Lakeview Senior Living

Based on observation, interview, and record review, conducted during a site visit on 02/11/25, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated all 51 residents were included in the tool and had a completed ABST evaluation. There had been 11 residents that had not been quarterly reviewed. A review of the facility's ABST indicated the "minimum time needed based onacuity" on day shift was 2.34 direct care staff and less than one direct care staff for night shift. A review of the facility's posted staffing plan indicated the following: Day shift: Two caregivers and two med techs; and Night shift: Two caregivers and one med tech.A review of the facility's staff schedule and timecards dated 02/04/25 to 02/11/25, indicated the facility had been short staffed on 02/09/25 on day shift and 02/11/25 for day and night shift. An interview with Staff 1 (Executive Director) and Staff 3 (Registered Nurse) indicated the following; Staff 3 was in the process on updating resident's service plans that had not been quarterly evaluated. Staff 1 acknowledged the residents whose acuity had not been quarterly updated in the ABST. It was determined the facility failed to fully implement and update an acuitybased staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on observation, interview, and record review, conducted during a site visit on 02/11/25, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated all 51 residents were included in the tool and had a completed ABST evaluation. There had been 11 residents that had not been quarterly reviewed. A review of the facility's ABST indicated the "minimum time needed based onacuity" on day shift was 2.34 direct care staff and less than one direct care staff for night shift. A review of the facility's posted staffing plan indicated the following: Day shift: Two caregivers and two med techs; and Night shift: Two caregivers and one med tech.A review of the facility's staff schedule and timecards dated 02/04/25 to 02/11/25, indicated the facility had been short staffed on 02/09/25 on day shift and 02/11/25 for day and night shift. An interview with Staff 1 (Executive Director) and Staff 3 (Registered Nurse) indicated the following; Staff 3 was in the process on updating resident's service plans that had not been quarterly evaluated. Staff 1 acknowledged the residents whose acuity had not been quarterly updated in the ABST. It was determined the facility failed to fully implement and update an acuitybased staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on interview and record review, conducted during a site visit on 07/08/24 and 07/09/24, it was confirmed the facility failed to ensure the completeness and accuracy of resident records for 1 of 1 sampled resident (#3). Findings include, but are not limited to:Resident 3 no longer resided in the facility. Compliance Specialist was unable to interview resident. During an interview on 07/09/24, Staff 1 (Executive Director) indicated no knowledge of Residents POLST. Staff 1 could not explain why the information on Resident 3's POLST and service plan did not match and had not been accurate to Resident 3's preference.A review of Resident 3's service plans dated 02/25/24 and 07/04/24 indicated resident was a do not resuscitate (DNR). Both service plans had not been signed off by the resident or resident's representative. A review of Resident 3's POLST dated 03/23/21 indicated resident was not a DNR and would like to be resuscitated and given CPR. The resident's service plan and POLST status had not matched. It was confirmed the facility failed to ensure the completeness and accuracy of resident records.On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, during a site visit conducted on 07/08/24 and 07/09/24, it was confirmed the facility had not completed quarterly service plan evaluations. Findings include, but are not limited to:During an interview on 07/09/24, Staff 1 (Executive Director) indicated there had been ten service plans that had not been updated quarterly. An email correspondence on 07/17/24, between Staff 1 and Compliance Specialist indicated the following service plans to be out of date;·Resident 5: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.·Resident 6: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.·Resident 7: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.·Resident 8: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.·Resident 9: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.·Resident 10: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.·Resident 11: Service plan dated 03/13/24. Due date of quarterly service plan evaluation: 06/13/24.·Resident 12: Service plan dated 03/11/24. Due date of quarterly service plan evaluation: 06/11/24.·Resident 13: Service plan dated 02/25/24. Due date of quarterly service plan evaluation: 05/25/24.·Resident 14: Service plan dated 02/23/24. Due date of quarterly service plan evaluation: 05/23/24.It was confirmed the facility had not completed quarterly service plan evaluations.On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The facility has been working on updating resident service plans to be up to date and person centered. Staff 1 indicated all service plans would be complete and updated in two weeks.

