Lakeland Senior Living

Based on interview and record review, it was determined the facility administrator or designee failed to immediately notify the local Department office, or the local AAA, of any incident of suspected abuse, promptly investigate all reports of suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 1 of 1 sampled resident (#7) who reported neglect to the facility. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 09/2018 with diagnoses including type 2 diabetes mellitus, coronary artery disease, peripheral neuropathy and sleep apnea with CPAP (continuous positive airway pressure).

At the resident’s request, this surveyor met with Resident 7 on 11/07/24 at 12:45 pm. During the interview, the resident reported that approximately one month ago, s/he fell in his/her room sometime after midnight. The resident stated it took the facility staff at least 30 minutes to respond after pressing the call pendant, during which time the resident said s/he was in severe pain.

The resident provided a copy of a hand-written letter, titled “Injury Report”, s/he said s/he provided to Staff 1 (ED) on 10/29/24 – four weeks after the above incident. The document stated staff had not responded to the call pendant for “at least 30 minutes” during which time s/he was “screaming” and in “indescribable” pain.

Resident 7’s report of being in pain while waiting 30 minutes for staff to respond represented an incident of suspected abuse which required the facility to immediately report the incident to the local Department office and investigate the incident to ensure the safety of residents.

In an interview on 11/07/24 at 2:10 pm, Staff 1 confirmed Resident 7 had provided him with the above letter. He acknowledged he had not reported the incident as suspected neglect/abuse, investigated the report and taken measures necessary to prevent reoccurrence of abuse.

The need to immediately notify the local Department office of any incident of suspected abuse, promptly investigate all reports of suspected abuse and take measures necessary protect residents and prevent the reoccurrence of abuse, was reviewed with Staff 1, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 9:30 am. They acknowledged the findings.

The surveyor directed the facility to report the incident to the local APD office; confirmation the incident was reported was received on 11/08/24 at 10:35 am.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to:

On 11/05/24 through 11/06/24 interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified:

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:

* Floor under/behind and between major equipment;
* Floor under and around ware washing area;
* Floor to wall transition throughout kitchen;
* Floor and wire shelving in walk-in refrigerator;
* Floor in walk-in freezer;
* Dining room self-serve coffee, snack, and popcorn station counter tops and cabinetry;
* Inside drawers and cabinets of dining room self-serve station;
* Interior and exterior of popcorn machine;
* Interior of clear plastic food display case;
* Food carts for delivering resident meals;
* Entry door and frame to the kitchen;
* Exit door and frame to dining room;
* Walls throughout kitchen;
* Ceiling, vents, and fans above food prep and storage areas;
* Interior and exterior of convection ovens;
* Interior and exterior of ovens;
* Flattop grill;
* Interior and exterior of deep fryer;
* Interior and exterior of large steamer;
* Interior of stainless steel steam wells;
* Interior of ice machine;
* Exterior top of coffee machines;
* Stand mixer;
* Table mixer;
* Can opener/housing;
* Interior of drawer below steamer;
* Interior of drawers in food prep areas;
* Exterior of garbage cans;
* Near/around ware washing area including caulk seal; and
* Coffee, soda, and juice station counter tops and interior of sink.

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

* Entry door frame to kitchen had missing hardware;
* Entry door to kitchen had missing hardware;
* Exit door to dining room had missing hardware;
* Baseboards throughout kitchen were not attached or falling off of the wall, including under the ware wash areas, food prep stations, and kitchen entrance and exit door;
* Stand mixer casing;
* Multiple cooking and serving tools and utensils;
* Floor drain by walk-in refrigerator was not sealed;
* Ware wash area caulking was broken and missing sections; and
* Walk-in refrigerator door was missing hardware to keep door securely closed.

c. There were several open food packages in the dry storage, walk-in refrigerator and walk-in freezer.

d. The temperature of prepared food items was not consistently measured and food items were not cooked to the required minimum internal cooking temperatures.

e. Food prep areas and tools used were not properly sanitized in-between handling and preparing potentially hazardous food.

