Woodside Senior Living Community

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when needed, determine, document, and communicate interventions to all staff, and monitor progress through resolution with at least weekly documentation for 3 of 4 sampled residents (#s 1, 3, and 5). Resident 3 experienced ongoing, severe weight loss. Findings include, but are not limited to: 1.Resident 3 was admitted to the facility in 01/2023 with diagnoses including diabetes and Parkinson’s disease. The resident’s 09/03/24 service plan, 07/18/24 through 10/14/24 progress notes and alert charting documentation, and 03/05/24 through 10/14/24 weight records were reviewed. Staff and the resident were interviewed. The following was identified: *06/05/24 – 150.2 pounds; *07/05/24 – 137.2 pounds; *08/05/24 – 129 pounds; and *09/05/24 – 132.8 pounds. Between 06/05/24 and 07/05/24, Resident 3 lost 13 pounds, or 8.65% of his/her total body weight in 30 days, which constituted severe weight loss and a significant change of condition. There was no documented evidence the facility evaluated the resident and referred the significant change of condition to the facility RN. Between 07/05/24 and 08/05/24, Resident 3 lost 8.2 pounds, or 5.97% of his/her total body weight in 30 days, which constituted severe weight loss and a significant change of condition. There was no documented evidence the facility evaluated the resident and referred the significant change of condition to the facility RN. Between 06/05/24 and 09/05/24, Resident 3 lost 17.4 pounds, or 11.58% of his/her total body weight in 90 days, which constituted severe weight loss and a significant change of condition. There was no documented evidence the facility evaluated the resident and referred the significant change of condition to the facility RN. Resident 3 experienced severe weight loss. There was no documented evidence of a referral to the facility RN for assessment, and the resident continued to lose weight. The need to ensure changes of condition were referred to the RN as needed was discussed with Staff 1, Staff 2, Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. They acknowledged the findings. Refer to C280, example 1. 2. Resident 1 was admitted to the facility in 12/2019 with diagnoses including hemiplegia and stroke. Observations of the resident, interviews with staff, and review of the resident's 03/22/24 service plan, 07/15/24 through 10/09/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. a. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Non-injury fall; * Injury of unknown cause, bruise; * Medication changes; * Hemorrhoids; and * Agitation with transfer/safety devices. b. The resident experienced a non-injury fall on 09/12/24. There was no documentation in the resident's record that the facility had promptly documented an investigation of the fall to determine the cause, minimize reoccurrence, and/or develop and implement interventions. c. The resident experienced a severe weight gain of 8.21 pounds or 5.95%, from 06/12/24 to 07/17/24. There was no documentation in the resident’s record to indicate the RN was made aware of the changes in the resident’s weight. The facility RN was not available for interview. Staff 1 (Administrator) indicated it was not clear if or when the RN was notified of the weight change. The resident’s weight continued to fluctuate 1-2 pounds up or down, between August 2024 and October 2024. The fluctuations were not significant for the resident. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were re-evaluated for effectiveness and clear, resident-specific directions were provided to staff was discussed with Staff 1 (Administrator), Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. The staff acknowledged the findings. Refer to C280, example 2. 3. Resident 5 was admitted to the facility in 04/2019 with diagnoses including heart attack and high blood pressure. Observations of the resident, interviews with staff, and review of the resident's 05/27/24 service plan, 07/15/24 through 10/14/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. a. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Skin tears to the hand and leg; * Medication changes; and * Dizziness. b. The resident sustained a skin tear to the right lower leg on 08/25/24. There was no documentation in the resident's record that the facility had promptly documented an investigation of the skin tear to determine the cause, minimize reoccurrence, and/or develop and implement interventions. c. The resident experienced a severe weight loss of 22.8 pounds, or 7.63%, from 06/21/24 to 09/20/24. There was no documentation in the resident’s record to indicate the RN was made aware of the changes in the resident’s weight. The facility RN was not available for interview. Staff 1 (Administrator) indicated it was not clear if or when the RN was notified of the weight changes. The resident continued to have weight fluctuations of 1-4 pounds up or down, from September 2024 to October 2024. The ongoing weight fluctuations were not significant for the resident. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were re-evaluated for effectiveness and clear, resident-specific directions were provided to staff was discussed with Staff 1 (Administrator), Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. The staff acknowledged the findings. Refer to C280, example 3.

