Avamere at Sherwood Assisted Living Facility

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, included resident preferences that supported the principles of choice and individuality, and provided clear directions to staff regarding the delivery of services for 3 of 5 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2024 with diagnoses including type 2 diabetes mellitus with diabetic nephropathy, chronic kidney disease, and long-term use of insulin.

During the acuity interview on 10/27/25, Resident 4 was identified as self-administering all of his/her medications, including insulin (to control blood glucose level).

Observations were made of the resident's self-administration of medication on 10/28/25, interviews with the resident and facility staff were conducted, and the service plan, dated 10/09/25, was reviewed.

Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions on signs and symptoms of hypo- and hyperglycemia to report;
* Instructions for proper maintenance of blood glucose monitor on left upper extremity and how to monitor for malfunctions;
* Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped meals;
* Electric wheelchair equipment precautions and instructions for proper maintenance; and
* Assistance required with dressing.

During the interview with the resident on 10/28/25 at 11:29 am, s/he stated the need for one-person assistance with dressing and putting his/her left knee brace on. S/he also expressed a fear of blood glucose level dropping in the morning around 5:00 to 6:00 am: “I don’t know when my blood sugar goes low. I feel and know when it is low during the day. I have glucose tablets, but they don’t work fast. I like to have Pepsi. Then it [blood glucose] is up in five minutes.”

Staff 14 (MT/CG) was interviewed on 10/30/25 at 12:25 pm and confirmed Resident 4 required one-person assist with “morning routine especially dressing, getting up, putting brace on … and reminders to go to meals because [s/he] likes to nap a lot.” Staff 14 and Staff 8 (MT), in an interview on 10/29/25 at 3:38 pm, both stated Resident 4 was fully independent with blood glucose monitoring and administration of all medications.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 2:14 pm. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 08/2025 with diagnoses including atrial fibrillation and hypertension.
The resident’s record was reviewed, including the current service plan, dated 08/21/25, and interviews with staff and the resident were conducted. The following was identified:

The service plan was not reflective of the resident’s current care needs and/or preferences in the following areas:

* Activities in relation to preferred activities; and
* Hearing deficit.

The need to ensure service plans were reflective of the residents’ current care needs and preferences was reviewed with Staff 2 (Director of Health Services/RN), Staff 3 (LPN), Staff 6 (Arbor Administrator), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 4:00 pm. They acknowledged the findings.

3. Resident 2 moved into the community in 05/2022 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease stage 3, neuromuscular dysfunction of bladder, and disorientation.
The resident’s record was reviewed, including the current service plan, dated 09/18/25, observations were made, and interviews with staff were conducted. The following was identified:

The service plan was not reflective of the resident’s current care needs and/or was not implemented in the following areas:

* Fortified meals;
* Meal set-up and as-needed assistance with preparing meals delivered to the resident’s room; and
* Smoking status.

On 10/28/25 at 10:57 am, Staff 19 (Cook) reported he had not been preparing fortified meals for the resident.

The need to ensure service plans were reflective of the residents’ current care needs and were implemented, was reviewed with Staff 1 (ED), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 3:18 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 5 sampled residents (# 2) whose orders were reviewed. This resulted in unnecessary pain and a visit to the emergency department for Resident 2. Findings include, but are not limited to:

Resident 2 had a history of urinary tract infections (UTI) and had a standing, as-needed order to obtain a urine specimen if the resident showed signs or symptoms of a UTI, including frequency, burning, urgency, painful urination, blood in urine, or change in behavior, and if the licensed nurse determined a positive result, to send it in for a culture and sensitivity test.

On 07/14/25, staff requested the resident’s legally authorized prescriber for a urinary analysis (UA) and culture and sensitivity order due to the resident having blood in his/her catheter bag, urge to urinate, complaints of pain, and increased confusion.

On 07/15/25, the facility received a signed order for a UA and culture and sensitivity test. Staff continued to document the resident’s status including increased confusion. There was no documented evidence a urine sample was collected as ordered.