Based on observation, interview, and record review, conducted during a site visit on 07/08/24 and 07/09/24, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:CS observed the following, · Staff for Day shift (6:00 AM through 6:00 PM) on 07/08/24 and 07/09/24: two CG and two MT.· Staff for Night shift (6:00 PM through 6:00 AM) 07/08/24: two CG and one MT.During an interview on 07/09/24, Staff 1 (Executive Director) indicated the facility ABST was not in compliance. S/he indicated there had been ten service plans that had not been quarterly updated. An email correspondence on 07/17/24, between Staff 1 and Compliance Specialist indicated the following service plans to be out of date;· Resident 5: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.· Resident 6: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.· Resident 7: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.· Resident 8: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.· Resident 9: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.· Resident 10: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.· Resident 11: Service plan dated 03/13/24. Due date of quarterly service plan evaluation: 06/13/24.· Resident 12: Service plan dated 03/11/24. Due date of quarterly service plan evaluation: 06/11/24.· Resident 13: Service plan dated 02/25/24. Due date of quarterly service plan evaluation: 05/25/24.· Resident 14: Service plan dated 02/23/24. Due date of quarterly service plan evaluation: 05/23/24.A review of the posted staffing plan and the facility ABST indicated the following; · Day shift from 6:00 AM to 2:00 PM staffed with two med techs and two caregivers.· Swing shift from 2:00 PM to 10:00 PM staffed with two med techs and two caregivers.· Night shift from 10:00 PM to 6:00 AM staffed with one med techs and two caregivers.It was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST).On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 3 of 3 sampled residents (#s1, 2, and 3). Findings include, but are not limited to:During an interview on 06/12/24, Staff 1 (ED) indicated the facility was cited during their survey conducted on 05/21/24 for service plans not being person centered. Staff 1 indicated s/he and Staff 2 (RCC) had been working on changing and updating all resident service plans. A review of service plans indicated the following; · Resident 1 service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduce falls. · Resident 2 service plan dated 04/22/24, indicated resident was a one person full assist twice per week.· Resident 3 service plan dated 04/30/24, indicated resident was a two person full assist twice per week. A review of the shower schedule indicated the following; · Resident 1 scheduled for showers on swing shift for Monday and Wednesdays. · Resident 2 scheduled for showers on swing shift for Sunday and Thursdays.· Resident 3 scheduled for showers on day shift for Wednesday and Saturdays. A review of shower sheets from 04/01/24 through 06/05/24 provided from the facility indicated the following;· Resident 1 had not been provided eighteen of twenty showers during the timeframe. · Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents ' hair was matted and scalp was irritated and scabby. · Resident 3 had not been provided five of nineteen showers during the timeframe. It was confirmed the facility failed to implement a service plan that reflects the resident's needs.On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.Verbal POC: ED and RCC have been going through all resident's service plans to make them more person centered. ED will bring back shower sheet and ensure staff have completed them and will audit to ensure showers are being provided.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication for 1 of 3 sampled residents (#1). Findings include, but are not limited to:During an interview on 06/12/24, Staff 1 (ED) indicated there had been issues with staff not observing residents take his/her medications. Staff 1 stated s/he had planned to request an order from Resident 1's physician to allow medications to be left at bedside, as this was Resident 1's preference. S/he acknowledged there was no current order.During an interview on 06/12/24, Resident 1 stated, "There have been times staff has left my medication on the counter since it takes me awhile to take my medication in the morning." A review of the service plan for Resident 1 dated 05/17/24, indicated the resident required assistance with medication two times a day. It was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication.On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.Verbal POC: The facility will follow the doctor's orders as prescribed effective immediately. The ED will reach out to doctor for approval to get a bedside medication order.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:During an interview on 06/12/24, Resident 1 indicated call light response times take longer than 20 minutes to get staff to respond and assist. Resident 1 indicated s/he had not received showers due to lack of staff. During an interview on 06/12/24, Staff 1 (Executive Director) indicated the facility scheduled two 12-hour shifts and does not follow the three 8-hour shifts. A review of the posted staffing plan indicated the following: · Day shift: Two caregivers and two med techs. · Swing shift: Two caregivers and two med techs. · Night shift: Two caregivers and one med tech.A review of the facility's staff schedule and timecards for 04/01/24 through 04/03/24 and 04/25/24 through 05/01/24, indicated the facility was consistently staffing to their posted staffing plan.A review of the facility-wide call light history report dated 04/25/24 through 05/01/24 indicated 32 call light response times that had exceeded 15 minutes. Twenty of those response times had exceeded 20 minutes with the longest wait time of 30 minutes. A review of service plans indicated the following:· Resident 1's service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduces falls. · Resident 2's service plan dated 04/22/24, indicated resident was a one-person full assist twice per week.· Resident 3's service plan dated 04/30/24, indicated resident was a two-person full assist twice per week. A review of the shower schedule indicated the following: · Resident 1 scheduled for showers on swing shift for Monday and Wednesdays. · Resident 2 scheduled for showers on swing shift for Sunday and Thursdays.· Resident 3 scheduled for showers on day shift for Wednesday and Saturdays. A review of shower sheets, dated 04/01/24 through 06/05/24, provided from the facility indicated the following:· Resident 1 had not been provided eighteen of twenty showers during the timeframe. · Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents' hair was matted and scalp was irritated and scabby. · Resident 3 had not been provided five of nineteen showers during the timeframe.It was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Staff 1 will continue to audit call lights and will ensure showers are completed.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to: During an interview on 06/12/24, Staff 1 (Executive Director) indicated the facility had been scheduling for two 12-hour shifts and was not appropriately staff to accommodate three 8-hour shifts. The facility had one resident who required two-person transfer and the current census was 49 residents. A review of the posted staffing plan and the facility ABST indicated the following; · Day shift from 6:00 AM to 2:00 PM staffed with two med techs and two caregivers.· Swing shift from 2:00 PM to 10:00 PM staffed with two med techs and two caregivers.· Night shift from 10:00 PM to 6:00 AM staffed with one med tech and two caregivers.A review of the facility's staff schedule and timecards, dated 04/01/24 through 04/03/24, and 04/25/24 through 05/01/24, indicated the facility was consistently staffing to their posted staffing plan.A review of service plans indicated the following; · Resident 1 service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduces falls. · Resident 2 service plan dated 04/22/24, indicated resident was a one-person full assist twice per week.· Resident 3 service plan dated 04/30/24, indicated resident was a two-person full assist twice per week. A review of the shower schedule indicated the following; · Resident 1 scheduled for showers on swing shift for Monday and Wednesdays. · Resident 2 scheduled for showers on swing shift for Sunday and Thursdays.· Resident 3 scheduled for showers on day shift for Wednesday and Saturdays. A review of shower sheets from 04/01/24 through 06/05/24 provided from the facility indicated the following;· Resident 1 had not been provided eighteen of twenty showers during the timeframe. · Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents' hair was matted and scalp was irritated and scabby. · Resident 3 had not been provided five of nineteen showers during the timeframe. It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to have a training program that includes abuse and reporting requirements. Findings include, but are not limited to:During separate interviews on 06/12/24, Staff 1 (ED) indicated the facility was cited during their survey conducted on 05/21/24 for incomplete training records including abuse and reporting. The facility will have an all-staff training on Friday 06/14/24 to go over abuse and reporting practices. When Staff 6 (MT) was asked the procedure for abuse and reporting, Staff 6's response was to contact the RCC, and s/he was not familiar with the correct policy and procedure for reporting. A review of the facility policy and procedure for elder abuse, neglect, and exploitation dated 12/09/21 indicated all personal care attendants will receive in-service training on elder abuse incidents, signs and symptoms of abuse, and reporting requirements during initial orientation. A review of Staff 3 (MT), Staff 4 (MT), and Staff 5's (CG) 30-day competency training records indicated Staff 3 and Staff 4 had complete training which included when to fill out incident report and call 911. The facility could not provide Staff 5's competency checklist. The three staff had completed the Relias training which included preventing, recognizing, and reporting abuse. It was confirmed the facility failed to have a training program that includes abuse and reporting requirements.On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The company and facility are working together to create a more extensive training program to include knowledge of abuse and reporting. ED will ensure all staff have completed required training within 30 days.