1.& 3. Residents #3 and #5: 1) Create a Change of Condition monitoring log by Administrator 2) Weight fluctuation summary will be pulled from the EHR system weekly by RCC. 3) For weights 3% or greater RCC will obtain a reweight. 4) Nurse will be notified if a weight loss has been identified by RCC. 5) Fax PCP with weight loss by RN or RCC. 6) Intervention for weight loss by RN. 7) Temporary Service Plan created and put into binder for staff to review and acknowledge with signature by RN, RCC or Med Tech. 8) Significant change of condition note in EHR system done by RN. 9) Weekly Nutrition at Risk meeting will be held with Clinical team at the morning clinical meeting. 10) Weekly charting on resident following the Change of condition by RN. 11) Med Tech change of shift form implemented and when completed placed in third check box for RN review. 12) RN will attend Change of Condion training through the Nurselearn portal. 2. Resident #1 1) Temporary Service Plan binder created and placed in cupboard for staff to review and acknowlege with signature by RCC. 2)Blank Temporary Service Plan sheets are placed in binders at each medication cart by RCC. 3) Staff training on filling out TSP and where to place them when completed by RN. 4) Weekly documentation by RN. 5) Clinical meeting daily with RN, RCC and Administrator. 6) Weight fluctuation summary will be pulled from the EHR system weekly by RCC. 7) For weights 3% or greater RCC will obtain a reweight. 8) Nurse will be notified if a weight gain has been identified by RCC. 9) Fax PCP with weight gain by RN or RCC. 10) Intervention for weight gain by RN. 11) Temporary Service Plan created and put into binder for staff to review and acknowledge with signature by RN, RCC or Med Tech. 12) Significant change of condition note in EHR system done by RN. 13) Weekly Nutrition at Risk meeting will be held with Clinical team at the clinical meeting. 14) Weekly charting on resident following the Change of condition monitor log by RN. 15) Staff training on weights by RN. 16) Med Tech change of shift form implemented and when completed placed in third check box for RN to review. Monitoring of corrections will be done by RN and Administrator.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed significant change of condition assessments in a timely manner for 3 of 4 sampled residents (#s 1, 3, and 5) who experienced significant changes of condition. Resident 3 experienced ongoing, severe weight loss. Findings include, but are not limited to: 1.Resident 3 was admitted to the facility in 01/2023 with diagnoses including diabetes and Parkinson’s disease. The resident’s 09/03/24 service plan, 07/18/24 through 10/14/24 progress notes and alert charting documentation, 03/05/24 through 10/14/24 weight records, and meal monitoring records were reviewed, and observations of the resident were completed. The resident and staff were interviewed. The following was identified: *06/05/24 – 150.2 pounds; *07/05/24 – 137.2 pounds; *08/05/24 – 129.6 pounds; and *09/05/24 – 132.8 pounds. Between 06/05/24 and 07/05/24, Resident 3 lost 13 pounds, or 8.65% of his/her total body weight in 30 days. Between 07/05/24 and 08/05/24, Resident 3 lost 7.6 pounds, or 5.54% of his/her total body weight in 30 days. Between 06/05/24 and 09/05/24, Resident 3 lost 17.4 pounds, or 11.58% of his/her total body weight in 90 days. Resident 3 experienced severe weight loss. There was no documented evidence the facility RN completed an assessment, and the resident continued to lose weight. An RN significant change of condition assessment was documented in the progress notes on 07/31/24. At that time weight monitoring was increased to three times a week, nutritional shakes were to be