On 07/28/25, a home health nurse reported blood in the resident’s urine bag and tubing, and a urine sample was collected for a UA and culture and sensitivity test. Staff continued to document the resident’s status, including that the resident had a possible UTI, had blood in his/her urine, and had increased confusion.

On 08/01/25 the facility received the resident’s UA report indicating multiple abnormal results. Upon receipt of the UA results, there was no documented evidence the legally authorized prescriber was notified.

On 08/01/25 the resident was placed on alert for possible UTI. Staff continued to document the resident’s status, including increased confusion and blood in his/her urine, from 08/01/25 through 08/04/25.

On 08/05/25, Resident 2 was sent to the emergency department for “extreme pain,” signs of infection, and increased confusion. The resident was diagnosed with a UTI and provided an order for antibiotics.

The facility failed to carry out physician orders as prescribed, which resulted in unnecessary pain and a visit to the emergency department.

The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 3:18 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 1 of 1 sampled resident (# 3) with documented refusals. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2025 with diagnoses including atrial fibrillation and hypertension.
The resident’s MAR, dated 10/01/25 through 10/27/25, and physician’s orders were reviewed. The following was identified:

Resident 3 had documented refusals on his/her MAR for the following orders:

a. Polyethylene glycol powder (for bowel care), take 17 grams by mouth every morning. The resident refused the medication nine times during the reviewed period. There was no documented evidence the provider was notified of refusals on six occasions.

b. Senna (for bowel care), 8.6 mg tablet, take two tablets by mouth at bedtime. The resident refused the medication 14 times during the reviewed period. There was no documented evidence the provider was notified of refusals on the 14 occasions.

During an interview on 10/30/25 at 1:45 pm, Staff 3 (LPN) and Staff 18 (VP of Clinical Operations) acknowledged there was no documented evidence the facility notified the provider when Resident 3 refused to consent to physician’s orders.
The need to notify the provider when a resident refused to consent to an order was reviewed with Staff 2 (Director of Health Services/RN), Staff 3, Staff 6 (Arbor Administrator), and Staff 18 on 10/30/25 at 4:00 pm. They acknowledged the findings. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed prior to beginning job duties for 2 of 3 newly hired staff (#s 12 and 13) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 10/28/25 through 10/30/25. The following was identified:

a. There was no documented evidence Staff 12 (CG), hired 04/04/25, had completed the following required pre-service orientation training prior to beginning their job responsibilities:

* Approved Home and Community Based Services (HCBS) course; and
* Pre-service dementia related to specific aspects of dementia including addressing pain, providing fluids, and use of person-centered approach.

b. There was no documented evidence Staff 13 (CG/MT), hired 08/05/25, had completed the following required pre-service orientation topics prior to beginning their job responsibilities:

* Resident rights and values of Community Based Care (CBC);
* Fire safety and emergency procedures; and
* Pre-service dementia training.

On 10/30/25 at 11:15 am, Staff 7 (Business Office Manager) confirmed Staff 12 and Staff 13 had been working independently and stated they would be removed from the schedule, until they completed pre-service orientation.
The need to ensure staff completed all required pre-service orientation and training prior to beginning their job responsibilities and for direct care staff to complete required pre-service dementia training prior to providing care to residents was reviewed on 10/30/25 at 1:05 pm with Staff 1 (ED) and Staff 7. They acknowledged findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 13 and 17) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 10/28/25 through 10/30/25. The following was identified:

a. There was no documented evidence Staff 13 (CG/MT), hired on 08/05/25, and Staff 17 (MT), hired on 05/06/25, demonstrated competency within 30 days of hire in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting changes of condition; and
* Conditions that require assessment, treatment, observation and reporting.

b. Staff 17 (MT), hired on 05/06/25, demonstrated competency in medication passing on 08/20/25, 108 days after his/her hire date.

The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was reviewed on 10/30/25 at 1:05 pm with Staff 1 (ED) and Staff 7 (Business Office Manager). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about fire and life safety procedures within 24 hours of admission in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 10/30/25 at 11:10 am.

