Applegate Place

Assisted Living Facility
1465 EAST CENTRAL, SUTHERLIN, OR 97479

Facility Information

Facility ID 70M022
Status Active
County Douglas
Licensed Beds 36
Phone 5414596300
Administrator REGAN TUCKER
Active Date Feb 1, 1997
Owner Sutherlin ALF, LLC
15900 SE 82ND DRIVE
CLACKAMAS OR 97015
Funding Medicaid
Services:

No special services listed

7
Total Surveys
29
Total Deficiencies
0
Abuse Violations
19
Licensing Violations
2
Notices

Violations

Licensing: 00252629-AP-208368
Licensing: 00174325-AP-138432
Licensing: RS174355
Licensing: CO16128
Licensing: RB133141
Licensing: RB132903
Licensing: RB121386
Licensing: RB118480
Licensing: CO11076
Licensing: CALMS - 00071829
Licensing: OR0005289700
Licensing: OR0004447100
Licensing: OR0004447101
Licensing: OR0004447103
Licensing: OR0004447104
Licensing: OR0004447106
Licensing: 00128752-AP-100376
Licensing: 00128758-AP-100384
Licensing: OR0002416400

Notices

OR0003993600: Failed to use an ABST
CO16128: Failed to provide medical treatment as ordered

Survey History

Survey KIT005247

1 Deficiencies
Date: 6/25/2025
Type: Kitchen

Citations: 1

Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
t Visit: 6/25/2025 | Not Corrected
1 Visit: 9/2/2025 | Not Corrected
Regulation:
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).
Inspection Findings:
Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner, and menu changes were made available to residents in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to:

Observation of the kitchen on 06/25/25 at 10:45 am through 1:30 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Interior of oven
* Grill/griddle
* Stove top
* Flooring between oven and table
* Open stainless steel tables
* Windowsill
* Plastic shelving
* Bulk food bin lids
* Metal shelf above stove
* Removable grill vents
* Drain under handwash sink
* Plastic bin holding cooking utensils/supplies

b. The following areas were found in need of repair:

* Large gap around ceiling vent.

c. Multiple items stored in reach in coolers were observed without open or prepared dates.

d. A package of sliced roast beef was observed open and exposed to potential contamination. A container of dry scalloped potatoes was observed stored open to potential contamination.

e. Silverware was noted to be preset and was not protected from potential contamination. A stack of paper plates was observed stored open to potential contamination. Multiple plastic condiment containers were noted stored uncovered/protected from potential contamination.

f. Facility did not have test strips available to validate concentration of sanitizer used for surface sanitation buckets, 3 compartment sinks and the chemical sanitizing dish machine.

g. Staff 2 (cook/person in charge) was observed to handle lettuce for salads and lemon wedges with bare hands therefor potentially contaminated ready to eat food products.

h. Staff 2 was observed to make salads for lunch meal and did not wash the lettuce prior to preparing the salad. The container/package of the romaine leaf lettuce was /package was reviewed and directed to wash before use.

i. Daily posted menu was noted to be from Tuesday June 17th. Staff 1 (Administrator) verified the menu should be posted daily and acknowledged the menu was not correct. The meal served for that day had a choice of Broccoli and Chicken bake. The kitchen staff prepared a Chicken and pea bake. The menu change was not communicated to residents prior to the meal as required.

j. Multiple dry good/bulk food bins were observed with scoops stored inside of the bins with the handles potentially contaminating the food products. Scoops were also observed stored outside of some bins with the food contact portion of the scoops open/uncovered allowing potential contamination of the food contact surfaces.

Surveyor reviewed above areas with Staff 2 who acknowledged the identified areas. At 1:00 pm the surveyor reviewed the areas in need of cleaning and poor practices with Staff 1 (administrator) who acknowledged the areas.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:
Plan of Correction:
(1)
a. Kitchen will receive a deep clean to remove all accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease including interior of oven, grill/griddle, stove top, flooring between oven and work table, open stainless steel tables, windowsill, bulk food bin lids, metal shelf above stove, removable grill vents, drain under handwash sink. Plastic shelving and plastic bin holding cooking utensils/supplies will be replaced with metal kitchen shelving and enclosed bins prior to date of alleged compliance. Cleaning checklist will be updated as appropriate to ensure these areas are accounted for with tasks designated as daily, twice weekly, weekly and twice monthly. Dietary Director and Administrator will monitor cleaning practices.
b. The large gap around ceiling vent was repaired immediately by adjusting the vent cover to cover the gap. Maintenance staff will monitor and, if necessary, will replace the vent cover.
c. All food will be labeled appropriately in the kitchen. Kitchen staff will check dates on prepared food and discard within appropriate timeframe. Unlabeled food was discarded immediately.
d. All food will be sealed/closed appropriately in the kitchen. Kitchen staff will ensure meat and other refrigerated items, and items stored in dry goods, will be sealed/closed to prevent potential contamination.
e. Silverware will no longer be pre-set in the dining room to prevent potential contamination. Additional silverware will be purchased so that there is enough quantity for three meal services daily and overnight staff will roll silverware within napkins to use in the dining room and tray service by date of alleged compliance. Paper plates that were used for staff only were removed from the kitchen immediately. Plastic condiment containers will be stored in containers with lids to prevent potential contamination.
f. Test strips were ordered immediately and are currently in use to test the surface sanitation buckets as well as the 3 compartment sinks. A daily log will be kept of test results and the Dietary Director or Administrator will monitor for compliance.
g. Cooks have been counseled about appropriate glove use for ready to eat items. Additional training related to food safety will be assigned and completed by date of alleged compliance.
h. Cooks have been counseled to wash ALL fresh produce prior to use. Additional training related to food safety will be assigned and completed by date of alleged compliance.
i. Daily menus will be posted and updated as required. Menu changes will be communicated to residents on a timely basis as required.
j. Dry/bulk bin scoop storage is in covered/enclosed containers to prevent potential contamination. Scoops will not be stored inside the food bins.