offered to the resident, and staff would “continue to monitor oral intake.” In addition, the RN noted the resident would “be followed under a Change of Condition” which would “. . . increase review of care plan changes to weekly . . .” and new assessments . . .” would be completed at least “. . . every 30 days . . .” until the resident’s weight was stable. On 08/11/24 the RN wrote a change of condition note stating Resident 3’s “intake has been stable,” and his/her “. . . weight has maintained within one pound this month.” As of 08/11/24 the resident had been weighed five times between 08/04/24 and 08/09/24, with a severe 30-day loss on 08/05/24. The 08/11/24 note by the RN did not acknowledge the severe weight loss of 7.6 pounds, or 5.54% of his/her total body weight, that the resident experienced between 07/05/24 and 08/05/24. There were no additional progress notes related to the resident’s ongoing, severe weight loss. Progress notes between 07/18/24 and 10/14/24 indicated the resident was being administered Ozempic (for diabetes) and experiencing intermittent nausea and vomiting. Meal monitoring for the resident was implemented on 07/18/24 and health shakes were implemented on 07/31/24. Meal monitoring records from 09/15/24 through 10/14/24 revealed that out of 91 documented meals, s/he ate an average of 70% of each meal. Of the 29 meals in which s/he ate 50% or less, s/he was offered a health shake 22 times and accepted the shake on 15 occasions. At the time of the survey, the resident’s weight was noted to be 123.6 pounds. The resident was observed to eat meals independently in the dining room. At lunch on 10/15/24, the resident ate approximately 75% of his/her meal. On 10/16/24 at lunch the resident ate approximately 25% of a salad and placed the main course in a to-go container and took it with him/her back to his/her apartment. Staff 15 (Dining Assistant) reported Resident 3 also drank approximately 50% of a health shake with lunch. From 05/05/24 (150.2 pounds) through 10/16/24 (126.4 pounds), the resident lost 23.8 pounds, or 15.84% of his/her total body weight. There was no documented evidence a significant change of condition assessment was completed by an RN in a timely manner for any of the identified severe weight losses experienced by the resident. In an interview on 10/16/24, Staff 1 (Administrator) and Staff 2 (Regional Director of Wellness/RN) acknowledged the system for assessment significant changes of condition had not been followed when Resident 3 experienced severe weight loss. The resident continued to experience severe weight loss. The need to ensure significant changes of condition were assessed by an RN in a timely manner was discussed with Staff 1, Staff 2, Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2019 with diagnoses including hemiplegia and stroke. Weight records, dated 06/12/24 through 07/17/24, and progress notes and physician communications dated 07/15/24 through 10/09/24, indicated the resident experienced the following: * The resident experienced a severe weight gain of 8.21 pounds, or 5.95%, in one month, from 06/12/24 to 07/17/24. The resident’s weight fluctuated up or down less than two pounds between August 2024 and October 2024. Multiple observations of the resident between 10/14/24 and 10/17/24 showed the resident was alert and oriented, directed his/her own care, and was able to assist with some ADLs. The resident required two staff assistance for transfers but one staff for other ADL needs. The resident was independent with food and fluid intake. The resident also had intermittent swelling/edema to the lower legs, feet, and ankles. The resident ate greater than 75% of the meal items delivered to him/her while in the dining