On 10/30/25 at 11:50 am, Staff 1 (Executive Director) and Staff 5 (Director of Maintenance) were asked to explain the facility's process for providing residents with instructions on fire and life safety procedures within 24 hours of admission. Staff 5 reported he was responsible for providing fire and life safety training to all residents. However, the facility was unable to produce any documented evidence confirming the training had been provided within 24 hours of admission.

The need for residents to be instructed about fire and life safety procedures within 24 hours of admission per the OFC was discussed with Staff 1, Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 2:14 pm. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 01/30/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas:

* Flooring throughout the kitchen, including underneath/behind prep counters, cooking equipment, storage racks, dishwasher and sink units – spills/drips/splatters/grease/food debris/build up of black matter;

* Wall and caulking surrounding the dirty dishes side of the dishwasher – significant build up of black matter;

* Operating air conditioning unit vent above ice maker – significant build up of dust;

* Exterior doors and handles of reach in refrigerator – spills/drips;

* Commercial can opener – blade finish worn off/build up of black matter surrounding casing;

* Hood area above and behind stove top and grill – significant build up grease/dust;

* Shelves below steam table – drips/spills/splatter;

*Oven and convection oven doors, knobs and handles – drips/spills/sticky/dust build up;

* Sides of oven – drips/spills/grease;

* Interior of refrigerator on steam table line – food debris/spills/splatter;

Other areas of concern include:

* Ceiling light above three sink area – uncovered.

* Improper storage:

- Two sheet pans of individual servings of cake uncovered in high traffic area; and

- Two boxes of disposable cups and lids on floor in hallway between kitchen and MC unit.

The areas of concern were discussed with Staff 1 (Dining Services Manager) and discussed with Staff 2 (Interim Executive Director) on 01/30/25 The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 09/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 09/27/23, conducted on 01/29/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/27/23 at 11:05 am, the facility kitchen was observed to need cleaning in the following areas: * The walk in refrigerator floor had black matter in the corners; * The walk in freezer door handle had orange matter;* The ceiling vent near entrance had dust build up;* The wall behind the stove had build up of grease;* The front of deep fat fryer had grease build up;* The wall beside deep fat fryer had splattered grease and black matter;* The lower shelves throughout the kitchen had food debris and splatters;* The top and cover of ice machine had spills/debris/drips;* The area behind and the shelves underneath the steamer, next to the stove had debris/dust; and* The exterior doors of the reach in refrigerator had streaks/splashes/drips.The ceiling light fixture in the prep area was uncovered. Boxes of Styrofoam cups and food containers were sitting directly on the floor in kitchen service area. The findings were discussed with Staff 1 (Dietary Manager) on 09/27/23 and were acknowledged.