The findings of the re-licensure survey, conducted 05/20/24 through 05/23/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 05/23/24, conducted 01/06/25 through 01/08/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility, which posed a risk to the safety of residents. Findings include, but are not limited to:During the re-licensure survey, conducted 05/20/24 through 05/23/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in report.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:During the survey, multiple non-sampled residents expressed their concerns during a group interview as well as individual interviews regarding complaints being minimized or going unaddressed. Examples given included:* Food was served cold;* No resident suggestion box;* Lack of staff; * Call light response time was too long;* Property theft; and* "They said they would look into it and I never heard back."On 05/22/24, Staff 1 (Executive Director) was interviewed about the facility's grievance resolution policy. She stated the facility had a grievance resolution policy, however, she had not yet implemented the system which included documenting the response to and resolution of resident complaints.The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 on 05/22/24. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:During the re-licensure survey, conducted 05/20/24 through 05/23/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes, and satisfaction was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged.Refer to the deficiencies in the report.

Based on observation and interview, it was determined the facility failed to ensure residents were treated with dignity and respect when receiving meal delivery to their apartments. Findings include, but are not limited to:During meal service observations from 05/20/24 through 05/23/24, meals delivered to resident rooms were served on paper plates, drinks were served in disposable cups, and utensils were plastic. The meals served to residents in the dining room were served on ceramic dishes with stainless steel flatware. During an interview on 05/23/24, Staff 6 (Culinary Director) stated all meals delivered to residents in their rooms were served on disposable products. Staff 6 reported that the warmer used for transport held only ten trays and that currently, up to approximately 25 residents were choosing to eat in their rooms. Staff 6 stated meal service to rooms had been attempted with non-disposable products at one point but that logistics had caused the facility to return to disposable products.Ensuring residents were treated with respect and dignity regarding meal service was discussed on 05/23/24 with Staff 2 (Resident Services Director) and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) whose new move-in evaluation was reviewed. Findings include, but are not limited to:Resident 5 moved into the facility in 02/2024.A review of Resident 5's move-in evaluation, dated 02/23/24 and 02/26/24, identified the facility failed to address the following required elements:* Interests, hobbies, social, and leisure activities;* Spiritual, cultural preferences and traditions;* Personality: including how the resident coped with change or challenging situations;* Pain: non-pharmaceutical interventions, including how s/he expressed pain or discomfort; and* History of dehydration or unexplained weight loss or gain.During an interview with Staff 2 (Resident Services Director) on 05/23/24 at 11:30 am, she reviewed the record and acknowledged the findings. The need to ensure move-in evaluations included all required elements was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease. The resident's clinical record was reviewed, including service plan dated 05/17/24 and progress notes and temporary service plans dated 03/02/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:* Activities;* Oxygen; * Refusal of care; * Meals/nutrition; and * Behaviors. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.2. Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression. The resident's clinical record was reviewed, including service plan dated 05/12/24 and progress notes and temporary service plans dated 01/01/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:* Reminders for meal time; * Behaviors;* Recommendations from outside providers; * Location of pain and non-pharmacological interventions; * Activities; and * Care of cat. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

3. Resident 3 was admitted to the facility in 05/2016 with diagnoses including hypertension and a history of UTI's (urinary tract infections).Observations and interview with the resident, and interviews with staff were completed. The resident's service plan dated 04/10/24, progress notes dated 01/20/24 through 05/20/24, and incident investigations were reviewed. The following was revealed:a. The following short-term change of condition lacked documentation of resident-specific actions or interventions needed, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and/or documentation of resolution:* 05/02/24: Increased confusion and possible UTI.b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed and communication of the determined actions or interventions to staff on all shifts:* 02/15/24: UTI;* 02/22/24: Buttock wound; and * 05/12/24: Fall.The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored weekly through resolution was discussed with Staff 2 (Resident Services Director) on 05/21/24 at 10:35 am, and during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged.4. Resident 2 was admitted 07/2020 with diagnoses which included a history of skin breakdown and diabetes.Observations and an interview with the resident, interviews with staff, review of the service plan dated 05/17/24, incident investigations, home health documentation, a hospital discharge summary, and progress notes dated 01/24/24 through 05/20/24 were reviewed. The following was revealed:a. A progress note, dated 04/08/24, indicated the resident was "throwing up" and was sent to the hospital.A hospital discharge summary revealed the resident had been admitted to the hospital on 04/08/24 for "Sepsis due to Streptococcus ..." S/he was discharged on 04/12/24 (four days later) and returned to the facility. There was no evidence the facility evaluated the resident's change in condition, referred the change to the facility RN, or monitored the resident consistent with his/her evaluated needs. In an interview on 05/23/24, Staff 2 (Resident Services Director) reviewed the resident's record and acknowledged the findings. No further information was provided. b. The following short-term change of condition lacked documentation of progress noted at least weekly, and/or documentation of resolution:* 02/15/24: Insulin not administered;* 02/27/24: Insulin not administered;* 03/15/24: Medication discontinued; and * 04/14/24: Low blood sugar. On 05/23/24 at 8:40 am, Staff 2 (Resident Services Director) reviewed the record and acknowledged the findings. The need to ensure Resident 2's short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and significant changes in condition were evaluated, referred to the facility RN, and monitored consistent with the resident's evaluated needs was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, changes were reported to the RN when needed, and progress was documented weekly until resolution for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Resident 1 experienced a severe weight loss and continued to lose weight. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease. The resident's clinical record was reviewed, including weight records dated 01/25/24 through 05/07/24, service plan dated 05/17/24, 05/2024 MAR, and progress notes, temporary service plans and incident reports dated 02/20/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.a. The resident's weight records stated: * 01/27/24 - 165 pounds; and * 02/23/24 - 161.2 pounds. On 03/15/24 Resident 1 was admitted to the hospital due complaint of right arm numbness and tingling and inability to move his/her right hand. S/he returned to the facility 19 days later on 04/03/24 with diagnoses including ischemia of right upper extremity and having undergone a right arm fasciotomy surgery. During interviews on 05/21/24 and 05/22/24, multiple staff stated that upon returning from the hospital the resident appeared to have lost weight and had a significant increase in care needs including wound monitoring and ADL care. There was no documentation that the facility evaluated the resident, referred to the facility nurse, or updated the service plan upon his/her return from the hospital. Prior to the resident's hospital admission, his/her weight was recorded as: * 01/27/24 - 165 pounds; and * 02/23/24 - 161.2 pounds. The resident was weighed on 04/14/24, 11 days after returning from the hospital, and weighed 139.1 pounds. This constituted a severe weight loss of 15.7%, or 25.9 pounds in three months. There was no documented evidence that the facility evaluated the severe weight loss recorded on 04/14/24, referred to the facility nurse, or updated the service plan as needed. The resident continued to experience weight loss. On 05/07/24, the resident's weight was recorded as 128.2 pounds. This constituted a severe weight loss of 7.8%, or 10.9 pounds, in one month. During an interview on 05/20/24, Staff 2 (Resident Services Director) stated the facility was aware of the resident's weight loss, and that Staff 3 (RN) had completed a significant change of condition assessment on 05/17/24, though she did not currently have access to it as it was on Staff 3's computer which was outside the facility. No new interventions had been put into place or communicated to staff. On 05/22/24, Staff 3 (RN) acknowledged the multiple severe weight losses and stated she was not able to identify when she was notified of the weight loss. The facility failed to evaluate Resident 1's severe weight loss, refer to the nurse, and update the service plan as needed, and the resident continued to experience severe weight loss. Refer to C 280, example 1. b. Resident 1 experienced the following changes of condition without interventions or actions determined, documented and communicated to staff on all shifts, and/or monitored weekly through resolution: * 02/29/24 - Medication change; * 03/02/24 - Fall with pain and bruising to left knee;; * 03/07/24 - Medication change; * 03/07/24 - Fall with pain and bruising to wrist and back; * 03/10/24 - Fall with lower back pain and return from ER; * 03/11/24 - Fall, no injury;* 03/11/24 - Fall with pain to right elbow and ribs; * 03/12/24 - Altered mental status and return from ER with medication changes;* 03/13/24 - Fall; * 04/03/24 - Return from hospital stay 03/15/24 through 04/03/24 with surgery to right elbow, change in medications and ADL participation; and* 04/19/24 - Fall with report of hitting head. The need to ensure changes of condition were evaluated, actions or interventions determined, documented and communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 on 05/22/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression. The resident's clinical record was reviewed, including the service plan dated 05/12/24, 05/2024 MAR, and progress notes, temporary service plans and incident reports dated 01/01/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.Resident 4 experienced the following changes of condition without interventions or actions determined, documented and communicated to staff on all shifts, and/or monitored weekly through resolution: * 01/24/24 - Unwitnessed fall at 3:00 am; * 01/24/24 - Unwitnessed fall at 8:00 am; * 01/24/24 - Unwitnessed fall at 1:20 pm; * 04/24/24 - Behaviors including asking a staff member for pain medication to sell; * 04/17/24 - Behaviors including verbal aggression towards staff and other residents; and* 04/22/24 - Behaviors including yelling at staff and walking into another resident's room. The need to ensure changes of condition had actions or interventions determined, documented, and communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

2. Resident 2 was admitted 07/2020 with diagnoses which included a history of skin breakdown and diabetes.Observations and an interview with the resident, interviews with staff, review of the service plan dated 05/17/24, incident investigations, home health documentation, a hospital discharge summary, and progress notes dated 01/24/24 through 05/20/24 were reviewed. The following was revealed:A progress note, dated 04/08/24, indicated the resident was "throwing up" and was sent to the hospital.A hospital discharge summary revealed the resident had been admitted to the hospital on 04/08/24 for "Sepsis due to Streptococcus ..." S/he was discharged on 04/12/24 (four days later) and returned to the facility. The decline in health and hospitalization constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment.During an interview on 05/23/24 at 8:40 am, Staff 2 (Resident Services Director) reviewed the record and acknowledged an RN assessment had not been completed. Staff 3 (RN) was not available for interview. The need to ensure RN assessments were completed with significant changes in condition was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.