room. In interviews on 10/14/24 and 10/15/24, the resident indicated s/he received plenty to eat and drink. The resident indicated s/he could get different items if s/he desired, as well as seconds. The resident expressed no concerns about the staff or his/her care from the facility. S/he said they would do what they liked when they wanted to do it. In interviews between 10/14/24 and 10/17/24, Staff 9 (MT), Staff 13 (CG), and Staff 14 (CG) indicated the resident required one person staff assistance for most of his/her ADL care, and two staff for transfers. The resident was alert and oriented and directed his/her own care. The staff indicated the resident frequently had edema of the lower legs, as s/he spent a lot of time in his/her electric wheelchair and was not always agreeable with elevating his/her legs. The resident was independent with food and fluid intake. No additional documentation regarding the resident’s weight gain was noted in the resident’s record. The facility failed to ensure an RN assessment was completed for the weight gain from June 2024 to July 2024 which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 04/2019 with diagnoses including heart attack and high blood pressure. Weight records, dated 06/21/24 through 09/20/24, and progress notes and physician communications dated 07/15/24 through 10/14/24 indicated the resident experienced the following: * The resident experienced a severe weight loss of 22.8 pounds, or 7.63%, in three months, from 06/21/24 to 09/20/24. The resident’s weight fluctuated up or down within 1-4 pounds in October 2024. The resident was weighed multiple times a week for approximately the last six months. The resident’s weights were primarily trending downward in small increments. Multiple observations of the resident between 10/14/24 and 10/17/24 showed the resident was alert and oriented, directed his/her own care and was independent with a majority of his/her ADLs. The resident was independent with food and fluid intake. The resident had intermittent swelling/edema to the lower legs, feet and ankles. The resident ate greater than 75% of the meal items delivered to him/her while in the dining room. In an interview on 10/14/24, the resident indicated s/he received plenty to eat and drink. The resident indicated s/he could get different items if s/he desired as well and felt the food was good. The resident expressed no concerns around the staff or his/her care from the facility. The resident further indicated s/he had ballooned up a lot from when s/he first moved in a few years back. The resident stated s/he had multiple heart attacks over the last few years and was actively working on eating less and losing weight. In interviews between 10/14/24 and 10/17/24, Staff 9 (MT), Staff 13 (CG) and Staff 14 (CG) indicated the resident was very independent with his/her ADL care and would ask for assistance as needed. The resident was alert and oriented and directed his/her own care. The staff indicated the resident had some edema of the lower legs but was good about elevating his/her legs whenever possible. The resident’s primary mode of ambulation was his/her electric wheelchair. The staff further indicated the resident could use a cane around the apartment and had a walker for slightly longer distances. The resident was independent with food and fluid intake. The staff were not aware of any weight loss plan for the resident. No additional documentation regarding the resident’s weight loss was noted in the resident’s record. The facility failed to ensure an RN assessment was completed for the weight loss from June 2024 to September 2024 which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. The staff acknowledged the findings.