Survey BF8W

1 Deficiencies
Date: 10/23/2024
Type: Complaint Investig., Licensure Complaint

Citations: 1

Citation #1: C0303 - Systems: Treatment Orders

Visit History:
1 Visit: 10/23/2024 | Not Corrected

Survey XH2X

2 Deficiencies
Date: 6/25/2024
Type: State Licensure, Other

Citations: 3

Citation #1: C0000 - Comment

Visit History:
1 Visit: 6/25/2024 | Not Corrected
2 Visit: 10/18/2024 | Not Corrected
3 Visit: 1/2/2025 | Not Corrected
Inspection Findings:
The findings of the kitchen inspection, conducted 06/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the re-visit to the kitchen inspection of 06/25/24, conducted 10/17/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the second revisit to the kitchen inspection of 06/25/24, conducted 01/02/25, 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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
1 Visit: 6/25/2024 | Not Corrected
2 Visit: 10/18/2024 | Not Corrected
3 Visit: 1/2/2025 | Corrected: 11/29/2024
Inspection Findings:
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, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 06/25/24 at 11:30 am through 2:00 pm revealed the following deficiencies:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Ceiling vent as you enter the kitchen;* Interior of reach in freezer;* Industrial can opener and housing;* Interior of microwave;* Open shelving where pots/pans were stored;* Interior of ice machine; and* Open shelving under steam table/service line.b. The following areas were found in need of repair:* Open shelving under steam table with damage to shelves causing an uncleanable surfaces. Multiple areas were covered by a tin foil like substance that was peeling/cracked and had dirty/debris accumulation;* Section of caulking in dish machine area had black debris build up;* Multiple cabinets had white duct tape covering worn areas of cabinets that was also worn and created a non smooth surface.c. Surface area on tray line and countertops in prep area with scratches and heavy wear, multiple areas on counter tops with chipped or missing surfaces. Some areas covered by black duct tape.d. Multiple items stored in reach in coolers were not dated when opened. Multiple items did not have prepared or use by dates.e. Multiple drinks and all fruit cups were not covered for room tray delivery. f. Kitchen staff member preparing and/or serving food did not have hair effectively restrained as required. Multiple care staff assisting with serving/delivering food did not have on aprons to serve as a protective barrier between care giving tasks and meal service tasks. One caregiver did not have hair restrained while in kitchen serving residents fruit.g. White cutting board was noted to be heavily stained and scored. Multiple fry/saute pans were found heavily scored and/or heavy carbon/back debris along edges and cooking surfaces. h. Multiple sanitation cloths/rags were stored on counters and not in sanitation buckets.The surveyor reviewed above areas with Staff 2 (Dining Services Director) and they acknowledged the identified areas. At 1:45 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Executive Director) who acknowledged areas needing addressed.
Based on observation and interview, 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. This is a repeat citation. Findings include, but are not limited to:Observation of the kitchen on 10/17/24 at 1:45 am through 3:00 pm revealed the following:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Industrial can opener and housing;* Open shelving where pots/pans were stored; and* Open shelving under steam table/service line.b. The following areas were found in need of repair:* Open shelving under steam table with damage to shelves causing uncleanable surfaces. Multiple areas were covered by a tin foil like substance not meeting code requirements;* Section of caulking in dish machine area had black debris build up; and* Multiple cabinets had white duct tape covering worn areas of cabinets not meeting construction material requirements per code.c. Surface area on tray line and countertops in prep area with scratches and heavy wear.d. Multiple items stored in reach in coolers were not dated when opened. Multiple items did not have prepared or use by dates. Some items were passed 7 days from prepared date and were in need of discarding per rule.e. Bag of frozen chicken breasts were stored directly on top of ground meat causing potential for cross contamination from chicken drippings.f. Multiple food items in reach in coolers/freezers observed not covered/protected from potential contamination.At approximately 2:45 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Executive Director) who acknowledged the identified areas needing addressed.
Plan of Correction:
1.a.Kitchen will receive a deep clean to remove all accumulation of food spills, splatters, loose food, trash debris, dirt, dust, black matter and grease including ceiling vent, interior of reach in freezer, can opener, microwave, open shelving, ice machine and dish machine. b.All food will be labeled appropriately in the kitchen and any unlabeled food will be thrown away.b.Shelving & cabinets bids will be obtained to replace any damaged cabinets. Bids for replacement of counter tops will also be obtained if needed. Bids will be reviewed and work scheduled. The State will be notified when work is scheduled. c.Equipment will be inspected and any worn or damaged equipment replaced including cutting boards, pots and pans.d.Aprons and hair covering requirements were discussed with staff and and implemented immediately.e. Room tray sanitation requirements were reviewed by staff and implemented immediately.2.The weekly cleaning check list will be reviewed to ensure that it reflects any areas of violations. QAPI audits will be done to further assess cleanliness and compliance.3. All areas will be monitored daily, weekly and quarterly.4.Corrections will be completed & monitored by Dietary Director, Administrator, and Mainenance Director. 1. a.Kitchen will receive a deep clean to remove all accumulation of food spills, splatters, loose food, trash debris, dirt, dust, black matter and grease including industrial can opener and housing, and open shelving. b. Existing steam table and damaged work island have been scheduled for removal. Bid for tile flooring repair has been received and work will be scheduled to repair flooring once island is removed. Replacement steam table equipment and stainless steel work table have been ordered for delivery. The State will be notified when work is scheduled. Any damaged or discolored caulking will be repaired/cleaned and/or replaced as needed. c. Stainless steel work tables have been sourced to replace the worn countertops and cabinets. Equipment will be ordered once the work on the island is complete to minimize kitchen disruption. d. All food will be labeled appropriately in the kitchen. Kitchen staff will check dates on prepared food and discard within appropriate timeframe and no later than 7 days. Unlabeled food was discarded immediately. e. All food will be stored appropriately in the kitchen according to Food Sanitation Rules. Food stored improperly was discarded immediately. f. All food will be stored appropriately in the kitchen according to Food Sanitation Rules. Food stored improperly was discarded immediately.2.The cleaning check list will be reviewed routinely to ensure that tasks are being completed. QAPI audits will be done to further assess cleanliness and compliance.3. Kitchen staff have received training on use of the FoodKeeper App (FoodSafety.gov) to determine safe storage guidelines, and will be required to complete the 1-hour training class through Oregon Care Partners "Keeping Food Safe and Nourishing for Older Adults" that focuses on how to safely store, prepare, and serve food to reduce the risk of foodborne illnesses to residents living in community-based care.4. All areas will be monitored daily, weekly and quarterly.5.Corrections will be completed & monitored by Dietary Director, Administrator, and Maintenance Director.

Citation #3: C0455 - Inspections and Investigation: Insp Interval

Visit History:
2 Visit: 10/18/2024 | Not Corrected
3 Visit: 1/2/2025 | Corrected: 11/29/2024
Inspection Findings:
Based on interview and observation, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C240.
Plan of Correction:
Refer to C240

Survey QL1R

5 Deficiencies
Date: 10/4/2023
Type: Complaint Investig., Licensure Complaint

Citations: 6

Citation #1: C0010 - Licensing Complaint Investigation

Visit History:
1 Visit: 10/4/2023 | Not Corrected
Inspection Findings:
The findings of the on-site investigation, conducted 10/04/23 through 10/04/23, 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Citation #2: C0200 - Resident Rights and Protection - General

Visit History:
1 Visit: 10/4/2023 | Not Corrected
Inspection Findings:
The findings of the on-site investigation, conducted 10/04/23 through 10/04/23, 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Citation #3: C0231 - Reporting & Investigating Abuse-Other Action

Visit History:
1 Visit: 10/4/2023 | Not Corrected
Inspection Findings:
The findings of the on-site investigation, conducted 10/04/23 through 10/04/23, 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Citation #4: C0260 - Service Plan: General

Visit History:
1 Visit: 10/4/2023 | Not Corrected
Inspection Findings:
The findings of the on-site investigation, conducted 10/04/23 through 10/04/23, 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Citation #5: C0361 - Acuity-Based Staffing Tool

Visit History:
1 Visit: 10/4/2023 | Not Corrected
Inspection Findings:
The findings of the on-site investigation, conducted 10/04/23 through 10/04/23, 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Citation #6: C0370 - Staffing Requirements and Training – Pre-Serv

Visit History:
1 Visit: 10/4/2023 | Not Corrected
Inspection Findings:
The findings of the on-site investigation, conducted 10/04/23 through 10/04/23, 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Survey EMLO

1 Deficiencies
Date: 6/13/2023
Type: State Licensure, Other

Citations: 2

Citation #1: C0000 - Comment

Visit History:
1 Visit: 6/13/2023 | Not Corrected
2 Visit: 8/22/2023 | Not Corrected
Inspection Findings:
The findings of the kitchen inspection, conducted 6/13/23, 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 first revisit to the kitchen inspection of 06/13/23, conducted 08/22/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
1 Visit: 6/13/2023 | Not Corrected
2 Visit: 8/22/2023 | Corrected: 8/12/2023
Inspection Findings:
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, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to:Observation of the kitchen on 6/13/23 at 10:20 am through 1:15 pm revealed the following deficiencies:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* White racks in reach in coolers;* Flooring in corners, edges, between and under equipment;* Portable fryer and waffle maker;* Ceiling vents and fire sprinklers;* Interior of reach in fridges and freezers;* Industrial can opener and housing;* Sides of range and grill; * Interior of ovens;* Removable hood vents above range/grill;* Food processor base;* Industrial slicer;* Interior of microwave;* Juice and cocoa machine;* Interior of cabinets in beverage service area; and* Interior of reach in fridge and freezer in activities room.b. The following areas were found in need of repair:* Metal shelving in cabinet cooler with pealing/missing coating exposing rusted metal;* Caulking by beverage area counter tops, missing or contained dirt/debris build up.:* Caulking in ware washing area had large accumulation of black mold like substance;* Fire sprinkler by hood was corroded and had a large accumulation of dust/dirt and debris;* Several small holes/open areas observed in walls under dish area and where pipes or electrical conduit were located;* Open shelving under steam table with damage to shelves causing an un-cleanable surface.c. Surface area on tray line and countertops in prep area with scratches and heavy ware, multiple areas on counter tops with chipped or missing surfaces.d. Multiple items stored in reach in coolers were not dated or labeled. One container of beef roast was several days past it's use by date.e. Hand washing sink did not have a splash guard to protect service trays from potential splash contamination. f. Facility did not have test strips available to validate concentration of sanitizer used for surface sanitation buckets and 3 compartment sinks. Upon review of safety information it was determine the chemical they were using was not recommended for kitchen surface cleaning. This was verified by Eco Lab representative to Staff 1 (Administrator). Facility upon gaining this knowledge immediately removed chemical from kitchen and bleach dilution would be used for sanitation of surfaces.e. Staff was observed to handle raw meat and did not effectively clean hands before moving on to other tasks. Multiple kitchen staff were observed to handle dirty dishes and then move to clean dishes without cleaning or washing hands between tasks. f. Staff member preparing and/or serving food did not have hair effectively restrained as required. g. Staff food was found stored in reach in refrigerators where resident food was stored. h. Chicken was observed stored above ground beef in reach in refrigerator. i. Scoops were found stored in bulk food item bins.Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas. At 1:00 pm the surveyors reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Administrator). S/he acknowledged the areas.