The findings of the re-licensure survey, conducted 08/22/22 through 08/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 08/24/22, conducted 12/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. 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 2nd revisit to the re-licensure survey of 08/24/22, conducted on 03/21/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: Based on observations on 08/22/22 at 10:20 am, the facility kitchen needed cleaning and repair in the following areas:a. Food spills, splatters, dirt, dust and black matter was observed on or beneath the following:* Walls and light switch in dish washer area;* Handwashing sink to the right of the ice machine:* Inside of microwave;* Air conditioning unit vents above ice machine;* The underside of the motor housing on the stand mixer;* Telephone located on a shelf above rear prep counter;* Floor around the deep fryer; * Lower storage shelves of the steam table;* Inside of the plate warmer;* Handles and shelves of multiple serving carts;* Large round floor fan; and* Grates on the exhaust fans in the walk-in refrigerator.b. The following areas needed repair:* Caulking around the warewashing area; * Weather strip on trim of the "In" door;* Scoop holder next to the ice machine;* Laminate was missing on the steam table cabinet;* Paint was peeling from the "Out" door;c. The following areas in the beverage/serving stations in the Dining Room needed repairs:* Hole in the wall of the beverage station;* Laminate was worn exposing bare wood in the beverage station cabinet where the garbage can was stored; and* Laminate was missing on the serving station cabinets.The areas needing cleaning and repair were reviewed with Staff 12 (Dietary Services Manager) on 08/22/22 and Staff 1 (ED) and Staff 8 (Plant Operations Assistant) on 8/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate service-planned interventions for effectiveness, initiate new interventions following a series of repeated falls, and monitor conditions through resolution for 2 of 4 sampled residents (#s 3 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including Multiple Sclerosis, chronic urinary tract infections and muscle weakness. The service plan noted a history of falls and identified the resident as a fall risk.The resident's service plan, dated 08/03/22, progress notes, dated 07/12/22 through 08/22/22, interim service plans, and incident reports were reviewed. The records indicated Resident 4 experienced three falls from 07/14/22 through 07/18/22. Interim service plans were created, which initiated the following interventions:* Staff will perform safety checks on the resident every 2-3 hours (07/18/22);* Staff will encourage the resident to use pendant to call for assistance (07/18/22); and* The resident should wear non-skid shoes/slippers and socks to promote secure footing (initiated 07/19/22).Resident 4 had six additional falls from 07/19/22 through 08/12/22 which occurred after these interventions were in place. There was no documented evidence these service-planned interventions were evaluated for effectiveness, and interim service plans written after these subsequent falls did not include new interventions to help prevent further falls.On 08/24/22 the need to implement resident-specific interventions following changes of condition, and to evaluate those interventions for effectiveness was discussed with Staff 1 (ED), Staff 2 (RN/ Director of Health Services) and Staff 3 (LPN). They acknowledged the findings.
2. Resident 3 was admitted to the facility in 05/2022. Review of the resident's progress notes, dated 05/23/22 through 08/17/22 revealed the resident experienced the following injuries:* 05/27/22- Skin tear to right hand; and* 05/29/22-Skin tear to left hand.The facility lacked documented evidence interventions were determined and communicated to staff on all shifts, and the injuries monitored at least weekly, through resolution.In an 08/23/22 Interview with Staff 2 (RN), she confirmed the resident's injuries were not properly recorded, and therefore were not monitored by the facility. The need to ensure short term changes of condition were evaluated, interventions determined, communicated to staff on each shift and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 (LPN) on 08/24/22. They acknowledged the findings.
2. Resident 9 was admitted to the facility in 08/2022. Review of the resident's progress notes, dated 10/23/22 through 12/20/22, revealed the resident experienced the following:* 11/25/22 - Moved into the assisted living from memory care facility; and* 12/08/22 - Returned from a hospital stay (12/01/22 - 12/08/22).The facility lacked documented evidence the short term changes of condition were evaluated and monitored with progress noted at least weekly through resolution.The need to ensure short term changes of condition were evaluated and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (RN/Director of Health Services) on 12/20/22. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition were evaluated, actions or interventions were determined and communicated with staff on all shifts, and/or were monitored through resolution with at least weekly documentation for 2 of 4 sampled residents (#s 6 and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 07/2022 with diagnoses including asthma, atrial fibrillation, and arthritis.A review of the resident's clinical record, including progress notes dated 10/23/22 through 12/20/22 and staff interviews revealed the following;* The resident had a physician's order to self-administer his/her medications without supervision.* Between 11/08/22 and 11/28/22 staff documented five occasions where caregivers were assisting the resident with taking his/her medications by "putting them in [the resident's] mouth" and reminding him/her to take them. According to a progress note dated 11/28/22 the resident "was struggling to take them [medications] and dropping them on the floor."* On 11/30/22, Staff 2 (RN/Director of Health Services), documented she had spoken with the resident's sister about facility staff having to remind him/her to take their medications often. The RN asked the sister if she thought the facility needed to start administering the resident's medications. The sister stated she would speak with the family about the issue.* Between 12/03/22 and 12/19/22, staff documented an additional three occasions on which staff assisted the resident with his/her medications.* On 12/19/22, Staff 4 (Resident Care Coordinator) documented she spoke with the resident about his/her medications and asked if s/he " ... would like for us to manage them ..." The resident responded, "not right now I just need to be woke up earlier so I can take them on time". The RCC documented she "set up a wake time of 7am" in the resident's service plan.In an interview with Staff 2 on 12/20/22, she stated she was aware of staff assisting the resident with taking medication on several occasions. She reported she had observed the resident taking his/her medications without assistance on more than one occasion, and s/he was able to self-administer without any difficulties. Staff 2 reported she had not evaluated the resident's ability to safely self-administer their medications during the time period reviewed.The need to ensure changes of condition were evaluated and monitored through resolution, with at least weekly documentation of progress, was discussed with Staff 1 (Executive Director), Staff 2, and Staff 24 (Regional Nurse Consultant) on 12/20/22. They acknowledged the findings.1. Resident #6 now realizes she is having difficulty taking her medications and agreed for community to manage. After a thorough medication review is conducted to reconcile her doctor's medication list to her list of medications she is self administering, and we have acccurate orders, Resident #6's medications will be managed by community. Evaluation and service plan will be updated to reflect community is managing her medications. Resident #9 has been placed on alert and staff have been adding updates on her in progress notes.2. To prevent recurrence, the 24 hour summary, communciations, and alert charting audit will be reviewed five days a week as part of daily standup meeting with the clinical management team. A list of residents on alert will be printed and reviewed during standup. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a resident change of condition is identified, the resident will be placed on alert charting which will include a LN assessement and any changes to the plan of care. Any changes to service plans as a result of a change of condition will be communicated to staff via either an ISP or updated full service plan to review and sign. 3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require change of condition monitoring. 4. The Executive Director and LNs are responsible for maintaining this system.