1. Resident #3 1)Created a Change of Condition monitoring log. 2)Weight fluctuation summary will be pulled from the EHR system weekly by RCC and audited for any weights 3% or greater. 3) For weights 3% or greater RCC will obtain a reweight. 4) Nurse will be notified if a weight loss has been identified by RCC. 5) Fax PCP with weight loss by RN or RCC. 6) intervention for weight loss or note with expecteded weight loss due to healthy dieting by RN. 7) Temporary Service Plan created and put into binder for staff to review and acknowledge with signature. 8) Significant change of condition note in EHR system done by RN. 9) Weekly Nutrition at Risk meeting will be held with Clinical team at the morning clinical meeting. 10) Weekly charting on resident following the Change of condition by RN. 11) Med Tech change of shift form implemented and when completed placed in third check RN box by Med Tech. 2. Resident #1 1)Created a Change of Condition monitoring log. 2)Weight fluctuation summary will be pulled from the EHR system weekly by RCC and audited for any weights 3% or greater. 3) For weights 3% or greater RCC will obtain a reweight. 4) Nurse will be notified if a weight gain has been identified by RCC. 5) Fax PCP with weight gain by RN or RCC. 6) intervention for weight gain by RN. 7) Temporary Service Plan created and put into binder for staff to review and acknowledge with signature. 8) Significant change of condition note in EHR system done by RN. 9) Weekly Nutrition at Risk meeting will be held with Clinical team at the morning clinical meeting. 10) Weekly charting on resident following the Change of condition by RN. 11) Med Tech change of shift form implemented and when completed placed in third check RN box by Med Tech. 3. Resident #5 1)Created a Change of Condition monitoring log. 2)Weight fluctuation summary will be pulled from the EHR system weekly by RCC and audited for any weights 3% or greater. 3) For weights 3% or greater RCC will obtain a reweight. 4) Nurse will be notified if a weight loss has been identified by RCC. 5) Fax PCP with weight loss by RN or RCC. 6) Intervention for weight loss or note for expecteded weight loss by RN . 7) Temporary Service Plan created and put into binder for staff to review and acknowledge with signature by RCC,Med Tech or RN. 8) Significant change of condition note in EHR system done by RN. 9) Weekly Nutrition at Risk meeting will be held with Clinical team. 10) Weekly charting on resident following the Change of condition by RN. 11) Med Tech change of shift form implemented and when completed placed in third check RN box by Med Tech for review by RN. Monitoring of corrections will be done by RN and Administrator.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility-administered medications for 3 of 4 sampled residents (#s 1, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2019 with diagnoses including stroke. The resident's 09/01/24 through 10/14/24 observation notes, 06/07/24 signed physician orders, and the 09/01/24 through 10/14/24 MARs/TARs were reviewed and revealed the following: * Eliquis ordered twice daily for blood thinner was noted as not given on 09/13/24 at 7:00 pm, reason documented, “not on hand, was already reordered,” and on 09/14/24 at 7:00 pm, reason “med coming in tonight.” The 9/14/24 7:00 am dose was signed as administered. 2. Resident 5 was admitted to the facility in 06/2022 with diagnoses including stroke, depression, and hypertension. Review of Resident 5’s MARs, dated 09/01/24 through 10/14/24, and physician’s orders, dated 07/19/24, identified the following: * The resident had an order for hydrocodone/APAP 5-325 mg 1 tablet by mouth every 6 hours PRN for pain. Use for pain greater than 7/10. * The PRN hydrocodone was administered 30 times; 23 times without a documented pain rating (1-10 scale), and seven times with a documented pain rating of 0-2. * The resident had an order for acetaminophen 650mg by mouth every 6 hours for pain. Use for pain less than 7/10. * The PRN acetaminophen was administered 62 times; 46 times without a documented pain rating (1-10 scale), and 11 times with a zero-pain rating. In an interview on 10/18/24 at 10:49 am Staff 2 (Regional Director of Wellness/RN) stated there was no documentation of a pain rating prior to the administration of the PRN acetaminophen and hydrocodone. On 10/17/24 at 12:35 pm, the need to ensure MARs were accurate and complete, including clear parameters and pain ratings, was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Wellness/RN), and Staff 4 (RCC). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 04/2019 with diagnoses including Diabetes (type II), hypertension, and acute renal failure. Review of Resident 4’s MARs, dated 09/01/24 through 10/14/24, and physician’s orders, dated 07/16/24, identified the following: There were five administrations of PRN oxycodone 10 mg without documentation of pain rating (1-10 scale). This rating was included in the instructions for the medication and was to be used in determining which PRN pain medication to administer. In an interview on 10/16/24 at 11:15, Staff 9 (MT) stated the pain rating scale was regularly used with Resident 4, but he/she acknowledged that this documentation was lacking for the doses listed above. On 10/17/24, the need to ensure MARs were accurate and complete, including clear parameters and pain ratings, was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Wellness/RN), Staff 4 (RCC), and Staff 5 (RCC). They acknowledged the findings.

