who was prescribed and used PRN psychotropic medication. Findings include, but are not limited to:Resident 6 was admitted to the facility in 07/2022 with diagnoses including anxiety disorder.The resident's physician orders and 10/01/22 through 10/24/22 MAR and progress notes were reviewed. The following was identified:* The resident had a physician order for lorazepam (a psychotropic medication) as needed for anxiety, which had been administered 18 times between 10/01/22 and 10/24/22. There were no resident-specific parameters on the MAR indicating how the resident expressed anxiety.* Staff documented administration of PRN lorazepam in the resident's progress notes, but did not indicate what interventions had been attempted without success prior to administration of the PRN psychotropic.The need to have resident-specific parameters for PRN psychotropic medications on the MAR, as well as the need for staff to document which non-drug interventions were attempted without success prior to administration of a PRN psychotropic, was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment for each resident and update the ABST information when there was a significant change of condition for 2 of 4 sampled residents (#s 2 and 4). Findings include, but are not limited to:On 10/25/22, the Facilities ABST assessment was reviewed with Staff 1 (Administrator). She confirmed the ABST tool determined the facilities staffing plan. The ABST staffing hours recommended were reviewed and found equal to the number of staff listed on the staffing plan.Further review of the ABST tool and usage identified the following:a. The ABST tool showed 42 residents had information entered into the system, however the facility census was 45.Staff 1 and 4 (RCC) acknowledged the tool was incomplete, with three residents residing in the facility not entered into the ABST. Staff 4 completed entering of the ABST assessment information for the three missing residents prior to end of day on 10/25/22.b. The ABST information was reviewed during survey for four sampled residents. Resident 2 and 4's ABST information was determined to have entries which were inaccurate. Staff 4 acknowledged the inaccuracies and reported the tool had not been updated after the residents had a significant change of condition. Staff 4 updated the information for both residents on 10/25/22.Staff 1 ran the report after all the ABST information was complete and updated. She changed the staffing plan and schedule to increase staffing to include an additional care staff to both day and evening shifts as was indicated on the report. During the survey, there were no concerns of the facility having inadequate staff. The need to complete ABST information for all residents in the facility and update the information in the tool after significant changes of condition was reviewed with Staff 1 and Staff 4.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 13, 14, 15, and 16) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents and 2 of 2 long-term staff (#s 7 and 22) completed infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to:Staff training records were reviewed on 10/25/22 and revealed the following:1. There was no documented evidence Staff 13 (MT), Staff 14 (MT), Staff 15 (CG), or Staff 16 (CG), hired 08/02/22, 08/30/22, 08/30/22, and 09/19/22, respectively, completed one or more of the following required pre-service orientation elements prior to performing any job duties:* Resident rights and values of CBC care;* Abuse reporting requirements;* Infectious Disease Prevention;* Fire safety and emergency procedures; and* Written job description.2. There was no documented evidence Staff 13, Staff 14, Staff 15, or Staff 16 completed the one or more of the following dementia training topics prior to providing care to residents:* Techniques for understanding, communicating, and responding to behaviors and reducing the use of antipsychotics;* Strategies for addressing social needs and engaging them in meaningful activities; and* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and the use of the person-centered approach.3. There was no documented evidence Staff 7 (Marketing), hired 05/03/22, or Staff 22 (Director of Environmental Services), hired 08/26/02, completed infectious disease prevention training prior to 07/01/22.The need to ensure training is completed by newly hired and long-term staff within the required time frame was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 15, and 16) demonstrated competency in all assigned job duties within 30 days of hire, including first aid and abdominal thrust. Findings include, but are not limited to:Staff training records were reviewed on 10/25/22 and the following was identified:1. There was no documented evidence Staff 15 (CG), hired 08/30/22, or Staff 16 (CG), hired 09/19/22, demonstrated competency in the following areas within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Identification, documentation, and reporting of changes of condition;* Conditions which require assessment, treatment, observation, and reporting;* General food safety, serving, and sanitation; and* First Aid/abdominal thrust.The need to ensure newly hired employees demonstrated competency in all assigned job duties, and completed first aid and abdominal thrust training, within 30 days of hire was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure and document 4 of 4 long-term staff (#s 11, 12, 17, and 18) completed 12 hours of annual in-service training, including at least 6 hours related to dementia care. Findings include, but are not limited to:Staff training records were reviewed on 10/25/22 and revealed the following:There was no documented evidence Staff 11 (MT), Staff 12 (CG), Staff 17 (CG), or Staff 18 (CG), hired 06/21/19, 12/23/19, 03/11/05, and 07/01/03, respectively, completed at least 12 hours of training related to the provision of care in CBC, with a minimum of six hours of training on dementia care topics.The to ensure long-term staff completed the required number of hours of annual in-service training and document the training was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months and to document all required elements of fire drills required by the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records were reviewed on 10/25/22, and the following was identified:* There was no documented evidence staff were instructed on fire and life safety on alternate months from fire drills; and* Fire drill records did not include evidence drills were being conducted on all shifts or alternate escape routes were used during drills.The need to provide fire and life safety instruction to staff and document all required elements of fire drills as required by the OFC was discussed with Staff 1 (Administrator) and Staff 5 (Operations Director) on 10/26/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. Findings include, but are not limited to:Fire and life safety records were reviewed on 10/25/22.There was no documented evidence of a written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.The need to ensure residents were provided instruction as required by the Oregon Fire Code was discussed with Staff 1 (Administrator) on 10/26/22.