2. Resident 3 was admitted to the facility in 05/2022.The resident's physician's orders, dated 05/02/22 and MAR, dated 08/01/22 through 08/22/22 were reviewed, and it was determined there were no signed physician's orders for the following PRN bowel medications and treatments:* Bisacodyl Laxative suppository;* Mi-Lanta suspension;* Loperamide suspension; * Milk of Magnesia suspension; and* Polyethylene Glycol powder.In an interview on 08/24/22, Staff 2 (RN/Director of Health Services) acknowledged the facility lacked written, signed orders in the resident's record for the medications. The need to ensure written, signed orders were in the resident's record for all medications and treatments administered by the facility was discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 (LPN) on 08/24/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 4 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 08/2018.A review of the 08/01/22 through 08/22/22 MAR and current physician's orders revealed the following medications were not documented to be administered as prescribed:* Humalog (insulin);* Gabapentin (anticonvulsant);* Acetaminophen (pain reliever); and* Velphoro (end stage renal disease).The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 08/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 1) who had documented medication refusals. Findings include, but are not limited to:Resident 1 was admitted to the facility in 08/2018 with diagnoses including diabetes and end stage renal disease.Resident 1's MAR was reviewed for the time period of 08/01/22 through 08/22/22. Staff documented Resident 1 refused the following medications multiple times: * Humalog (insulin); and* Velphoro (end stage renal disease). There was no documented evidence the facility notified Resident 1's physician/practitioner of the refusals.The need to notify the physician of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 08/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 8) who had documented medication refusals. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the facility in 08/2022 with diagnoses including anxiety.Resident 8's MAR was reviewed for the time period of 12/01/22 through 12/20/22, and signed physician orders and progress notes were reviewed from 10/23/22 through 12/20/22. Staff documented Resident 8 refused the following medications multiple times in several days consecutively: * Citalopram (antidepression); * Retaine MGD eye drops; and * Systane complete solution eye drops.The resident's signed physician order, dated 08/23/22, indicated to notify if the resident refused any medications or treatment "for more than 2 days in a row".There was no documented evidence the facility notified Resident 8's physician/practitioner of the refusals as ordered.The need to notify the physician of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 12/20/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (#22) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 08/23/22 and revealed the following:Staff 22 (CG), hired on 07/05/22, lacked documentation of demonstrated competency in: * Changes associated with normal aging;* Identification, documentation and reporting of changes of condition; and* Conditions that require assessment, treatment, observation and reporting.The need to ensure staff have documented evidence of competency demonstrated in assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 5 (RCC) and Staff 10 (Business Office Manager) on 08/23/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 12 hours of annual in-service training, including 6 hours of dementia care training, had been completed for 2 of 3 long-term staff (#s 16 and 23) whose records were reviewed. Findings include, but are not limited to: On 08/23/22, training records were reviewed and revealed the following:* Staff 16 (MT), hired 05/11/18, and Staff 23 (CG), hired 12/07/20, lacked documentation of having completed a minimum of 12 hours annual in-service training, including 6 hours of the dementia care training.The need to ensure that all staff had documented evidence of completing a minimum of 12 hours annual in-service training, including 6 hours of dementia care training, was discussed with Staff 1 (ED), Staff 5 (RCC), and Staff 10 (Business Office Manager). They acknowledged the findings.