Survey 1NVN

19 Deficiencies
Date: 3/28/2022
Type: Validation, State Licensure, Re-Licensure

Citations: 20

Citation #1: C0000 - Comment

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Not Corrected
4 Visit: 2/23/2023 | Not Corrected
Inspection Findings:
The findings of the re-licensure survey conducted 03/28/22 through 03/30/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the initial survey of 03/30/22, conducted 08/22/22 through 08/23/22, 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 second re-visit to the initial survey of 03/30/22, conducted 12/05/22 through 12/06/22, 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 third re-visit to the re-licensure survey of 03/30/22, conducted 02/22/23 through 02/23/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Citation #2: C0160 - Reasonable Precautions

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Corrected: 9/30/2022
Inspection Findings:
Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:During the survey, conducted 03/28/22 through 03/30/22, the followingobservations were made regarding the facility's implementation of infection control practices to address the COVID-19 pandemic:* During the survey the survey team as well as other visitors to the facility were asked to to screen themselves in;* Throughout the survey, multiple employees were observed within close proximity to others including residents without face masks, with face masks fitted improperly, and pulling face masks away from their mouths as they spoke. The survey team spoke with Staff 1 (Director) and other facility staff multiple times during the survey. Employees continued lack of wearing face masks while in close proximity to others including residents, face masks fitted improperly, and pulling face masks away from face when speaking.The need to ensure the facility implemented proper infection control practices to protect residents and staff from the COVID-19 virus was discussed on 03/30/22 with Staff 1 (Director), Staff 2 (Resident Care Coordinator) and Staff 3 (RN).

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to:On 08/22/22, Staff 2 (RN) was observed wearing a cloth face mask. The need to ensure all staff wear medical-grade, disposable face masks to prevent the spread of COVID-19 was discussed with Staff 2 on 08/22/22, and with Staff 12 (ED/Administrator) on 08/23/22. They acknowledged the findings. Staff 2 donned a disposable mask immediately after the discussion on 08/22/22.
Plan of Correction:
OAR 411-054-0025 (4) Reasonable Precautions1. Staff will be provided with documented training on infection control. Including Covid-19, the wearing of face masks. 2.Staff will be trained on infection control and standard precautions during orientation. 3. This area will be evaluated during orientation period and monthly staff meetings4. The Administrator/licenced community nurse and the resident coordinator will ensure the corrections completed and then monitored daily. C160-OAR 411-054-0025 (4) Reasonable precautions 1.Staff will be provided with documented training on the requirements of The Oregon Health Authority of wearing masks in long term care settings. They will also will receive training to know the difference between "Face Coverings" and "surgical grade masks"2.This will be monitored daily by the Med Tech at the start of every shift during shift change. Any deviation from the rule will be corrected immediately. Surgical grade masks are provided to staff.3.This will be evaluated daily by Med Tech on duty, Resident Care Coordinator, Administrative Assistant. The Resident Care Coordinator and Executive Director will ensure compliance.

Citation #3: C0231 - Reporting & Investigating Abuse-Other Action

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to investigate all injuries of unknown cause in order to rule out suspected abuse or neglect for 1 of 1 sampled resident (#1), who experienced an injury of unknown cause. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2021. Clinical records were reviewed and revealed the resident experienced an injury of unknown cause.A progress note dated 02/23/22 stated the following:* "Resident requested diclofenac gel to the left ankle. Resident reports s/he is not sure what happened to cause it to hurt. Left ankle has some bruising but resident reports s/he does not know what happened."; and* " ...Resident visited by Mercy Home Health...also reports resident [complains of] new left foot pain and occasional numbness and tingling radiating up his/her leg." In an interview with the resident on 03/30/22, s/he stated their left ankle had been injured and bruised, but could not recall how the injury occurred. In an interview with Staff 1 (Director) on 03/29/22, she confirmed the incident was not investigated to rule out abuse and neglect.The facility lacked documented evidence the incident was thoroughly investigated to rule out abuse or neglect of care as a contributor to the resident's injury.The need to ensure injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1, Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/30/22.
Plan of Correction:
OAR411-054-0028 (1-3) Abuse Reporting and Investigation1. All incident reports will be reported in a written format usiing the accident and reporting form.2. All staff will be provided with training on accident and reporting and complete the State appoved Relias Training.All incidents will will be comprehensively investigated in a timely manor.Whn cannot be ruled out, or for injuries of unknowen orgin, DHS abuse neglect reporting requirements will be followed.3. All incidents will be reviewed daily during standup and clinical meetings. During the daily drill-down review,all incidents will be verified to confirm: a)Investigation is comomprehensive, b)Notifications are made, c)self reporting ruled out or self report is completed,d) Interventions or remediesare implemented to reduce reoccurrence or severity of injury.The Administrator or designee will review and finalize the completed incident report. The Administrator on record will review and confirm all components of the investigatory process haave occurred and the investigation was doumented timely. 4. The Administrator and/or designee will be responsible to ensure the corrections are completed/monitored

Citation #4: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 9/8/2022
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The facility kitchen was observed on 03/28/22 and 03/29/22 and the following was noted:a. Peeling or missing paint on or inside the following:* Seven shelf cabinets;* Lower cabinets throughout the kitchen; and*Wall behind the prep sink.b. The following areas were in need of cleaning:* Entryway door frame had dirt and black matter on it's surface;* Wall between the entryway door and the hand washing sink had dark matter on it;* The oven hood had a thick layer of grease on it's surface; and* The tile floor throughout the kitchen was sticky and the grout had a dark substance on it.c. The following equipment were in need of repair:* The thermostat attached to the ware washer was not working properly; and* The three door refrigeration unit was not keeping food to the minimum required temperature of 41 degrees. On 03/29/22 at 3:25 pm a jar of mayonnaise in the cooler was tested. The temperature of the mayonnaise was 55 degrees. The facility was then asked to discard the protein based foods in the unit. The need to ensure the kitchen was clean, in good repair and in accordance with Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Director) on 03/30/22. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:A tour of the facility kitchen, on 08/22/22, revealed the shelves and cabinets throughout the kitchen which were identified to have peeling or missing paint on the 03/28/22 through 03/30/22 survey had been covered with vinyl tape which had peeled, or was peeling off. The need to ensure the kitchen is maintained in good repair was discussed with Staff 4 (Lead Cook) and Staff 12 (ED/Administrator) on 08/22/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0030 (1)(a)1.(a)Kitchen cabinets/shelves throughout the kitchen will be painted to include behind the prep sink to ensure all cleanable surfaces. ( b)A deep clean of the kitchen will be completed to include wall between the entry door and the hand washing sink, the oven hood and floor tile(c)Warewasher will be serviced for repair or replacement of thermostat. Temperture will be monitored and logged with each use and then daily.The the refrigeration unit has been fixed and being monitored and logged daily. 3.The cleaning schedule will be reviewed daily, then weekly and monthly to identify any challenges or concerns and completion of duties.Maintenance Director will do a walk through using an maintenace audit tool to indentify and repair any areas of concern, including painting of walls and cabinets. 4.The administrator or designee, Dietary Manager and maintenance Director will be responsible to see that the corrections are completed/monitored.