Resident #1,4 and 5 1) An audit of all as needed medication to insure all medicatons have a pain scale before medication is given done by Wellness team. 2) Daily audit of EHR system for meds not given by clinical team will be completed. 3) Weekly MAR audit to be completed by RCC to ensure accurate and complete MAR's are maintained for all facility-administered medications to include clear parameters and pain ratings. Monitoring of corrections will be done by RN and Administrator

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

Based on interview and record review, it was determined the facility failed to ensure residents who self-administered their medications were evaluated for safety and a physician’s order was in place for the self-administration, and for administration of medications to a spouse or roommate, if applicable, for 2 of 2 sampled residents (#s 2 and 5) reviewed for self-administration. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2024 with diagnoses including hypertension, osteoarthritis, and lung mass. In an acuity interview on 10/14/24, Resident 2 was identified as administering all of his/her own medications and administering insulin injections for his/her spouse, who resided in the shared apartment. Review of Resident 2’s most recent evaluation, dated 08/29/24, and physician’s orders, signed 08/09/24, revealed the resident had been evaluated and approved to administer, store, and coordinate his/her own medications. There was no documented evaluation or physician’s order in place approving Resident 2 for administering injectable insulin to his/her spouse. On 10/16/24, the need to ensure all residents who self-administered medications, or who administered medications to a spouse or roommate had a physician’s order in place and an evaluation completed prior to self- administration was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Wellness/RN), Staff 4 (RCC), and Staff 5 (RCC). They acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2022 with diagnoses including stroke, depression, and hypertension. During the acuity interview on 10/14/24, Resident 5 was not identified as self-administering his/her medications. However, during interview and record review, it was revealed Resident 5 self-administered one of his/her medications, Vitamin B-12. There was no documented evidence the facility evaluated Resident 5’s ability to safely self-administer the medication. In an interview on 10/18/24 at 10:49 am, Staff 4 (RCC) confirmed Resident 5 self-administered Vitamin B-12 and an evaluation was not completed prior to the resident self-administering the medication. On 10/17/24 at 12:35 pm, the need to ensure residents who self-administered medications had an evaluation completed prior to self-administration was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Wellness/RN), and Staff 4. They acknowledged the findings.

1. Resident #2 1) PCP faxed for approval for Resident to administer medication to spouse by RCC 2) Self Medication assessment completed for Spouse by RN 3) RN will use pre move-in audit tool. 4) Self Medication assessment will be completed with 30 day and 90 day Growth and Wellness plans by RN. 5) Self Medication EHR report audit will be done monthly by RN 2. Resident #5 1) Resident no longer wished to self administer his B-12. Medication was taken to the med. cart and medication changed to staff will administer by RCC. Monitoring of corrections will be done by RN.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on interview and record review, it was determined the facility failed to ensure their posted staffing plan was updated to match the staffing plan generated by their Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to. The facility’s ABST and posted staffing plan were reviewed on 10/15/24 and 10/16/24. The posted staffing plan did not reflect the staffing plan generated by the ABST. The need for the posted staffing plan to match the ABST-generated staffing plan was discussed with Staff 1 (Administrator), Staff 2 (Regional Wellness Director/RN), Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. They acknowledged the findings.

1) ABST reviewed daily for accuracy in the posted staffing plan by Aministrator. 2) Posted staffing plan updated with changes by Administrator.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 17 and 18) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/16/24. There was no documented evidence that Staff 17 (CG), hired 09/13/24, and Staff 18 (CG), hired 09/06/24, demonstrated competency in one or more of the following areas: * General food safety, serving and sanitation; and * First Aid/Abdominal Thrust. The need to ensure all newly hired direct care staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (Regional Wellness Director/RN), Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24. They acknowledged the findings.

1) BOC to follow community tracking tool. 2) BOC to assign training to new employee. 3) RCC to check with BOC to confirm completion of classes before training starts on the floor. 4) BOC to audit tracker monthly to make sure classes are completed. If any classes are incomplete classes will be assign to employee. Quarterly review by BOC and Administrator for accuracy and inservice topics.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long term direct care staff (#4) completed the required number of annual in-service training hours and 3 of 3 long term staff (#s 4, 19, and 20) completed annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 10/16/24. a. Based on anniversary hire dated, there was no documented evidence Staff 4 (RCC), hired 09/08/21, had completed 12 hours of annual in-service training, to include infectious disease training and six hours related to dementia care, between 09/2023 and 09/2024. b. There was no documented evidence Staff 19 (Cook), hired 04/21/20, and Staff 20 (Housekeeper), hired 09/15/21, had completed annual infectious disease training in 2023. The need to ensure staff completed all required training in the specified time periods, was discussed with Staff 1 (Administrator), Staff 4 (RCC), and Staff 5 (RCC) on 10/17/24.