f. Multiple staff were handling clean and dirty dishes, serving residents food, and/or preparing food without hair restraints.

g. Multiple staff entered and exited the kitchen without practicing hand hygiene.

h. Multiple potentially hazardous food items were observed in cold food storage areas uncovered or unsealed, unlabeled, without open dates, and/or without use by dates.

i. Staff did not check and were unaware how to properly check the surface sanitizer solution concentration to ensure sanitizer was dispensing at correct parts per million (PPM) for sanitizing buckets, ware wash machine, and three-compartment sink.

j. Staff 4 (Dining Services Manager) stated he prepared eggs to order, that included soft yolk. The facility did not have pasteurized eggs available.

k. Staff were observed to eat while preparing food for residents.

On 11/06/24 at 1:55 pm, Staff 4 toured the kitchen with this surveyor and acknowledged areas that were not clean and/or in good repair. Safe food handling practices and infection control were discussed.

On 11/06/24 at 4:15 pm, Staff 1 (ED) and Staff 6 (Regional Operations Support) toured the kitchen with this surveyor and reviewed areas of the kitchen that were not clean and in good repair and were made aware of concerns identified in food handling practices and infection control.

On 11/07/24 at 8:10 am, a walkthrough of the kitchen was completed and the areas needing cleaning had substantially improved.

The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules) was reviewed with Staff 1, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6, and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

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:

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and side rail evaluations were completed for 1 of 1 sampled resident (#5) whose side rail evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2024 with diagnoses including urinary retention and use of a catheter.

The resident’s move-in evaluation dated 09/24/24 was reviewed and the following required elements were not addressed:

* Customary routines including sleeping, eating, and bathing;
* Interests, hobbies, social, and leisure activities;
* Physical health status;
* Personality;
* Dental status;
* Ability to manage medications;
* Pain including pharmaceutical and non-pharmaceutical interventions;
* Nutrition habits, fluid preferences, and weight if indicated;
* Emergency evacuation ability;
* History of dehydration;
* Recent loses;
* Unsuccessful prior placement; and
* Environmental factors including lighting and room temperature.

The need to ensure move-in evaluations addressed each required element was reviewed with Staff 1 (ED), Staff 2, Staff 3, Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 05/2017 with diagnoses including diabetes mellitus type 2, morbid obesity, and use of a catheter. The resident was observed to have bilateral quarter-length siderails on his/her bed.

The resident’s record was reviewed, and the following was identified:

On 11/07/24 at 1:02 pm, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager) and Staff 8 (Caregiver Supervisor) stated they were unaware the resident had siderails and Staff 2 confirmed there was not a completed evaluation for the resident’s use of siderails.

The need to ensure residents were evaluated for the use of siderails was reviewed with Staff 1 (ED), Staff 2, Staff 3, Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 1 of 6 sampled residents (#5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2017 with diagnoses including diabetes mellitus type 2, morbid obesity, and use of a catheter. The resident was observed to have bilateral quarter-length siderails on his/her bed throughout the survey.
Observations were made of the resident's care from 11/05/24 through 11/08/24. Interviews with the resident, facility staff and the residents outside provider were conducted. The current service plan dated 09/10/24 was reviewed.

Resident 5's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Use of bilateral quarter-length siderails including instructions for use and monitoring for safety;
* Use of nebulizer including instruction to staff;
* Use of a hospital bed;
* Dental status and lack of denture use;
* Instructions for monitoring of chronic skin conditions and provision of treatments;
* Preference of when room door was propped open and/or locked; and
* Use of eye glasses.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside providers, adjust the service plan as necessary, and ensure staff were informed of new interventions for 1 of 4 sampled residents (#1) who received outside services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/2023 and readmitted in 8/2024 with diagnoses including left leg amputation and intervertebral disc disorders.

The resident's progress notes, outside provider notes and interim service plans (ISPs) dated 08/03/24 to 11/04/24, and the resident’s most current service plan dated 10/10/24, were reviewed and the following was identified:

* A significant change of condition note dated 09/10/24, completed by Staff 2 (Wellness Manager/RN), indicated Resident 1 had a transfer pole that needed to be “put up by his/her bed.”