Citation #5: C0252 - Resident Move-In and Eval: Res Evaluation

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Corrected: 9/30/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure evaluations were updated within 30 days of move-in and quarterly evaluations were completed timely and were reflective of the residents' current needs for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 01/2022. The resident's most recent evaluation was requested on 03/28/22. There was no documented evidence Resident 4's initial evaluation dated 01/14/22 was updated and modified as needed during the 30 days following the resident's move into the facility. 2. Resident 5 was admitted to the facility in 01/2020. The resident's most recent quarterly evaluation was requested on 03/28/22, 03/29/22 and 03/30/22. The resident's quarterly evaluation was not in the resident's chart nor was it available to the survey team during the survey. During the exit interview on 03/30/22, Staff 1 (Director) stated Resident 5's quarterly evaluation had been completed and provided a copy of an evaluation dated 02/07/22. A review of the evaluation found it was not reflective of the resident's current health status or care needs in the following areas: * Resident's irregular sleeping pattern and sleeping in wheelchair;* Recent emergency room visit due to a fall with injury;* Six falls between 12/28/21 through 03/27/2022;* Increase in ADL assistance;* Multiple medication changes; and* Resident's increase in behaviors and confusion. The need to ensure 30 day and quarterly evaluations were completed timely and reflective of the residents' current status was discussed with Staff 1 (Director), Staff 2 (RN), Staff 3 (Resident Care Coordinator) and Staff 11(Director of Operations) on 03/30/22.
4. Resident 1 was admitted to the facility on 10/18/21. Documentation of the resident's 30 day evaluation and quarterly evaluation were requested by the survey team on 03/28/22 and 03/29/22.During the exit interview Staff 1 (Director) stated Resident 1's quarterly evaluation had been completed and provided a copy of an evaluation dated 01/17/22.A review of the evaluation found it was not reflective of the resident's health status and needs at the time of the evaluation in the following areas:* Recent hospitalization;* Oxygen use;* Falls; and* PT and OT services. The need to ensure residents were re-evaluated within 30 days of move-in and quarterly was discussed with Staff 1, Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/30/22. 5. Resident 3 was admitted to the facility in 11/02/21. The initial evaluation was labeled as such however was dated 12/02/21.Documentation the residents evaluation had been updated with changes within 30 days of move -in and quarterly was requested by the survey team on 03/28/22 and 03/29/22. In an interview with Staff 3 (Resident Care Coordinator) on 03/29/22 at 3:47 pm, she confirmed the facility could not produce the evaluations.During the exit interview Staff 1 (Director) stated the 30 day re-evaluation and the quarterly evaluation had been completed and provided a copy of the quarterly evaluation dated 01/31/22.A review of the evaluation dated 12/02/21 found it was identical to the initial evaluation provided to the survey team on 03/28/22.The facility lacked documented evidence Resident 3's initial evaluation was updated with changes within 30 days of move into the facility.A review of the quarterly evaluation found it was not reflective of the resident's recent falls. The need to ensure resident evaluations were updated within 30 days of move-in and quarterly was discussed with Staff 1, Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/30/22.
Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 1 of 1 sampled resident (#6) whose facility record was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 08/2022 with diagnoses including COPD. Review of the resident's new move-in evaluation revealed the facility failed to address the following required elements: * Visits to health practioners, ER, hospital or NF in the past year;* History of treatment and effective non-drug interventions for mental health; and* Nutrition habits and fluid preferences, The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 12 (ED/Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0034 (2-4) Resident Move-in and Eval: Res Evaluation1. Residents' 3, 4 and 5 are being updated to reflect resident's current health status, care needs, including any recent fall.2.All resident evaluations will be reviewed to ensure all required componets are reflective of his/her needs.3. Upon admission of new resident, quarterly and/or with a significant change of condition4. The Administrator/licensed nurse and Resident Care coordinator will be responsible to ensure the system has been correctedC252-Resident Move-in and Eval1.Resident # 6's evaluation will be updated to include the following componants;Visits to health practioners, ER, hospital or NF in the past year. History of treatment and effective non-drug interventions for mental health, nutritional habits and fluid preferences. 2.The RN will participate and sign off on all initial, quarterly and change of condition evaluations.3. This will be reviewed upon move-in, during quarterly updates or when any change of conditions occcur.4. RN, Resident Care Coordinator and Executive Director or designee will ensure compliance.

Citation #6: C0260 - Service Plan: General

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed upon move-in, with updates and changes as appropriate within the first 30 days, updated quarterly, and service plans were reflective of residents' current health status and care needs for 3 of 4 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 01/2022. On 03/28/22 through 03/30/22, Resident 4's most recent service plan was requested. There was no documented evidence the facility had completed an initial service plan or a 30-day service plan update. 2. Resident 5 moved to the facility in 01/2020. On 03/28/22, Resident 5's most recent service plan was requested. The service plan available to staff and the survey team was dated 11/08/21 and indicated it was not updated quarterly as required. Observations, interviews, and review of the service plan revealed the service plan was not reflective of the resident's status and care needs and did not provide clear directions to staff in the following areas: * Sleep disturbances.* Current level of orientation;* Toileting needs and incontinent care;* Recent falls and interventions; * Two persons transfer assist with gait belt;* Use of side rails and hospital bed; and* Use of spill-proof cup with all beverages. The need to ensure service plans were completed upon move-in, updated as required, reflective of the resident's status and care needs, and provided clear directions to staff was discussed Staff 1 (Director), Staff 2 (RN), and Staff 3 (Resident Care Coordinator) on 03/30/22. They acknowledged the findings.
3. Resident 1 was admitted to the facility in 10/2021. Resident 1's service plan dated 10/19/21 was reviewed and indicated it was not updated quarterly as required and was not reflective of the resident's needs and lacked clear direction to staff in the following areas: * Assistive devices for hearing and vision;* Dental status and care needs;* Pet status and care needs; and * Side rails including risks and safety information.The need to ensure service plans were reflective of resident's needs, provided clear instruction to staff and were updated quarterly was discussed with Staff 1 (Director), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/30/22. They acknowledged the findings.4. Resident 3 was admitted to the facility on 11/02/2021.The resident's record was reviewed and indicated the service plan was last reviewed on 11/02/21 and not quarterly as required. In an 03/29/22 interview with Staff 3 (Resident Care Coordinator), she confirmed the service plan had not been updated quarterly. The need to ensure service plans were reflective of resident's needs, provided clear instruction to staff and were updated quarterly was discussed with Staff 1 (Director), Staff 2 (RN), and Staff 3 (Resident Care Coordinator) on 03/30/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0036 1-4 Service Plan: General1).Service Plans for resident's 4 & 5 are under review to include to reflect the resident's needs & preferences, including, sleep disturbances, current level of orientation, toileting needs and incontinent care, recent falls and interventions, two person transferassist with gait belt, use of side rails and hospital bed and use of spill proof cup with all beverages.2). All resident service plans are currently under review to assure accuracy and personalization. Temporary service plans are available for use to notify all staff of changes as those changes occur.3). Resident service plans are reviewed and revised quarterly and more often as needed.4). Comliance is assured by the Resident Care Coordinator, Licensed Nurse and Executive Director

Citation #7: C0270 - Change of Condition and Monitoring

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on record review and interview, it was determined the facility failed to ensure short-term changes of condition were monitored and progress documented at least weekly through resolution, and the effectiveness of interventions was monitored for 3 of 4 sampled residents (#s 1, 3 and 5) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2020 with diagnoses including left hemiparesis and ménière's disease (inner ear disorder). The service plan noted the resident had a history of falls and an unstable gait and was a two-person assist with a gait belt when ambulating. The service plan directed staff to monitor and notify the RN of increased weakness or any other ambulation and mobility concerns and to remind and encourage the resident to call for transfer and ambulation assistance. Progress notes, temporary service plans, and incident reports reviewed from 12/28/21 through 3/27/22 noted six incidents when the resident was either guided to the floor or found on the floor. The pattern of falls was not reviewed, and the facility failed to consistently review service-planned interventions following each fall to determine if they were being provided and were effective or whether additional interventions were needed.The need to monitor the effectiveness of interventions for changes of condition was discussed with Staff 1 (Director), Staff 2 (RN) and Staff 3 (Resident care Coordinator) on 03/30/22. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 10/2021. The resident's 12/28/21 through 03/28/22 clinical records were reviewed and revealed the resident experienced the following changes of condition: * 01/12/22 Return from hospital after COVID-19 diagnosis.* 01/12/22 Medication changes, including new order for oxygen;* 01/12/22 Bruises to lower buttocks and thighs;* 01/31/22 Fall;* 02/02/22 Fall;* 02/07/22 Fall, bruises on arm; and* New medication order for preservision (eye health).The facility lacked documented evidence interventions were determined, documented, communicated to staff and the conditions monitored and noted at least weekly through resolution.The need to ensure all changes of condition were evaluated with interventions determined, documented, communicated to staff on all shifts and conditions monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Director), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/30/22. They acknowledged the findings.3. Resident 3 was admitted to the facility in 11/2021. The resident's 12/28/21 through 03/28/21 clinical records were reviewed and revealed the resident experienced the following changes of condition: * 01/18/22 Fall out of rocking chair, skin irritation;* 02/15/22 Fall, bruises to forehead;* 02/25/22 Confusion;* 03/03/22 Rash to chest and abdomen, new medication order for nystatin cream (fungal infections);* 03/10/22 New medication order for alprazolam (anxiety);* 03/21/22 Fall out of bed; and* 03/21/22 Fall out of bed.The facility lacked documented evidence interventions were determined, documented, communicated to staff and the conditions monitored and noted at least weekly through resolution.The need to ensure all changes of condition were evaluated with interventions determined, documented, communicated to staff on all shifts and conditions monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Director), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/30/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0040 (1-2)1). A Fall risk review is being completed for resident #5 by the Licensed Nurse. New fall interventions wil be put into place if other interventions are deemed non-effective. New interventions will be monitored, reviewed and noted for effectiveness. Service Plan under review for resients # 1 & # 3 for any changes that may need updated with clear instructions for the staff.2. Staff will receive in-servicing specific to monitoring for short term change of condition and significant change of condition. If warranted the resident will be placed on the alert log with all supporting components being completed including, interventions and documentation of effectiveness of interventions.The Registered Nurse will utilize the Significant Change of Condition Log to direct who requires a weekly nursing assessment until the resident is back to their baseline health status or a new baseline is established.The registered nurse will update the service plan based on the nursing assessment to ensure staff are notified of the residents current needs. Staff will monitor the residents status until the resident condition resolves and they are back to their baseline. 24 houOAr book/process will be reviewed daily during stand- up/ clinical3). The system will be reviewed daily in clinical review to ensure compliance is maintained.4). The Executive Director or designee Licensed Nurse, Resident Care Coordinator will be responsible to ensure the correctionsare completed/monitored.