1) BOC to follow community tracking tool. 2) BOC will Assign Dementia, HCBS, LGBTQIA2S,and Infection Control courses through Oregon Care Partners in January of each year. 3) BOC will audit tracker monthly. 4) Quarterly review with BOC and Administrator for accuracy.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and 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. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 10/17/24. There was no documentation that residents were provided fire training at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 10/17/24, Staff 1 indicated the facility had not been documenting specific training that was provided to all residents on an annual basis. There were discussions at resident council meetings, but they were not well-documented regarding all required areas. Staff 1 acknowledged the findings.

1) Resident Fire and Life safety entered into TELS system for yearly prompt and sign off after completion by Maintenance Director. Audit will be done evry six months to assure resident fire and life safety is completed yearly. Monitoring of correction will be done Maintenance Director and Administrator.

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 Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen on 07/22/24, from 10:40 am through 12:45 pm, revealed the following deficient practices: 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 above grill/stove; * Wall behind prep area next to walk-in; * Larger oven on the right side; * Shelving holding steamer; * Windowsill; * Large can opener and housing; * Open wood shelving under steam line; * Reach-in deli cooler; * Reach-in freezer; * Fans and cages in walk-in cooler; * Movable utility/baking racks; * Large white tub holding drinks; * Plastic bins holding fresh produce; * Toaster; and * Interior of microwave. b. The following areas needed repair: * Caulking behind handwashing sink; * Windowsill with water damage to wood, with cracked and peeling paint; * Missing tile in entry way to kitchen; * Missing grout in dining room beverage area tile; and * Damaged wood on piler near kitchen entry/exit. c. Multiple food items/packages/containers found in walk-in cooler, reach-in deli cooler, reach-in freezer, and dry food storage that were open to potential contamination. d. Multiple food items missing opened/prepared dates or use-by dates and/or were past the use-by date documented on the label. e. Multiple kitchen staff were observed to handle ready-to-eat (RTE) food items with bare hands and were not wearing gloves as required. f. Multiple single-service food storage devices and/or food equipment with food contact surfaces were observed stored open to potential contamination, as they were not covered or inverted as directed by rule. g. Some food items on resident room trays were not covered and protected from potential contamination during meal delivery. h. Multiple cutting boards were found heavily scored and stained and in need of replacement. Cupcake/muffin baking pans were observed with heavy amounts of baked-on food debris. i. Dining area was observed to have pre-set silverware that was not protected from potential contamination as required. In an interview on 07/22/24 at 12:30 pm, Staff 1 (Administrator) and Staff 2 (Dining Services Manager) were informed of concerns found. They acknowledged the findings.

1. All area identified in an including the ceiling above the  grill/stove has been added to the TELS maintenance system for bid to be repainted, and the open shelving under steam line is added to TELS system for doors to be added. All other areas found to be deficient in a are inprocess of being cleaned. 2. All areas identified in b are inprocess of being repaired or added to the TELS maintance system for our Maintenance Director to address. All areas identified in subsections c,d,e,f,g and i, staff training will be provided to team members for the following topics: Proper storage for dry food items Proper storage for cold food items Proper labeling of open/prepared dates or use-by dates Proper handeling of ready to eat foods Proper storage of food coverage or being inverted proper room tray set up and delivery proper protocol for preset silverware to prevent potential contamination 3. h New cutting boards, muffin pans, large white tubs and cutting board shaver were ordered on 7/23/2024. 4. To ensure this violation doesn't happen again, all areas in a,b,c,d,f and h will be monitored via cleaning schedules and areas e,g and i will be monitored via weekly/spot check 5. e Gloves and glove holder placed at service line. 6. The areas idendified in subsections a,b,c,d,f and h will be monitored per the frequency identified on the cleaning schedules and the areas identified in subsections e,g and i will be monitored weekly/spot checked. 7. i Silverware will be rolled so it is protected from protential contamination. 8. The Dining Services Director will be responsible to see that the corrections are completed/monitored by reviewing the cleaning schedules and kitchen sanitation inspection audit tool on a weekly basis.   Submitted by Becky Johnson