Based on interview and record review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records from 03/2022 through 07/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components:* Location of simulated fire origin;* Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and* Number of occupants evacuated.In an interview on 08/24/22, Staff 7 (Plant Operations Manager) reported that the facility was not relocating or evacuating residents as part of the fire drill process. While the facility had completed one full evacuation drill in April 2022, resident participation was not documented, and fire drill records revealed that residents were not consistently involved in the fire drill process. The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 (ED) and Staff 7 on 08/24/22. They acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to: On 08/22/22, Staff 1 (ED) was asked to explain the process of providing resident instruction upon admission and reinstruction annually. Staff 1 (ED) stated that fire drill and safety procedures were reviewed with the resident within the first week of admission, and not within the first 24 hours of admission. Staff 1 (ED) stated that re-instruction was not provided annually. The need to ensure residents were instructed on general safety procedures within 24 hours of admission and re-instructed at least annually was discussed with Staff 1, Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 270 and C 305.

Based on observation and interview, it was determined the facility failed to ensure the exterior pathways were accessible and maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 08/22/22. The following was noted as needing repair:* A section of the exterior pathway at the rear of the facility had standing water and was not easily passable. The exterior was toured with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22 at 10:15 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include but are not limited to:Observations of the facility on 08/22/22 revealed the following:* The following doorframes, doors or walls were gouged or scraped: - Dining room entrance and exit doors; - First, second and third floor elevator doors; - Facility main entrance doorways; - Corners of the wall in the hallway next to the Activity Room; and - Resident apartments 308 and 310.* Light fixtures throughout the dining room had visible debris in the fixture;* Second and third floor laundry rooms had a large amount of debris behind the machines;* A washing machine in the second floor laundry room was full of standing water;* There were holes in the wall on the right side of the third floor game room above the puzzle table; and* There were long screws protruding from the bases of several of the legs of the pergola on the back patio.The facility was toured with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22 at 10:15 am. They acknowledged the findings.

Based on observation and interview it was determined that the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor. Findings include, but are not limited to:The facility was toured on 08/22/22. Resident windows and common area windows on the second and third floors opened vertically and windowsills were lower than 36 inches. The windows lacked a mechanism to prevent the window from opening fully to prevent accidental falls. The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant). They acknowledged the findings.

Based on observation and interview it was determined that the facility failed to ensure that covers, grates or screens of wall heaters do not exceed 120 degrees Fahrenheit. Findings include, but are not limited to:During a tour of the facility on 08/22/22, the following observations were made:* At 2:40 pm, a wall heater was observed in apartment 102. When turned on, the surface temperature was 220 degrees Fahrenheit.* At 2:55 pm, a wall heater was observed in apartment 220. When turned on, the surface temperature was 200 degrees Fahrenheit.* At 3:00 pm, a wall heater was observed in apartment 313. When turned on, the surface temperature was 240 degrees Fahrenheit.The need to ensure that all covers, grates or screens of wall heaters and associated heating elements do not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22. They acknowledged the findings. Staff 7 stated he would disconnect any wall heaters that were in resident apartments.