* A home health provider note dated 09/23/24 indicated Resident 1 “needs transfer pole put up.”

* Resident 1’s service plan dated 10/10/24 and reviewed ISP’s lacked information regarding the transfer pole.

Observations during the survey revealed no transfer pole was installed in the resident’s apartment.

During an interview on 11/06/24 at 9:00 am, Staff 2 stated the facility had a transfer pole for the resident prior to his/her amputation surgery in 08/2024 but acknowledged the pole had not been installed.

The need to ensure coordination and continuity of care with outside provider recommendations was discussed with Staff 1 (ED), Staff 6 (Regional Operations Support), and Staff 7 (Regional Payroll Support) on 11/07/24 at 5:00 pm. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc

(2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 2 of 3 sampled resident (#s 4 and 5) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including shortness of breath.

Resident 4’s clinical records and MAR were reviewed during the survey.

The resident had signed physician orders to inhale ipratropium albuterol via nebulizer three times a day. The MAR indicated that the resident refused the medication 20 times from 10/01/24 through 11/04/24.

There was no documented evidence the facility notified the prescriber each time the resident refused to consent to the orders.

On 11/04/24, the failure to notify prescribers of refusals was discussed with Staff 1 (ED), Staff 6 (Regional Operations Support), and Staff 7 (Regional Payroll Support). They acknowledged the findings.
2. Resident 5 was admitted to the facility in 05/2017 with diagnoses including diabetes mellitus type 2, morbid obesity, and use of a catheter.

Resident 5’s clinical records and 10/2024 MAR were reviewed during the survey.

Resident 5 had signed physician orders for the following:
* Desitin daily defense 13% cream to be applied two times daily;
* Nystatin external cream to be applied twice daily; and
* Nystatin external powder to be applied four times daily.

The MAR indicated the resident refused the above orders on 140 occasions between 10/01/24 and 10/31/24.

There was no documented evidence the facility notified the prescriber of the refusals.

The need to ensure prescribers were notified of resident refusals was reviewed with Staff 1 (ED), Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 long-term non-direct care staff (#4) completed annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 11/06/24 at 8:40 am with Staff 15 (Business Office Manager) and revealed there was no documented evidence Staff 4 (Dining Services Manager), hired on 12/13/19, completed annual training on infectious disease outbreak and control.

The need to ensure long-term non-direct care staff completed the required annual infectious disease training was discussed with Staff 1 (ED), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/07/24 at 5:00 pm. They acknowledged the finding.

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.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair, for 2 of 2 sampled residents (#s 2 and 4) whose apartments were observed during the survey. Findings include, but are not limited to:

During the survey, the carpet in the living rooms of Resident 2 and 4’s apartments was observed to have large, soiled areas.

In an interview on 11/06/24, Staff 5 (Maintenance Manager) stated the facility had not updated its carpet cleaning schedule to its new software system and acknowledged Resident 2 and 4’s carpets had not been cleaned recently. In an interview on 11/06/24, Staff 1 (ED) provided a record of the facility’s previous carpet cleaning schedule which indicated Resident 2 and 4’s carpets had last been cleaned in 04/2024.

The need to ensure all interior materials and surfaces were kept clean and in good repair was reviewed with Staff 1, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24. They acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

This Rule is not met as evidenced by:

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 12/01/2022. 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