Citation #8: C0282 - Rn Delegation and Teaching

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Corrected: 9/30/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (# 1) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview, Resident 3 was identified to have received assistance with insulin injections via pre-filled insulin pen by non-licensed staff. Review of the residents delegation records and 03/2022 MARs were reviewed on 03/30/22 and revealed the following:Resident 3 had a physician's order for sliding scale insulin injections three times a day and scheduled insulin injections once a day.Staff 3, Staff 7 and Staff 2 (MTs) were responsible for storing the insulin pens, testing and recording the resident's CBGs, following the physician's orders for the sliding scale, unlocking the insulin pen, adjusting the dial to the correct dose and handing the pen to the resident. The staff were then responsible for observing the resident as s/he injected the medication and for observing the resident for changes and reporting those changes to the RN. Staff 3, Staff 7 and Staff 12 were required to be delegated and supervised by an RN to perform these tasks.On 03/29/22 delegation records for staff assisting Resident 3 with insulin injections were requested.There was no documented evidence Staff 3, Staff 7 and Staff 12 were delegated to perform special nursing tasks for the resident. Staff 3, Staff 7 and Staff 12 assisted the resident with insulin injections from 03/01/22 through 03/28/22, without a current evaluation of skills by the delegating RN. When requested, no additional documentation could be located. In a 03/30/22 interview with Staff 12 (Regional Director), she acknowledged the staff were not delegated to perform the tasks for the resident. Staff 2 (RN) was present at the facility to administer the next scheduled dose of insulin for Resident 1. A document detailing the delegation plan for Staff 3, Staff 7 and Staff 12 was provided prior to survey exit. The facility RN would be available to administer insulin injections until the delegations were completed.The need to ensure all staff who administered insulin injections were delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Director) and Staff 2. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#8) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:During the acuity interview on 08/22/22, Resident 8 was identified to be administered insulin injections by non-licensed staff.The delegation records for Staff 3, 9, and 13 (MAs) were reviewed on 08/23/22. The following deficiencies were identified: a. Re-delegation of Staff 9 was not completed within 30 days, the time frame identified by the RN on the initial delegation, In addition, re-delegation for Staff 3 and 13 were not completed within 60 days of the initial delegation. b. Re-delegation records lacked documentation of the following:* An RN assessment of the resident's condition to determine if the resident's condition remained stable and predictable;* Individual observation/return demonstration of competence of the CG to determine if the CG remains capable and willing to safely perform the task;* Rationale for how frequently the client should be reassessed by the RN; and* Rationale for how frequently the unlicensed person(s) should be supervised and re-evaluated based on the competency of the caregiver. c. Multiple documents had dates that were crossed out without explanation or initials. The need to ensure all non-licensed staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN), Staff 3 (RCC), Staff 11 (Operations Director) and Staff 12 (ED/Administrator) on 08/23/22. Staff 2 acknowledged she had not documented all Division 47 delegation components. No further information was provided.
Plan of Correction:
OAR 411-054-0045 (1) (f)(B) RN Delegation and Teaching.1.Registered nurse completed delegations for all staff All required documentation components including, self medication assessment, skills abilities and willingness of the unlicensed staff to complete the task; that they were competent to preform task, that they understood that the task was client specific and not tranferable;rational for why the task is being delegated. 2.Residents that require nursing duties will be assessed by the facilty RN to determine if the resident is stable and predictable to receive delegation of the task to unlicensed staff. 3.The system will be be reviewed daily/weekly and quarterly to ensure compliance is maintained.4. The registered Nurse, Executive Director will be responsible to ensure compliance. C282-RN Delegation and Teaching 1.All insulin dependent diabetics will be reassessed for their stability and predictability by an RN establishing a baseline for each resident. All new diabetics will be assessed for their stability and predictablity.2.All Med Techs's will be re-delegated for the tasks of CBG monitoring and insulin administration using the standardized forms. They will be re-evaluated at detemined intervals for compliance. All new Med Techs will be delegated using the standarized forms to ensure that the initial delegation is documented and that they are re-evaluated at the time line set forth by the delegating RN.3. Delegation process will be audited by RN routinely on a weekly basis for compliance.4.Findings of these audits will be reviewed by the communities QA program for compliance. The RN will be responsible for this process.

Citation #9: C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to updated the resident's service plan as necessary and to inform staff of new interventions recommended by on-site health service providers for 1 of 1 sampled resident (#1). Findings include, but are not limited to:Resident 1 was re-admitted to the facility from the hospital on 01/12/22 after experiencing COVID-19.The resident's 12/28/21 through 03/28/22 progress notes, 01/27/22 "On and Offsite Provider" notes, 10/19/21 service plan and Temporary Service Plans (TSP's) were reviewed. The records indicated Resident 1 received home health services from an outside provider for occupational and physical therapies. Review of the On and Offsite Provider forms indicated home health providers left the following instructions for the facility:* 01/17/11 "Please ensure the potty pad for [patient's] dog is placed along the shower and not in [patient's] walking path to the toilet and sink"; and* 02/02/22 "Recommend [patient] have [stand by assistance] for toileting, for safety during transfers, hygiene and clothing management."There was no documented evidence the facility updated the resident's service plan with those instructions or communicated the new instructions to staff.The failure to update the service plan and communicate instructions to staff was discussed with Staff 1 (Director), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/20/22. They acknowledge the findings.
Plan of Correction:
OAR 411-054-0045 (2) Res Hlth Srvc: On and Off site Health Srvs1.Resident # 1 has returned to independent with dressing and toileting. Dog care service plan has been corrected.Staff have received training wiith reviewing, documenting and following through with off site/On site provider notes. This has been added as part of the triple check process.2. Triple check process. Staff will review, put TSP in place as instruction by provider, monitored and documentation will follow.3.This will be reviewed during daily clinical meetings.4. The Executive Director or designee Licensed Nurse, Resident Care Coordinator will be responsible to ensure the correctionsare completed/monitored.

Citation #10: C0303 - Systems: Treatment Orders

Visit History:
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Not Corrected
4 Visit: 2/23/2023 | Corrected: 1/5/2023
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled residents (#8) whose orders were reviewed. Findings include, but are not limited to:Resident 8 was admitted to the facility in 07/2021 with diagnoses including insulin dependent diabetes. Review of the 08/10/22 physician orders and the 08/01/22 through 08/22/22 MAR revealed the following: The physician orders instructed facility staff to administer insulin based on a sliding scale that corresponded with the resident's blood glucose levels. Per the sliding scale, the resident should have been administered 1 unit of insulin on 08/01/22 during the 7 am medication pass. There was no documented evidence the facility administered the insulin. On 08/12/22, based on Resident 8's blood glucose levels, the physician order instructed staff to administer 3 units of insulin at 4 pm. Documentation of the MAR indicated the resident was administered 4 units. On 08/21/22, based on Resident 8's blood glucose levels, the physician order instructed staff to administer 5 units of insulin at 4 pm. Documentation on the MAR indicated the resident was administered 10 units. The need to ensure physician orders were carried out as prescribed was discussed with Staff 12 (ED/Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled resident (#11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 11 was admitted to the facility in 09/2020 with diagnoses including Addison's Disease. Review of the resident's current physician orders and 11/01/22 through 12/04/22 MAR revealed the following: *Odansetron and promethazine were both prescribed to be administered twice daily PRN for nausea. The resident was administered both medications three times on 11/22/22, 11/24/22, 11/28/2022, and 11/30/22;*Instructions for the administration of PRN odansetron for nausea indicated the medication should not be administered for at least four hours after promethazine. Promethazine and odansetron were administered at the same time on 28 occasions in November, and on six occasions in December; and*Loperimide, ordered PRN for loose stools/diarrhea, was administered on 11/30/22 for "gas."The failure to ensure physician orders were carried out as written was discussed with Staff 12 (ED/Administrator) and Staff 19 (RN) on 12/06/22. They acknowledged the findings.
Plan of Correction:
C303-Systems Treatment Orders1.Med Techs will receive documented training on reading and following physician orders as they are written, including sliding scale insulin.2.This will be monitored for accuracy during clinical 24 hour book review and MAR monitoring. 3. Daily clinical meetings M-F with the health service team.4. Resident Care coordinator and Licensed nurse will monitor, train and ensure compliance.C303-Systems Treatment Orders1.Med Techs will receive documented training on reading and following physician orders as well as parameters.2.This will be monitored for accuracy during clinical 24-hour book review and MAR monitoring. 3. Daily clinical meetings M-F, weekly and quarterly with the health service team.4. Resident Care Coordinator and Registered Nurse will monitor, train and ensure compliance.

