Woodside Senior Living Community

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

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

Based on interview and record review, 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.

The findings of the re-licensure survey, conducted 5/26/21 through 5/27/21, 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 for 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 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

The findings of the first re-visit to the re-licensure survey of 5/27/21, conducted 9/2/21, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to monitor each resident consistent with his or her evaluated needs and service plan, for 1 of 2 sampled residents (#2) who had multiple falls. Findings include, but are not limited to:Resident 2 was admitted to the facility in 2018 with diagnoses including diabetes mellitus - Type 2 with neuropathy, congestive heart failure, obesity, chronic obstructive pulmonary disease (COPD), hypertension and developmental delay. The resident was admitted to hospice on 2/16/21, in large part because s/he was not compliant with health professionals' recommendations and physician orders to address various medical conditions and, as a result, the resident's health was declining. Resident 2's non-compliance and declining health also increased his/her fall risk. Review of the record indicated Resident 2 had five non-injury falls between 4/14/21 and 5/6/21, as follows:* 4/14/21: "legs gave out" causing fall while walking in apartment;* 4/24/21: fell asleep while eating breakfast and fell out of wheelchair;* 5/5/21: fell out of wheelchair while outside smoking;* 5/6/21: was found by CG in apartment "shaking" and slid out of wheelchair; and* 5/6/21: pushed call pendant and was found on the floor in apartment.Review of the facility "Event Reports", "Incident Investigations", Temporary Service Plans (TSPs) and the service plan itself indicated the following deficiencies:* The facility failed to thoroughly investigate each fall to identify and document factors that may have contributed to the resident's fall; * The facility failed to monitor the service-planned fall interventions to determine if they were being implemented and were effective at the time of the fall, or if new interventions needed to be developed and implemented based on the investigation of the cause(s) of the fall; and* When new interventions were identified on the "Incident Investigation" form, they were not added to the resident's service plan and communicated to staff for implementation via a TSP.The need to ensure falls were thoroughly investigated and fall interventions were monitored for effectiveness, was discussed with Staff 1 (Administrator), Staff 2 (RN/Wellness Director), Staff 3 (Regional RN), Staff 4 (Regional Director) and Staff 6 (RCC) on 5/27/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit 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:During the survey, wall-mounted heaters were observed in one-bedroom apartments. Heaters in two separate rooms were observed on and the wall heater cover grate reached a temperature above 220 degrees Fahrenheit when tested by the surveyor. A third room with a wall heater cover grate reached a temperature above 175 degrees Fahrenheit when tested by the surveyor.On 5/27/21, the need to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) and Staff 4 (Regional Director). They acknowledged the findings.