The findings of the re-licensure survey, conducted 6/21/21 through 6/23/21, 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 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 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 06/23/21, conducted 11/08/21 through 11/09/21 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, 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 ensure incidents and accidents were promptly investigated to rule out abuse and neglect, for 2 of 4 sampled residents (#s 1 and 5) whose incidents were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in July 2018 with diagnoses including diabetes and Parkinson's disease. The resident's service plan dated 6/8/21 and interviews with care staff between 6/21/21 and 6/23/21 indicated the resident was dependent for all ADL care. The resident was also noted to be non-verbal and was unable to direct her/his own care. Review of incident investigations and progress notes from 3/2/21 through 6/18/21 showed the following: * A facility investigation dated 3/10/21 indicated the resident had sustained an injury of unknown cause in the form of a bruise to the right arm. A facility investigation was not completed promptly to rule out abuse and neglect, nor was the injury reported to the local SPD office. * A progress note dated 3/26/21 indicated the resident had sustained an injury of unknown cause in the form of a bruise to the left knee. * A progress note dated 5/2/21 indicated the resident had sustained an injury of unknown cause in the form of a bruise to the left wrist.Investigations of the 3/26/21 and 5/2/21 injuries of unknown cause were not completed to rule out potential abuse and neglect and were not reported to the local SPD office when appropriate. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations) on 6/23/21. The staff acknowledged the findings. The facility was asked to report all three injuries of unknown cause to the local SPD office. Confirmation of the reports were provided prior to survey exit.
2. Resident 5 was re-admitted to the facility in November 2020 following a hospitalization related to an exacerbation of mental illness symptoms.Progress notes dated 11/25/20 stated Resident 5 "made a physical threat to one resident" upon return to the facility. There was no documented evidence the facility thoroughly investigated the incident or reported the incident to the local SPD office.The need to ensure all incidents of abuse or suspected abuse were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations) on 6/22/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the resident move-in evaluation included all required elements for 1 of 1 sampled resident (#6) recently admitted to the facility. Findings include, but are not limited to:Resident 6 was admitted to the facility in June 2021 with diagnoses including encephalopathy.A review of the resident's clinical record revealed the move-in evaluation, dated 6/4/21, lacked information regarding the following required elements:* Spiritual, cultural preferences and traditions;* Mental health issues, including presence of depression, thought disorders or behavioral or mood problems, history of treatment and effective non-drug interventions;* Decision making abilities;* Personality, including how the person copes with change or challenging situations;* Vision;* Ability to manage medications;* Laundry;* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;* List of treatments, including type, frequency and level of assistance needed;* Indicators of nursing needs, including potential for delegated tasks;* Complex medication regimen; and* History of dehydration or unexplained weight loss or gain.In an interview on 6/23/21, the need to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN), Staff 3 (Regional Director of Operations) and Staff 20 (Nurse Practitioner). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status, provided clear direction to staff and were followed for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 6). Findings include, but are not limited to:1. Resident 1 was admitted to the facility in July 2018 with diagnoses including diabetes and Parkinson's disease.a. Review of the resident's service plan dated 6/8/21 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff or was not followed by staff in the following areas:* Grooming;* Ambulation, walking/standing;* Communication abilities and needs; and* Bathing/showering needs. b. Observations of the resident during the lunch meal on 6/22/21 showed staff were giving the resident water while s/he was eating. The service plan and recent swallow evaluation indicated the resident could not have thin liquids with her/his meals. Thickened liquids could be provided with meals and water outside of meal times, no other thin liquids were approved. The surveyor intervened during the meal observation and consulted with Staff 2 (Wellness Director/LPN) who ensured re-education was provided to the individual staff observed and added additional printed information in the resident's room.The need to ensure resident service plans were reflective of current care needs, provided clear directions to staff and were followed was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations). The staff acknowledged the findings.2. Resident 2 was admitted to the facility in May 2017 with diagnoses including diabetes and a current ankle fracture.Review of the resident's service plan dated 5/28/21 showed the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas:* Catheter care;* ADL needs related to current fracture;* Increased fluid needs; and* Insulin use, hypoglycemia/hyperglycemia risk.The need to ensure resident service plans were reflective of current care needs, provided clear directions to staff and were followed was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations). The staff acknowledged the findings.
3. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.Resident 3's records were reviewed during survey and indicated the service plan dated 6/1/21 and temporary service plans were not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas:* Elopement risk and necessary interventions;* Frequency of safety checks;* Interventions related to distressing hallucinations and delusions; and* Interventions related to recent losses and depression.The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations) on 6/23/21. They acknowledged the findings.
4. Resident 4 was admitted to the facility in April 2020 with diagnoses including diabetes.A review of the resident's current service plan, dated 4/14/21, revealed there was no information included related to his/her dependence on insulin or the signs and symptoms of hypo- and hyperglycemia staff should observe for and report.The need to ensure service plans were reflective of residents' current status and needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN), Staff 3 (Director of Operations) and Staff 20 (Nurse Practitioner) on 6/23/21. They acknowledged the findings.5. Resident 6 was admitted to the facility in June 2021 with diagnoses including encephalopathy. A review of Resident 6's initial service plan, dated 6/8/21, revealed it had not been updated to reflect her/his current status and needs. The service plan indicated the resident was independent with all ADLs.In interviews with Staff 18 (MT) on 6/22/21, Staff 5 (RCC) and Staff 8 (CG) on 6/23/21, they reported Resident 6 was not independent and required cueing and/or full assistance with all ADLs. The staff also indicated Resident 6 had memory and cognitive issues.There was no documented evidence the resident's service plan had been updated to reflect the changes in the level of assistance needed by the resident or how staff were to respond to the resident's cognitive and memory issues.On 6/23/21 the need to ensure the service plan was updated as needed to reflect a resident's current status and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN), Staff 3 (Regional Director of Operations) and Staff 20 (Nurse Practitioner). They acknowledged the findings.