Based on observation, interview, and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by an RN, including documented findings, resident status and interventions made as a result of the assessment, for 2 of 2 sampled residents (#1 and 2) who experienced significant changes of condition. Resident 1 experienced severe weight loss and continued to lose weight. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease.The resident's clinical record was reviewed, including weight records dated 01/25/24 through 05/07/24, service plan dated 05/17/24 and progress notes dated 02/20/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.a. Review of weight records revealed the following: * 01/27/24 - 165 pounds; * 02/23/24 - 161.2 pounds; and* 04/14/24 - 139.1 pounds. This constituted a severe weight loss of 25.9 pounds, or 15.7%, in three months. There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. The resident continued to experience severe weight loss, as documented by: * 05/07/24 - 128.1 pounds. This constituted a severe weight loss of 10.9 pounds, or 7.8%, in one month. As of survey entrance on 05/20/24, the facility had no documented evidence that a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. At the time of the survey, 05/23/24, the resident weighed 126.0 pounds. During interviews on 05/21/24 and 05/22/24, staff stated they did not have any observations of how much the resident had been eating recently as the resident ate all meals in his/her room and trashed any remaining food in the Styrofoam containers the food was delivered in. Resident 1 experienced severe weight loss between February and April of 2024, there was no documented evidence of an RN assessment to include findings, resident status, and interventions made as a result of the assessment and the resident continued to lose weight. b. Resident 1 was admitted to the hospital 03/15/24 due to change in cognition and right upper extremity numbness, and returned to the facility on 04/03/24. During the hospital stay, the resident underwent fasciotomy surgery to his/her right arm. Upon return, the resident had a surgical wound, changes in multiple medications, new activity restrictions, and an increased need for care assistance.As of 05/21/24, the facility had no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. During an interview on 05/22/24, Staff 3 (RN) stated she had completed a change of condition assessment on 04/14/24 but had not provided it to the facility until emailing it to Staff 2 (Resident Services Director) on 05/22/24. The need to ensure a significant change of condition assessment was completed and documented by the RN, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (ED), Staff 2 and Staff 3 on 05/22/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure service providers leave written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care if necessary for 1 of 2 sampled residents (#4) who received outside services. Findings include, but are not limited to:Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression. Resident 4's progress notes, dated 01/01/24 through 05/19/24, were reviewed, as well as all outside provider communications. The following was identified:a. The facility did not receive or document outside provider notes and recommendations from the resident's primary care provider visits on the following dates:* 01/18/24; * 01/30/24; * 02/27/24; * 03/12/24; * 03/26/24; * 04/09/24; and * 05/07/24. b. The resident had biweekly appointments with behavioral support services. The facility did not receive or document outside provider notes and recommendations from January 2024 through April 2024.The need to coordinate care with outside providers and ensure service providers left written information in the facility that addressed on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure the staff who administered medications visually observed the resident take the medications for 1 of 1 sampled resident (#1) whose records were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease.The resident's 04/01/24 through 05/19/24 MARs and physician's orders were reviewed. During the acuity interview on 05/20/24, Staff 2 (Resident Services Director) and Staff 3 (RN) stated the facility administered all of Resident 1's medications. During an interview with Resident 1 on 05/21/24, a pill cup with six pills was observed on the resident's bedside table. The resident stated staff "often" left medications without observing him/her take them. Staff 10 (MT) stated on 05/21/24 that Resident 1 at times had difficulty taking all of his/her medications in the morning. She stated Resident 1 had requested additional time to take medications in the past. Staff 10 stated she did not leave medications in the resident's room, but had observed pill cups in the room in the past. On 05/23/24, Staff 2 stated she was aware this had occurred in the past. She stated she also had requested an order from Resident 1's physician to allow medications to be left at bedside, as this was Resident 1's preference. She acknowledged there was no current order. The need to ensure the staff person who administered medication visually observed the resident take the medication was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for medications, for 1 of 3 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 07/2020 with diagnoses which included high blood pressure.Resident 2 had an order for clonidine 0.1 mg one tablet three times a day for hypertension (high blood pressure). Staff were instructed to "hold for hypotension [low blood pressure]." Review of the MARs from 05/01/24 through 05/20/24 revealed the following: * Lack of clear parameters for hypotension and when the medication should be held; and * Staff were administering the medication without obtaining a blood pressure to determine if the medication should be held.In an interview on 05/22/24 at 1:20 pm, Staff 10 (MT) reviewed the resident's MAR. She confirmed the clonidine lacked specific instructions for staff including when the medication should be held.The need to ensure MARs were accurate and included clear parameters for staff was discussed with Staff 2 (Resident Services Director) on 05/22/24 at 3:45 pm, and during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to ensure their ability to safely self-administer medications for 1 of 1 sampled resident (#4). Findings include, but are not limited to:Resident 4 was admitted to the facility in 01/2023.During the acuity interview on 05/20/24, Resident 4 was identified as self-administering his/her own medications. On 05/22/24, Staff 2 (Resident Services Director) and Staff 3 (RN) acknowledged during separate interviews that Resident 4 did not have a quarterly evaluation completed to ensure s/he could safely self-administer his/her own medications. The need to ensure residents who chose to self-administer medications were evaluated at least quarterly to ensure their ability to do so safely was discussed with Staff 2 on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat resident behaviors had written, resident-specific parameters and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication for 1 of 1 sampled resident (#1) who had PRN psychotropic medications. Findings include, but are not limited to:Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression and anxiety.Review of the resident's 04/01/24 through 05/19/24 MARs and current physician orders revealed the following:* An order for alprazolam 1 mg tablet to be administered by mouth two times daily as needed for anxiety; and * The medication was administered 17 times.The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as anxiety. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication, and during interviews on 05/22/24 and 05/23/24, staff stated they were not aware of any non-pharmacological interventions to attempt prior to administering the medication. The need to ensure there were resident-specific descriptions of how the resident behaviors presented, and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the relicensure survey, conducted 05/20/24 through 05/23/24, interviews with staff and residents were conducted and staffing schedules were reviewed.In an interview on 05/20/24, Staff 2 (Resident Services Director) reported the facility was unable to always staff to the level of the posted staffing schedule, but that when this occurred the vacancies were filled by one of four administrative staff.On 05/21/24 at 5:00 pm Staff 2 reported she was working as a caregiver from 2:00 pm to 6:00 pm to fill in for a caregiver who had called off. Staff 2 was observed conducting administrative work throughout the facility between 2:00 pm and 5:30 pm, when surveyors left the building.Throughout the survey multiple sampled and unsampled residents and staff reported that the facility was frequently understaffed.On 05/23/24 staffing schedules for the weeks of 05/05/24 and 05/12/24 were reviewed. Ten of the 14 days reviewed had one or more shifts that were not staffed to the staffing level determined by the facility to meet resident needs.The facility's failure to ensure it had a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 2 on 05/23/24 and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 13, 14 and 15) completed all required pre-service orientation training, 3 of 3 newly hired direct-care staff (#s 13, 14 and 15) completed all required pre-service dementia training, and 7 of 7 newly-hired and long term staff (#s 5, 6, 7, 8, 13, 14 and 15) completed the approved Home and Community Based Services (HCBS) course by 03/31/24. Findings include, but are not limited to:Staff training records reviewed on 05/21/24 at 8:30 am with Staff 4 (Business Office Director) identified the following:1. There was no documented evidence Staff 7 (Housekeeping), Staff 13 (CG), Staff 14 (CG) or Staff 15 (MT), hired on 02/13/24, 01/31/24, 01/09/24, and 01/03/24, respectively, had completed the following required pre-service orientation topic:* Department approved infectious disease prevention training.2. Staff 13, Staff 14 and Staff 15 lacked documented evidence of required pre-service dementia training.3. Staff 5 (Maintenance Director), Staff 6 (Culinary Director), Staff 7, Staff 8 (Housekeeping), Staff 13, Staff 14 and Staff 15 lacked documented evidence of completing the required HCBS course by 03/31/24.The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities, and all staff completed required HCBS training by 03/31/24 was discussed with Staff 4 on 05/21/24, Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (Executive Director) via telephone during the exit conference. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 13, 14 and 15) had documented evidence of demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed with Staff 4 (Business Office Director) on 05/21/24. The following was identified:Staff 13 (CG) hired 01/31/24, Staff 14 (CG) hired 01/09/24, and Staff 15 (MT) hired 01/03/24, lacked documented evidence they had demonstrated competency in all job duties, and had been trained in First Aid and abdominal thrust training within 30 days of hire. Staff 4 reported in an interview on 05/22/24 that competency checklists had not been completed for newly hired direct care staff, apart from medication pass duties for MTs. Staff 4 also reported the facility did not have a system in place for training and demonstrating competency in first aid and abdominal thrust.The need to ensure staff completed all required training and demonstrated competency within 30 days of hire was reviewed with Staff 4 on 05/22/24, Staff 2 (Resident Services Director) on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to consistently provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:Fire and life safety records were reviewed with Staff 5 (Maintenance Director) on 05/21/24 and 05/22/24. The facility provided documentation of one fire drill in the last six months, which occurred on 04/30/24. The facility was not relocating residents from the simulated fire area, therefore, there was no documentation of:* Escape route use;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* Number of occupants evacuated.In addition, there was no documentation of fire and life safety instruction for staff consistently being provided on alternate months. The need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Executive Director) on 05/21/24 and Staff 5 on 05/22/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:On 05/22/24, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 5 (Maintenance Director). Staff 5 reported he did not have documented evidence of annual fire and life safety instruction to residents.The need to ensure residents were re-instructed at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire was reviewed with Staff 2 (Resident Services Director) and Staff 5 on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:Observations on 05/20/24 identified the following areas in need of cleaning or repair:* Handrails throughout the facility had patches of worn varnish, exposing bare wood;* Built-in bench surrounding entry living room had large areas of worn varnish and bare wood; * Chairs in dining room had chips and gouges on wood surfaces; * Double door in dining room leading to outside had black streaks and multiple paint scrapes; and * Carpet outside Room 145 had a large black circular stain.The areas needing cleaning and repair were reviewed with Staff 5 (Maintenance Director) and Staff 2 (Resident Services Director) on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:The facility was toured on 05/20/24. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows in common areas and resident rooms lacked a system which limited how much the windows could be opened to prevent accidental falls.The need to ensure operable windows were designed to prevent accidental falls was discussed with Staff 5 (Maintenance Director) and Staff 2 (Resident Services Director) on 05/23/24, and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to:On 05/20/24 at 4:15 pm Room 144, a one-bedroom unit, was observed to have a wall heater in the bedroom. The heater was located where a resident could come into incidental contact with it. When the heater was turned on and allowed to heat up, the metal surface of the heater reached 181.2 degrees F. In an interview on 05/22/24 Staff 5 (Maintenance Director) reported that 12 rooms in Wing E had this type of wall heater.The risk posed by the hot surface of the wall heaters was discussed with Staff 5 on 05/21/24, and with Staff 1 (Executive Director) on 05/21/24 and 05/22/24. They acknowledged the findings and deactivated the heaters until a long-term solution could be ascertained.

Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. Findings include, but are not limited to:On 05/21/24, water temperatures in resident rooms 105, 215, and 237 measured 102, 103, and 108 degrees Fahrenheit, respectively. In an interview on 05/22/24, Staff 5 (Maintenance Director) reported that the facility was aware of low water temperatures in rooms 103, 105, 203, and 205, and "many years ago" a plumber had determined that the issue was related to the water being at the end of the line, related to the water heater, in this area of the facility. The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 5 on 05/22/24, Staff 2 (Resident Services Director) on 05/23/24, and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:The building was toured on 05/20/24. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.On 05/21/24, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 5 (Maintenance Director) and Staff 1 (Executive Director). They acknowledged the findings.

Based on observation, interview, and record review conducted during a site visit on 02/21/24 and 02/22/24, it was confirmed the facility failed to have a service plan that reflects the resident's needs for 1 of 1 sampled resident (#4). Findings include, but are not limited to: On 02/22/24, CS observed the following: · Staff assisted Resident 4 with ambulation and bathroom assistance. · An erase board in the medication room indicated Resident 4 needed one-hour checks. During shift change from day shift to swing shift on 02/22/24, CS interviewed Staff 3 (CG), Staff 4 (CG), Staff 5 (CG), Staff 6 (CG), Staff 7(CG), and four additional unsampled staff who all indicated Resident 4 was not independent with transferring/ambulation, toileting, and bathing. Staff indicated Resident 4 was on frequent checks to assist with his/her toileting needs. During an interview on 02/22/24, Resident 5 indicated Resident 4's service plan had not properly reflected his/her needs. A review of Resident 4 service plan dated 01/20/24, indicated the following: · Receive one person assistance with bathing twice a week. · Independent with bladder management, sometimes wearing briefs and was independent with changing those. · Independent with transferring and mobility. A review of a temporary service plan (TSP) dated 12/10/24, indicated resident must have help with ambulation to the bathroom, bed, and wheelchair. An additional TSP on 01/10/24 indicated staff to encourage the resident to use call pendent for transfers. A review of the shower schedule indicated Resident 4 was to receive showers on Tuesdays and Thursdays. A review of Resident 4's shower sheets indicated from 01/20/24 through 02/21/24 the resident had been provided three out of eight showers on 01/29/24, 02/16/24, and 02/20/24.On 02/22/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The ED and RCC plan to have a care conference with residents' daughter to reflect the resident current care needs and a TSP will be created for resident in the meantime.

Based on observation, interview, and record review, conducted during a site visit on 02/21/24 through 02/22/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:On 02/22/24, CS observed the following: · The elevator was still broken.· Three CGs and two MTs working. · During lunchtime from 1:00 PM through 2:00 PM, one CG took a resident across the street to the hospital while the other two CG's were assisting residents up and down the elevator. The facility's posted staffing plan was observed and reviewed on 02/21/24, which included the need for the following staff:· Day shift: two MTs and three CGs· Swing shift: two MTs and three CGs· Night shift: one MT and two CGsDuring an interview on 02/21/24, Staff 1 (ED) indicated the facility's main elevator had been broken since the end of December 2023. There was a separate elevator located in the memory care. When residents in the assisted living needed to get between floors staff members had been assisting. There must be one staff member stationed on the first floor and one on the second floor. Due to this, s/he had added an additional staff member to assist. The additional staff had not been added to the schedule until 02/15/24. Staff 1 stated, "There had been a few residents who had fallen on the stairs, however it had been a direct result of the elevator being broken."A review of timecards for 02/05/24 through 02/06/24, indicated the facility had been staffed lower than the posted staffing plan listed above. A review of call light logs from 02/05/24 through 02/06/24, indicated 56 call light response times exceeded 15 minutes, and of those, 36 exceeded over 20 minute response times.A review of the staff schedule for 01/07/24 through 02/22/24 indicated the facility had not been consistently staffing an additional staff member to meet the additional needs with the broken elevator. A review of Resident 4s service plan dated 01/20/24, indicated resident was to received assistance with bathing twice a week. A review of the shower schedule indicated Resident 4 was to receive showers on Tuesdays and Thursdays. A review of Resident 4's shower sheets indicated from 01/20/24 through 02/21/24 the resident had been provided three out of eight showers on 01/29/24, 02/16/24, and 02/20/24. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.On 02/22/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Elevator is starting to be fixed on Thursday 02/22/24 and will continue into next week, the facility will continue to add an additional staff personal for assistance. There had only been one person who showered a resident, the RCC had that person train a few additional staff in the hopes of the resident receiving showers twice a week like their service plan stated. ED will continue to monitor call light response times and conduct additional training to staff within the next week. Staff have in place to give reminders to residents to take the elevator.