The findings of the kitchen inspection, conducted 07/22/24, 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 revisit to the kitchen inspection of 07/22/24, conducted 10/07/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, conducted during a site visit on 06/25/24, it was confirmed the facility failed ensure a safe medication administration system for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: A review of Resident 2's January 2024 MAR and progress notes indicated the following: · There were nine occurrences where a medication was not given due to the facility not having it available. In separate interviews, Staff 1 (Executive Director) and Staff 3 (MT) stated the following: · The med cards had numbers on them and when it got to the blue section, they re-ordered. · Occasionally they ran out of a medication. · Sometimes they were waiting on the doctor. · There was a new policy with med cart audits on a weekly basis. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 06/25/24. It was confirmed the facility failed to ensure a safe medication administration system. Verbal plan of correction: Management went over the medication re-ordering process in the monthly all staff meeting after the incident and in the med tech training meeting. RCC's are now doing a weekly audit of medications including liquid, spray, and oral medications.

Based on interview and record review, conducted during a site visit on 06/25/24, it was confirmed the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 2 of 2 sampled staff (#s 4 and 5). Findings include but are not limited to: A review of completed training documents for Staff 4 (MT) and Staff 5 (CG) indicated the following: · Staff 4 was hired on 02/20/24 and did not have completed competency/skill checklists for CG or MT duties. · Staff 5 was hired on 04/19/24 and did not have completed competency/skill checklists for CG duties. During an interview on 06/25/24, Staff 1 (Executive Director) stated they were unable to locate some of the completed training documents for some staff. The findings were reviewed with and acknowledged by Staff 1 on 06/25/24. It was determined the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Plan of correction: ED and RN will immediately do an audit of all staff training records to make sure staff have documented training in the file. All staff will be retrained, and paperwork will be filled out as needed. ED will also find a new space to keep records to prevent loss of paperwork in the future.

Based on interview and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include: Review of posted staffing plan, timecards for 07/06/22, call light response times for 07/06/22-07/07/22, Acuity Based Staffing Tool (ABST), and service plans for Residents #1-3. The facility has not completed entering all of the residents into the ODHS staffing tool. The posted staffing plan reports that there are to be 2 med techs and 2 care partners on Days and Swing Shifts and 1 med tech and 1 care partner on Noc shift. The timecards showed 5 staff for days, 3 for swing, and 2 for Noc. The Express payroll invoice did not show any agency staff working on 07/06/22. The facility did not staff per their staffing plan on swing shift for 07/06/22. Call light logs revealed multiple call light response times ranging between 20 minutes to 1 hour and 36 minutes. The above information was shared with Staff #1 on 07/28/22. Staff #1 acknowledged the findings of the call light response times. Interviews on 07/28/22, Staff #1 stated that they are using the ODHS ABST, however, they have only entered in about 13 residents out of the 46. The facility ' s expectation is for staff to be responding to call lights within 7 minutes. They are auditing the call light logs about twice per month or if there are complaints. Staff #3-4 stated that there is not enough staff to respond to residents timely. Call lights are going off for longer than 20 minutes. The care staff are also responsible for doing room trays which can take a while.

Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: Review of timecards for 07/06/22, call light log for 07/06/22-07/07/22, posted staffing plan, ODHS ABST, and service plans for Resident #1-3. The ABST has not been updated with all of the residents in the facility. The posted staffing plan is not reflective of the ABST as it has not been fully updated and implemented yet. Call light logs revealed multiple call light response times ranging between 20 minutes to 1 hour and 36 minutes. The above information was shared with Staff #1 on 07/06/22, who was in agreement. In an interview on 07/28/22, Staff #1stated that they are using the ODHS ABST, however, they have only entered in about 13 residents out of the 46. They are working on getting this updated. The ABST based staffing plan does not match the facility ' s posted staffing plan because it is not yet finished. The facility 's expectation is for staff to be responding to call lights within 7 minutes. Staff #3-4 stated that there is not enough staff to respond to residents timely. Call lights are going off for longer than 20 minutes.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 07/28/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day