4. Resident 1 was admitted to the facility in July 2018 with diagnoses including diabetes and Parkinson's disease. The resident's 6/8/21 service plan, 3/1/21 through 6/18/21 progress notes, temporary service plans and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:* Skin rash/breakdown to the buttocks;* Bruising to the left knee, left wrist and right arm; and* Swallowing issues.The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly, provided clear resident specific directions to staff and interventions were reviewed for effectiveness was discussed on 6/23/21 with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations). The staff acknowledged the findings. 5. Resident 2 was admitted to the facility in May 2017 with diagnoses including diabetes and anxiety. The resident's 5/28/21 service plan, 3/1/21 through 6/18/21 progress notes, temporary service plans and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident specific directions to staff in the following areas:* New medications;* Leg swelling;* Weight changes;* Low blood sugars;* Ankle fracture;* Falls;* Bruising, abrasions and rashes to multiple areas; and* UTI. The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and resident specific directions for staff was discussed on 6/23/21 with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations). The staff 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 monitored weekly through condition resolution and resident specific interventions were determined, documented, communicated to staff and evaluated for effectiveness for 5 of 7 sampled residents (#s 1, 2, 3, 5 and 8) who had documented short term changes of condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in February 2021 with diagnoses including mild cognitive impairment and dementia.A significant change assessment and service plan completed 6/1/21, indicated Resident 3 continued to ambulate and transfer independently but had experienced a progression in dementia symptoms and "cognitive dementia has progressed to the point she is having auditory and visual hallucinations." Progress notes dated 6/5/21 indicated the resident "walked outside of the facility to the police station saying someone was trying to euthanize [him/her]." The resident was escorted back to the facility by a police officer. The note stated facility staff later found the resident "outside again trying to walk across the street to the police station."There was no documented evidence the facility determined what interventions were needed related to the resident's new risk for elopement and there was no documented evidence the facility monitored the resident after the elopements. The need to ensure residents, who experienced short term changes of condition, were monitored weekly through condition resolution and resident specific interventions were determined, documented, communicated to staff and evaluated for effectiveness was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Director/LPN) on 6/21/21. They acknowledged the findings. Staff 2 updated Resident 3's Growth and Wellness evaluation and service plan with resident specific interventions to address Resident 3's elopement risk prior to survey exit.2. Resident 5 was admitted to the facility in 2018.Facility records indicated Resident 5 had a history of verbal aggression directed towards others and a history of behaviors which put her/him at risk for harm to self or others.An incident report dated 5/28/21 indicated the resident was involved in a physical altercation with another resident. The incident report indicated Resident 5 was placed on safety checks as an immediate intervention. There was no documented evidence the intervention was communicated to staff and there was no documented evidence the resident or the effectiveness of the intervention were monitored weekly through resolution. During an interview with Staff 1 (Administrator) and Staff 2 (Wellness Director) on 6/22/21, they stated no temporary service plan or weekly monitoring was implemented for Resident 5.The need to ensure residents who experienced changes of condition were monitored weekly through resolution and resident specific interventions were communicated to staff and evaluated for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations) on 6/22/211. They acknowledged the findings.3. Resident 8 was admitted to the facility in January 2021 with multiple mental illness diagnoses.An event report and incident investigation stated on 6/4/21, the facility's fire alarm system indicated there was a fire in Resident 8's room. The incident report stated per the fire department's investigation, the cause of the fire was related to the resident's clothing being saturated with oil. "As it began drying the oil breakdown caused heat in [Resident 8's] clothing which resulted in spontaneous combustion." The report stated the resident signed an agreement with the fire department and the facility, with specific interventions to ensure fire safety.There was no documented evidence the interventions were communicated to staff as the facility did not have documented evidence a change of condition evaluation was initiated and there was no documented evidence the effectiveness of the interventions, developed by the fire department and the facility, were monitored weekly through resolution. The need to ensure residents who experienced changes of condition were monitored weekly through condition resolution and resident specific interventions were communicated to staff and evaluated for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations) on 6/23/21. They acknowledged the findings.