Citation #11: C0310 - Systems: Medication Administration

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Not Corrected
4 Visit: 2/23/2023 | Corrected: 1/5/2023
Inspection Findings:
Resident 3 was admitted to the facility in 2021 with diagnoses including diabetes. The resident's 03/01/22 through 03/28/22 MARs and physicians orders dated 03/22/22 were reviewed and revealed the following:* There were blanks 03/01/22 through 03/06/22 for the 7:00 am CBG data with no explanation of what the reading was; and* The was no documentation noting the amount of insulin given for the 7:00 am, 11:00 am or 4:00 pm doses of Novolog Flexpen insulin 03/04/22 through 03/27/22; and* There were blanks on 17 occasions between 03/04/22 and 03/28/22 for CBG data with no explanation of what the reading was. The need to ensure MARS were accurate and included the initials of the person administering the medication or tracking the required information was discussed with Staff 1 (Director) and Staff 2 (RN) and Staff 3 (Residential Care Coordinator) 03/04/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate and provided clear instruction and parameters for administration of PRN medications for 2 of 4 sampled residents (#s 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:Resident 5 was admitted to the facility in 1/2020 with diagnoses including pruritus (itching) of the skin. The resident's physician orders and 03/01/22 through 03/28/22 MARs were reviewed, and the following was identified: The resident had three PRN topical medications, hydrocortisone (anti-itch) cream, ketoconazole (antifungal) cream, and nystatin (antifungal) powder.Resident 5's 03/01/22 through 03/28/22 MAR lacked documented evidence the PRN creams and powder were being administered; however, interviews with the staff revealed these PRN creams and powder were being applied to the resident daily, but staff were not documenting the treatments on the MAR or anywhere else. The need to ensure staff signed their initials when treatment was administered on the MAR was discussed with Staff 3 (Residential Care Coordinator) on 03/30/22. She acknowledged the findings.
3. Resident 6 was admitted to the facility in 08/2022 with diagnoses including COPD. Review of the resident's current signed physician orders and the 08/01/22 through 08/22/22 MAR revealed the following: * Physician orders for PRN pain medications, including oral acetaminophen, acetaminophen suppository, morphine sulfate and oxycodone, were listed on the MAR. There were no parameters identified which instructed staff the sequence in which to administer the medications.* The MAR indicated scheduled topical fentanyl patches (for pain) were placed on the resident's skin on 08/14/22, 08/17/22, and 08/20/22, but did not identify the site of placement. * The resident had a PRN order for Naloxone Nasal Spray (opiod overdose treatment). There were no instructions to staff which identified the signs and symptoms of an overdose. * Instructions on the MAR for the administration of diltiazem (A-fib) included holding the medication if the resident's blood pressure was outside the listed parameters. On 08/13/22, 08/14/22, and 08/15/22, the medication was noted to have been administered, but there were blanks where staff were to have recorded the resident's blood pressure. The need to ensure the MAR was accurate and included clear instruction to staff was discussed with Staff 12 (ED/Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 11 (Regional Operations Director) on 08/23/22. They acknowledged the findings. 4. Resident 8 was admitted to the facility in 07/2021 with diagnoses including insulin-dependent diabetes. Current physician orders instructed staff to administer insulin based on a sliding scale which corresponded to the resident's blood glucose levels. Review of 08/01/22 through 08/22/22 MAR revealed staff were to document the site of administration, the number of insulin units needed and the number of insulin units given. The site of administration and the number of insulin units given were left blank on 08/05/22 and 08/18/22 for the 7 am medication pass.The need to ensure the MAR was accurate and included clear instruction to staff was discussed with Staff 12 (ED/Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 11 (Regional Operations Director) on 08/23/22. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 4 of 4 sampled residents (#s 6, 7, 8, and 9). This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 03/2021 with diagnoses including glaucoma and chronic constipation. A review of the resident's 08/01/22 through 08/22/22 MAR and current physician orders identified the following:* The resident was prescribed polyethylene glycol for constipation, along with three additional bowel medications. There were no parameters for when staff should administer the polyethylene glycol;* The resident had a physician's order for Imprimis (eye drops for glaucoma), but this was not on the MAR; and* An order for cyanocobalamin injections (Vitamin B-12) indicated it should be injected every 30 days starting 03/20/21. The MAR indicated a prescription for Vitamin B-12 was written on 04/13/22. Review of the current MAR (08/01/22 through 08/22/22) revealed the medication had not been administered.In interviews with Staff 2 (RN) on 08/23/22, she verified there were no parameters for the polyethylene glycol. She indicated she had a note on her desk the Vitamin B-12 injection had been administered on 08/15/22, but it had not been entered on the MAR. She stated the next injection was scheduled for 09/14/22. On the same date, Staff 3 (RCC) reported she had added the eye drops to Resident 7's MAR on 08/22/22.The need for the MAR to be accurate was discussed with Staff 12 (ED/Administrator) and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.2. Resident 9 was admitted to the facility in 01/2022 with diagnoses including anxiety. A review of the resident's 08/01/22 through 08/22/22 MAR revealed the following:* There were no parameters for docusate sodium 100 mg capsule (for constipation). The resident was prescribed two additional medications for constipation, and there was no direction to staff regarding when to administer docusate sodium.The need for the MAR to be accurate was discussed with Staff 12 (ED/Administrator) and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 2 sampled residents (#s 11 and 12) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 11 was admitted to the facility in 09/2020 with diagnoses including Addison's Disease. Review of the resident's 11/01/22 through 12/04/22 MAR and 09/07/22 signed physician orders revealed the following: PRN Oxycodone and Acetaminophen were both prescribed for pain. The MAR lacked instruction to unlicensed staff regarding which medication to administer first. A PRN Epinephrine pen was prescribed by the physician to treat an allergic reaction. The instructions on the MAR directed staff to "use as directed", but lacked further resident specific information or instruction to staff. *Alprazolam, ordered twice daily for anxiety, lacked instruction to staff regarding how far apart the doses could be administered.The need to ensure the MAR was accurate, included parameters and resident specific instructions for the administration of PRN medications was discussed with Staff 12 (ED/Administrator) and Staff 19 (RN) on 12/06/22. They acknowledged the findings. 2. Resident 12 was admitted in 09/2020 with diagnoses including asthma. The resident's current physician orders and 11/01/22 through 12/04/22 MAR were reviewed. Resident 12's physician orders indicated the resident was to be administered albuterol sulfate via nebulizer PRN for asthma. There were no resident specific instructions on the MAR as to the signs and symptoms which would necessitate administration of the medication. The need to ensure the MAR was accurate, included parameters and resident specific instructions for the administration of PRN medications was discussed with Staff 12 (ED/Administrator) and Staff 19 (RN) on 12/06/22. They acknowledged the findings.
Plan of Correction:
1.MAR has been reviewed it has been determined that two of the creams are no longer being used and a request to discontinue has been sent to the Resident #5's PCP. Staff have been retrained to document when providing treatments.2.All staff involved in the management of medications and treatments will receive additional training regarding accuracy, documentation requirements, improved overall communicatio, Medication Administration/ Treatment administartion records will be randomly reviewed by The resident Care Coordinator to identify errors in documentation or lack there of.3.Any errors or holes in Mars will be reviewed timely with the employee and will be reviewed, in depth, at least quarterly via quality iimprovement program for patterns and the need for additional training. 4.Compliance is assured by Resident Care Coordinator, Licensed Nurse/Executive Director.C310-Medication Administration1.Resident #7 MAR has been corrected to include parameters for bowel medications and order for eye drops has been added to the MAR. History of pharmacy orders for B-12 injection was given but not documented, this has been corrected in the MAR.Resident #9 MAR has been corrected to reflect parameters of order to be given for prescribed bowel medications.Resident #6 under review with hospice to determine effectiveness of pain medications. Parameters will be written on new order by hospice. Hospice will include training for staff of signs and symptoms of overdose and will provide instructions on administering Naloxone. Nurse consultant will be coordinating with hospice and providing additional training staff. Resident #6 MAR has been corrected with Fentanyl patch site placement. Resident #8 The Med Tech will receive documented training by Licensed nurse on sliding scale insulin.2. Ongoing documented training for all med techs.3. The Mar will be evaluated daily M-F during clinical meetings and during shift change. 4. RCC and RN responsible for ensuring compliance.C310-Medication Administration1. Resident #11 MAR has been corrected to include: order of administration for Oxycodone and Acetaminophen, detailed instructions for Epinephrine pen, and parameters for Alprazolam. Resident #12's MAR has been updated to include: resident specific instructions with signs/symptoms to necessitate administration of medication. 2.The MAR will be evaluated daily M-F during clinical meetings and during shift change.3.The MAR will be reviewed daily-M-F, monthly, quarterly 4.The Resident Care Coordinator and Registered Nurse will be responsible for reviewing and monitoring to ensure compliance.