Based on observation and interview, conducted during a site visit on 02/21/24 and 02/22/24, it was confirmed the facility failed to keep all equipment necessary for the health, safety, and comfort of the resident in clean and good repair. Findings include, but are not limited to:On 02/21/24 and 02/22/24, CS observed the main elevator was broken and not in use.During separate interviews on 02/21/24 and 02/22/24, staff indicated the elevator was broken and had been since the end of December 2023. Staff 1 (ED) indicated there was a separate elevator located in the memory care. When residents in the assisted living needed to get between floors, staff members had to assist.It was confirmed the facility failed to keep all equipment necessary for the health, safety, and comfort of the resident in clean and good repair.On 02/22/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The elevator is starting to be fixed on Thursday 02/22/24 and will continue into next week.

Based on interview and record review, during a site visit conducted on 10/11/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: In separate interviews on 10/11/23, Staff 1 (ED) and Staff 2 (MC ED) stated the call light response time was between 5-10 minutes.CS was unable to obtain call light logs for April 2023. A review of the call light logs for 10/09/23-10/11/23 indicated 38 occurrences where response times exceeded 20 minutes. The staff schedule from 09/03/23-10/14/23 indicated multiple open uncovered shifts. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.On 10/11/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility is constantly working on hiring staff, still using agency staff but trying to work on getting permanent staff. Will put more focus on call light response times on a daily and weekly basis.

Based on interview and record review, conducted during a site visit on 10/11/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:In an interview on 10/11/23, Staff 1 (Executive Director) stated the facility is using the ODHS ABST. S/He was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The facility is home to 58 residents. Staff 1 explained the facility had been staffing to two 12 hour shifts where two MT and two CG are scheduled for both shifts. Staff 1 stated s/he does not know how to convert their staffing levels using the acuity-based staffing tool.On 10/11/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required six care staff on day shift, five care staff on swing shift, and two care staff on night shift. There were 39 residents' profiles that had not been updated quarterly. A review of the posted staffing plan indicated for day shift there are to be three CG and two MT, on swing shift there are two CG and two MT, and on NOC shift there are to be two CG and one MT. The posted staffing plan does not match the ABST nor the current facility staffing.It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.On 10/11/23, the findings were reviewed with and acknowledged by Staff 1.

Based on observation, interview, and record review, during a site visit conducted on 10/11/23, it was confirmed the facility failed to provide a lockable storage space. Findings include, but are not limited to:CS observed rooms 234, 240, 231, 217, and 244. One of five sampled apartments did not have a lockable storage space. A review of maintenance logs indicated several resident apartments that did not have a lockable storage space installed and/or a key had not been provided to the resident. In separate interviews on 10/11/23, Staff 1 (Executive Director) stated, "I believe maintenance has replaced all the locks about a month ago. Some locks were broken, and some apartments did not have a lock." Staff 3 (Maintenance) stated, "I installed locks in apartments that wanted them, most residents refused." It was confirmed the facility failed to provide a lockable storage space.On 10/11/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility has the locks and will install in all rooms. Should be completed "within the next two weeks."

The findings of the kitchen inspection, conducted 08/17/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 08/17/23, conducted 11/01/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main kitchen in the Assisted Living on 08/17/23 revealed the following:* Walls and floors had an accumulation of black matter and/or dust throughout the kitchen;* Walk-in refrigerator and freezer units had food debris on the floors;* Doors and door jambs had paint chips and gouges;* Black debris and grease build-up was found inside the oven;* Multiple food items inside the walk-in cooler was not covered, labeled, or dated;* Ice machine lid was left unattended while the lid was left open;* There was a dented can in the dry storage;* A cutting board was observed with gray deep scores, creating an uncleanable surface; and*Several boxes of food were stored on the floor of the dry storage and freezer.Additionally, 2 out of 3 kitchen staff were sampled for evidence of current food handler cards. Staff 2 (Culinary Services Director) and Staff 3 (Cook), failed to have documented evidence of a food handler card. Staff 1 (Interim ED) reported Staff 2 and Staff 3 were pulled from the kitchen until they could complete the Oregon food handler course.On 08/17/23, the areas needing cleaning, repair and correction were reviewed with Staff 1. He acknowledged the 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 complaint investigation conducted 04/11/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and observation, it was confirmed that the facility failed to keep equipment clean and in good repair. Findings include:Compliance Specialist (CS) #1 observed on 04/11/2023 the facilities kitchen oven/stove is not working. Interview with Staff #2 on 04/11/2023 stated the facilities oven/stove is not working. The part has been ordered and will be installed no later than 04/30/2023. The facility has adjusted the menu during this time with hot food item that can be cooked with the other items in the kitchen.