2. Resident 5 was readmitted to the facility in November 2020 following a hospitalization related to an exacerbation of mental illness symptoms in which the resident was considered to be at risk for harm to self and/or others per facility's progress notes. The hospital discharge records indicated a behavioral health safety plan was implemented with resident specific interventions including:* Resident specific symptom warning signs:* Resident specific coping strategies;* Resident specific social supports;* Resident specific professional supports;* Environmental safety precautions; and * What to do in case of emergency.The nursing change of condition Growth and Wellness Plan (assessment/service plan) completed upon Resident 5's re-admittance to the facility did not address the hospital's discharge safety plan and the interventions were not included in the assessment/service plan.The need to ensure RN assessments were thorough and included interventions was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN) and Staff 3 (Regional Director of Operations) on 6/22/211. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for all significant changes of condition, to include documenting findings, resident status and interventions made as a result of the assessment, in a timely manner, for 2 of 5 sampled residents (#s 5 and 6) who experienced significant changes of condition. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in June 2021 with diagnoses including encephalopathy.A review of the move-in evaluation, dated 6/4/21, and the initial service plan, dated 6/8/21, indicated Resident 6 was independent with all ADL's and was a high risk for, but had no history of, falls. Progress notes dated 6/9/21 through 6/17/21 revealed the resident was not independent, required either cueing or full assistance with all ADLs and had experienced two falls. A change of condition note, dated 6/18/21, was written by Staff 2 (Wellness Director/LPN).There was no documented evidence an RN had completed a thorough assessment in a timely manner which included findings, resident status and interventions made as a result of the assessment.The need for an RN to conduct a thorough assessment in a timely manner for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN), Staff 3 (Regional Director of Operations) and Staff 20 (Nurse Practitioner). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview on 6/21/21, Resident 4 was identified to be administered insulin injections by non-licensed staff.Delegation records for Staff 11, 15 and 18 (MTs), reviewed on 6/22/21, lacked documentation the RN had determined that Resident 4's condition was stable and predictable and failed to include a rationale for how frequently the resident should be reassessed by the RN. The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator), Staff 3 (Regional Director of Operations) and Staff 20 (Nurse Practitioner) on 6/22/21 and 6/23/21. They acknowledged the findings. An RN assessment for Resident 4, which included all required delegation elements, dated 6/23/21 and signed by Staff 20, was provided prior to exit.