Citation #12: C0325 - Systems: Self-Administration of Meds

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Corrected: 9/30/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure a resident who self administered their insulin pen was evaluated at least quarterly to ensure the ability to self administer medications for 1 of 1 sampled resident (#4). Findings include, but are not limited to:Resident 3 was admitted to the facility in 11/2021 with diagnoses including diabetes.In an 03/29/22 interview with Staff 3 (Resident Care Coordinator), she stated Resident 3 self administered his/her insulin using an injector pen. Review of the resident's Medication Self Administration form dated 10/26/21 found the evaluation was not thorough and was not preformed quarterly. The need to ensure residents who self administered their medications were thoroughly evaluated at least quarterly was discussed with Staff 1(Director), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 03/30/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure there was a physician's order in the facility record for the resident to self-administer medications for 1 of 1 sampled resident (#7) who self-administered medication. This is a repeat citation. Findings include, but are not limited to:Resident 7 was admitted to the facility in 03/2021 with diagnoses including glaucoma and chronic constipation.The resident was identified during the acuity interview on 08/22/22 to self-administer his/her medication. A review of the resident's 08/01/22 through 08/22/22 MAR and physician orders, along with staff interview, revealed the following:* The MAR indicated there were nine medications "not given by facility";* There was a physician's order dated 07/01/22 for the resident to self-administer Tylenol (for pain) and eye drops (for glaucoma); and* There was no physician's order in the resident's record for him/her to self-administer Biotin, calc/mag/zinc, Centrum Silver tab, fish oil, garlic, and Vitamin B-6 tab (all supplements), docusate sodium (for constipation), or Lutein (for eye care).In an interview with Staff 3 (RCC) on 08/22/22, she reported she had contacted the resident's physician for an order to self-administer the additional medications not listed on the existing self-administration order.The need to have a physician's order for the resident to self-administer medication was discussed with Staff 12 (ED/Administrator) and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0055 (5) Systems: Self Administration of Meds1.Self Administration of medication Evaluation has been completed in detail.2.Self Adminstration of medications will be evaluated upon admission, quarterly and with any change that the RN may determine of the residents' ability. 3.The RN will evaluate at the time of admission, quarterly and as needed.4. The Registered Nurse will assure compliance C325-Self Administration1.Resident #7 has been assessed for their ability to safely Self Administer Medications. A PCP order has been obtained for the resident to safely Self Medicate.2. All other residents will be reviewed and assessed as needed for Self Medication. Orders from PCP will be obtained as needed.3. All residents that have been deemed safe to Self Medicate will be assessed quarterly and with any significant changes of condition.4. The Self Medication process will be audited by the RCC & RN monthly with the QA program for compliance. The RN will be responsible for this process.

Citation #13: C0330 - Systems: Psychotropic Medication

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Corrected: 9/30/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled resident (#1) who received psychotropic medications. Findings include, but are not limited to:Resident 1 was admitted to the facility in 11/2022 with diagnoses including anxiety.The resident's 03/2022 MARs and physician orders dated 03/22/22 were reviewed and the following was noted:Resident 5 was prescribed Alprazolam 0.25 mg once daily as needed for anxiety/agitation. Alprazolam was administered on 03/09/22, 03/10/22, 03/11/22, 03/12/22, 03/13/22 and 03/14/22.The facility lacked documented evidence non-pharmacological interventions were attempted and ruled ineffective prior to administration of Alprazolam.During an interview on 03/30/22, Staff 3 (Resident Care Coordinator) confirmed the facility had not documented if non-pharmacological interventions were attempted and ineffective prior to administering the Alprazolam for Resident 3. The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications was discussed with Staff 1 (Director), Staff 2 (RN) and Staff 3. They acknowledged the findings.
Resident 6 was admitted to the facility in 08/2022 with diagnoses including COPD. Review of the Resident's current physician orders and 08/01/22 through 08/22/22 MAR revealed the resident had orders for both lorazepam and quetiapine for anxiety. There were no resident-specific parameters listed on the MAR which instructed staff which medication to administer first. The need for all PRN psychotropic medications to have resident-specific parameters was discussed with Staff 12 (ED/Administrator) and Staff 2 (RN), Staff 3 (RCC), and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure there were written, resident-specific parameters for PRN psychotropic medication used to treat behaviors for 2 of 2 sampled residents (#s 6 and 9) who were prescribed as-needed psychotropic medication. This is a repeat citation. Findings include, but are not limited to:1. Resident 9 was admitted to the facility in 01/2022 with diagnoses including anxiety. A review of the resident's 08/01/22 through 08/22/22 MAR revealed the following:* The resident had a prescription for PRN lorazepam 0.5 mg tab (for anxiety), which was administered on 08/06/22, 08/15/22, 08/16/22, and 08/19/22; and* There were no resident-specific parameters on the MAR for lorazepam.The need for all PRN psychotropics to have resident-specific parameters was discussed with Staff 12 (ED/Administrator) and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0055 Systems: Psychotropic Medication1.Staff will be provided with training on non pharmacological interventions. The Mars and service plans are under review and will be updated with Non-pharmacological interventions.2.A PRN report will be printed and will be reviewed daily during morning clinical meeting.3. Psychotropic medications will be reviewed daily to ensure compliance and then weekly to review frequency of PRN Psychotropic medication given and to determine if Non-pharmacological interventions are effective.4.Compliance is assured by Resident Care Coordinator, Licensed Nurse/Executive Director.C330-Psychotropic Medication correction 1.Resident # 9 & # 6 have been re-evaluated to ensure that there are resident specific parameters in place for staff to follow prior to administering the PRN psychotropic medications.2.All other residents in the community have been assessed for PRN psychotropic medications and non-pharmalogical interventions put into place for staff to follow prior to the administration of the PRN medications. 3.All PRN psychotropic medications along with the non-pharmalogical interventions will be reviewed monthly through the QA program for compliance. 4.The RCC will be responsible for this process.

Citation #14: C0372 - Training Within 30 Days: Direct Care Staff

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Not Corrected
4 Visit: 2/23/2023 | Corrected: 1/5/2023
Inspection Findings:
Based on interview and record review, it was determined 2 of 4 sampled, newly hired direct care staff (#s 8 and 9) failed to complete first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:A review of the facility's training records on 03/30/22 revealed: Staff 8 (Care Partner) hired on 11/16/21, and Staff 9 (Care Partner) hired on 02/17/22, did not have documentation of first aid and abdominal thrust training completion within the required 30 days of hire.On 03/30/22, the need to ensure first aid and abdominal thrust training was completed within the required timeframe was discussed with Staff 1 (Director), Staff 2 (RN), Staff 3 (Resident Care Coordinator) and Staff 11(Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 15 and 17) completed first aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 08/23/22. Staff 12 (ED/Administrator) provided certificates of completion of first aid/abdominal thrust training for Staff 15 (Med Aide/Care Partner) and Staff 17 (Care Partner), hired 06/13/22 and 06/11/22, respectively. Both staff completed the training on 08/10/22, more than 30 days after the dates they were hired.The need to completed first aid/abdominal thrust training within 30 days of hire was discussed with Staff 12 and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 21 and 22) completed first aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 12/06/22. There was no documented evidence Staff 21 (Care Partner) and Staff 22 (Care Partner), hired 10/18/22 and 10/17/22 respectively, completed first aid and abdominal thrust training within 30 days of hire. The need to ensure staff demonstrate competency in all required areas within 30 days of hire was discussed with Staff 12 (ED/Administrator) on 12/06/22. She acknowledged the findings.
Plan of Correction:
OAR 411-054-0070Training within 30 days: Direct Care Staff1.All staff have completed their training for Abdominal Thrust and we are in the process of completing First Aid.2.All staff will be provided with Abdominal Thrust & First Aid Training during the first couple of days of hire while completing relias training. 3.Training will be set up by the Administrative Assistant and will be responsible for the monitoring of all staff Pre service and First Aid/Abdominal Thrust training.4. Adminstrative Assistant, Executive Director will assure compliance.C372-Staff Training1.Moving forward, all new hires will receive initial and 30 day training prior to working the floor.2.All required training initial and 30 day will be completed during the onboarding process to avoid going past the 30 day requirement.3.This will be completed during the onboarding process for any and all new hires.4.Administrator will be responsible for this process to ensure compliance.1. 30 day required training has been scheduled for staff # 21 & #22. 2.This will be completed during the onboarding process for any and all new hires.3. Onboarding check off form has been included in the new hire packet. This will be reviewed by the Administrator with every new hire at the time of onboarding and then audit of staff files quarterly 4.Administrator will be responsible for this process to ensure compliance.