Based on interview and record review, it was determined the facility failed to ensure self-administration of medication evaluations were completed quarterly and to have a current order from a legally recognized practitioner for self-administration of prescription medications for 1 of 2 sampled residents (#4) who self-administered their medication. Findings include, but are not limited to:Resident 4 was admitted to the facility in April 2020 with diagnoses including diabetes.During the acuity interview on 6/21/21, Resident 4 was identified as self-administering all of his/her medications, except insulin injections.A review of the clinical record revealed the self-administration evaluation had not been completed quarterly and there was no current signed physician's order for the resident to self-administer medications.The need to complete evaluations quarterly and to have a current signed physician's order for self-administration in the resident's chart was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/LPN), Staff 3 (Regional Director of Operations) and Staff 20 (Nurse Practitioner) on 6/23/21. They acknowledged the findings. Prior to survey exit, Staff 2 provided a self-administration evaluation dated 6/21/21 and an order for self-administration signed by a physician on 6/23/21.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics, including pre-service dementia training, was completed prior to providing services to residents for 1 of 3 newly hired staff (#15). Findings include, but are not limited to:Review of staff training records on 6/22/21 and 6/23/21 revealed Staff 15 (CG), hired 4/18/21, lacked documented evidence of having completed pre-service dementia care training.The need to ensure all staff completed pre-service orientation was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 6/23/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly-hired direct care staff (#s 15 and 18) demonstrated competency in all required areas and other duties as applicable within 30 days of hire. Findings include, but are not limited to:Review of staff training records on 6/22/21 and 6/23/21 revealed there was no documented evidence Staff 15 (CG), hired 4/18/21, and Staff 18 (MT), hired 5/12/21, had demonstrated competency in all required areas within 30 days of hire, including:* The role of service plans in providing individualized resident care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition; and* Conditions that require assessment, treatment, observation and reporting. Staff 18 (MT) also lacked documented evidence of competency to perform the duties of a medication technician and First Aid/Abdominal Thrust. During an interview with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 6/22/21, survey directed that Staff 18 (MT) not administer medication to residents until competency of ability to safely carry out the duties of a medication technician had been determined. Staff 1 provided documented evidence prior to exit on 6/23/21 that Staff 18 had demonstrated competency to perform her job duties. The need to ensure staff have demonstrated competency in all required areas and job duties assigned and completed First Aid/Abdominal thrust certification within 30-days of hire was discussed with Staff 1 and Staff 3 on 6/23/21. 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 6/21/21 and 6/22/21 revealed the following:* The first floor laundry room sink cabinet had a broken door, a missing door, gouges with exposed raw wood on the exterior, and warped shelving with brown discoloration on the interior. There was a gouge in the drywall by the entrance door. The door and the adjacent wall had black smudges.* The second floor laundry room sink cabinet had one missing door, another door off its hinges, interior shelving off its hinges and debris on the bottom shelves of the cabinets. The wall behind the garbage can had black scrapes and chipped paint.* The hopper in the room adjacent to the second floor laundry had brown and green matter on the inside of the basin and the floor was sticky. * The shelves outside resident rooms throughout the facility had dried drips and spills. * The windows at the end of hallways, in the dining room and activity room had build-up of gray matter on sills and blinds. * The carpet on the second floor had multiple areas with extensive brown/black discoloration, more densely concentrated between room 231 and the laundry room, down the hall towards the elevator and in the middle stairwell. * Room 103 smelled strongly of urine. The carpet had extensive black/brown discolorations throughout the apartment. The transition molding between carpet and kitchenette linoleum flooring was separating. The window-sill had a build-up of gray/black matter. There were gouges in the wood on the bathroom door. One of the closet doors was off its hinges. * Room 105 had extensive deep gouges in the drywall on the walls throughout the apartment. The molding on the interior of the apartment door was missing on one side of the wall. The bathroom door molding was pulling away from the wall. The transition molding from the linoleum to the carpet was missing, with an accumulation of debris built up in the gap between the two. There were two approximately six inch holes in the linoleum floor by the toilet. There were multiple holes in the wall by the toilet. The bathroom door and towel rack had black and brown smudges. The refrigerator had multiple dents and chipped paint. There was extensive small bits of paper, food debris and dry wall chips on the carpet and throw rug.The environment was toured with Staff 1 (Administrator) on 6/21/21 and with Staff 3 (Regional Director of Operations) on 6/22/21. They acknowledged the findings.