Citation #15: C0374 - Annual and Biennial Inservice For All Staff

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure long-term staff completed the required minimum 12 hours of in-service training annually for 1 of 1 long-term staff (# 7) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (Director) on 03/30/22.There was no documented evidence Staff 7 (Care Partner), hired 02/16/21, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care. The need to ensure all required in-service training hours were completed annually and the facility had a system to track all required in-service training hours was discussed with Staff 1 (Director), Staff 2 (RN), Staff 3 (Resident Care Coordinator) and Staff 11(Director of Operations) on 03/30/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0070 (6-7) Annual Training and other requirements1.Staff #7 will complete continued education to meet the required 12 hours of annual in-service trainings including six hours related to dementia.2. All staff training records will be audited to ensure documented evidence of 12 hours of annual inservice training has been completed.3 This system will be audited monthly4.The Executive Director or designee will be responsible to ensure the corrections are completed and monitored

Citation #16: C0420 - Fire and Life Safety: Safety

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to document all required components of fire drills and provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:Fire drill records from 10/2021 through 03/2022 were reviewed on 03/29/22. The facility lacked documented evidence fire drills were conducted every other month and included the following required components:* Date and time of day;* Location of simulated fire origin;* The escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed;* Staff members on duty and participating residents; and* Number of occupants evacuated.The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills. On 03/30/22, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (Director). She acknowledged the findings.
Plan of Correction:
OAR 411-054-0090 (1) (a-d) Fire and Life Safety:Drills and instruction1. Fire Drills will conducted and recorded at a minimum of every other month at different times of the day, evening and night shift. Fire and Life Safety Training will be provided on alternating months.The Fire Drill document will include the following components: Date and time of day , location of simulated fire orgin, the escape route used, problems encountered and comments relating to the residents who resisted or failed to participate in the drills, evaluation time period needed, staff members on duty and participating number of occupants evacuated.2. Fire Drills and Fire and Life Safety Training will be completed with current staff to ensure awareness and understanding of emergency procedures including but not limited to evacuation routes, fire extinguisher use, locating and reading the fire panel, etc. Staff will be provided with written Fire drill protocol for reference. The fire drill documents will be filed in the Fire Drill/Fire safety Binder in order of month.3. The system will be evaluated monthly to ensure all requirements have been met and documented.4. Maintenance Director and And Executive Director or designee will be responsible to ensure corrections are completed and monitored.

Citation #17: C0422 - Fire and Life Safety: Training For Residents

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:Fire drill records from 10/2021 through 03/2022 were reviewed on 03/30/22. The facility lacked documentation of the following required elements:* Evidence alternate routes were used during fire drills;* Staff interviewed knew the designated point of safety; and* Evidence residents were being instructed on fire and life safety procedures within 24 hours of admission and annually.The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Director) and Staff 2 (RN) on 03/30/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0090 (1)(e-h)-(2-5)Fire and Life Safety: General1. General Fire and Life Safety training will be provided and documented for current residents with in 24 hours of admission and at minimum annually.2. General Fire and Life Safety training will be provided for all new residents within 24 hours of admission and at a minimum annually Training to include the following: alternative exit route used during fire drills.Additionally. documentation of participation in fire drills and training to assess ongoing evacuation capabilities of both residents and staff and interventions and resolution related to resident evacuation concerns identified during drills3. This System will be evaluated at a minimum of monthlyto ensure al requirements have been met and documented.4. The Maintenance Director and Ececutive Director or designee will be responsible to ensure corrections are completed/monitored

Citation #18: C0455 - Inspections and Investigation: Insp Interval

Visit History:
2 Visit: 8/23/2022 | Not Corrected
3 Visit: 12/6/2022 | Not Corrected
4 Visit: 2/23/2023 | Corrected: 1/5/2023
Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C160, C240. C252, C282, C310, C330, C372, and C513.
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 Department. Findings include but are not limited to:Refer to C303, C310 and C372.
Plan of Correction:
C455-POC in place for all citations

Citation #19: C0510 - General Building Exterior

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 6/17/2022
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure exterior grounds were orderly, free of litter and refuse, and pathways were maintained in good repair. Findings include, but are not limited to: The facility grounds were toured on 03/28/22 and 03/29/22, and the following was observed: * The sidewalk in front of the facility had multiple areas where the concrete had separated, creating deep and large gaps between sidewalk joints. This created a potential tripping and fall hazard for residents; * Cigarette butts were observed along the sidewalk curb and bark dust near the staff smoking area; * The interior courtyard off the dining room had unmanaged landscaping, accumulation of dog waste throughout the grassy area, overturned containers, refuse, and litter on the ground, outside furniture had a buildup of dirt and debris, and the cushions were worn and stained; * There was an ashtray and small garbage receptacle full of cigarette butts; * An unused bike was on the ground near the barbecue grill; and * A large piece of carpet placed in front of the outside courtyard door was worn, torn, stained, and frayed along the edges. The building exterior was toured with Staff 1 (Director) on 03/30/22. She acknowledged the findings.
Plan of Correction:
OAR 411-054-0200 (3) General Building Exterior1.Immediiate actions to correctthe rule violaion include, ensuring grounds are orderly, free of litter and refuse, and pathways are maintained and in good repair. large gaps between sidewalk joints will be filled.Cigarette butts will be cleaned up and a new cigarette butt disposal tower will be purchased. , bike will me removed, small mat and cushions in the courtyard will be replaced. Courtyard will be cleaned up and landscaped.2.The system will be corrected so this violation will not happen again by completing consistant environmental walk throughs to ensure all exterior pathways and outsideside ares are in good repair and any concerns are identified and followed up timely 3.The ares needing correction will be evaluated on a monthly basis with environmental audit.4. Executive Director or designee and maintenance Director will be resposible to see the corrections are completed/monitored

Citation #20: C0513 - Doors, Walls, Elevators, Odors

Visit History:
1 Visit: 3/30/2022 | Not Corrected
2 Visit: 8/23/2022 | Corrected: 9/8/2022
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:Observations of the facility on 03/28/22 through 03/30/22 showed the following areas were in need of cleaning and/or repair: * Multiple walls, doors, and door frames throughout the facility were dinged, chipped, gouged, scraped, and splintered, including inside resident units; * The handrail between rooms 123 and 125 was gouged and splintered; * Window tracks throughout the facility had debris, dirt, dust and dead insects; * Carpet throughout the common areas and hallways had spots and stains, including inside resident units;* The baseboards had long black scuffs and black accumulation along the perimeter of the dining room; * Strong pervasive odors were noted from the west hallway that did not dissipate throughout the day; * Baseboards throughout the facility, including hallways and common areas, were chipped, scraped, and gouged; * Multiple pieces of furniture throughout the facility had spills and stains on the arms and seats, the lower legs were scratched and chipped; and * The laundry/utility room floor needed cleaning along the based boards, behind the washer and dryers and around the hopper sink. The areas in need of cleaning and repair were shown to and discussed with Staff 1 (Director) on 03/30/22. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to:During a tour of the facility on 08/22/22 the following areas were noted to be in need of cleaning and repair: * Multiple doors and base boards throughout the facility had scratches and gouges in the wood;* Carpet throughout the common areas and hallways had spots and stains; * Multiple pieces of furniture throughout the facility had spills and stains on the arms and seats, the lower legs were scratched and chipped; and * The hopper sink in the laundry room was leaking from the base with a small stream of water running to the drain in the middle of the room. The base of a a cardboard box stored under the hopper sink was saturated.The areas in need of cleaning and repair were reviewed with Staff 12 (ED/Administrator) on 08/22/22. She acknowledged the findings.
Plan of Correction:
OAR 411-054-0200 (4)(d-i) Doors walls, elevators, odors 1. Walls, doors and door frames, the hand rails between rooms 123-125 will be immediately repaired, including furniture, baseboards identified.Laundry room & dining room will be deep cleaned and stained cusions and carpet will be shampooed throughout community in common areas and residents rooms. West hall way has been identified as carpet from vacant room. Carpet will be replaced.2.Staff will receive in-servicing on reporting damage. Staff will utilize maintenance request logas a meansof communication regarding repair needs that are not urgent. Maintenance Director will respond to repair needs timely.3.Weekly and monthly review of maintenance log and follow up and monthly as part of QA process.4. The Executive Director or designee and Maintenance Director will be responsible to ensure the corrections are completed/monitored

Survey 1MS8

0 Deficiencies
Date: 6/9/2021
Type: Complaint Investig.

Citations: 1

Citation #1: C0010 - Licensing Complaint Investigation

Visit History:
1 Visit: 6/9/2021 | Not Corrected
Inspection Findings:
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 unannounced complaint investigation conducted 06/09/2021. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.