Lone Oak Assisted Living Facility

The findings of the kitchen inspection, conducted 08/16/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first re-visit to the kitchen inspection of 08/16/24, conducted 11/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the second revisit to the kitchen inspection of 08/16/24, conducted 02/07/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the main facility kitchen on 08/16/24, from 10:30 am through 1:30 pm, revealed the following deficient practices:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:* Ceiling vents and light fixtures;* Sprinkler heads;* Interior of microwave;* Interior and exterior of commercial toaster;* Range top;* Sides of industrial equipment (oven/range/grill);* Top shelf of service line;* Industrial mixer;* Floors throughout the kitchen had black matter build-up, food debris, and grease in corners and behind, in between, and under equipment;* Walk-in cooler floor;* Walk-in freezer door threshold;* Utility carts;* Floor and walls of entry way to kitchen/dining room; and* Cabinets storing clean dishes.b. The following areas needed repair:* Multiple utility carts with cracks/damage;* Gas range top flame causing excessive carbon build up/damage to pots and pans;* Baseboards and walls near kitchen entry way and dining room beverage area with scrapes, gouges, and other damage.c. Multiple food items/packages/containers found in cold food storage that were not covered or properly closed/sealed and were exposed to potential contamination.d. Multiple food items were not dated when opened and/or prepared. Multiple food items found past their use-by dates.e. Single service utensils and plates found in dry storage area open/exposed to potential contamination.f. Multiple pans, pots, and/or cutting boards were noted to be heavily worn, stained, scratched, and/or damaged.g. Cook was observed preparing and serving food with facial hair not restrained. A staff member was observed serving soup with long acrylic nails that were not covered by gloves as required.h. Dining room was observed with tables pre-set at 10:30 am for lunch service at noon. Food contact surfaces of utensils and tableware were not covered or inverted to protect from potential contamination.Staff 2 (Dining Service Director) toured the kitchen with surveyor and acknowledged areas of concern. At 1:30 pm, surveyor reviewed identified issues with Staff 1 (Administrator), and they acknowledged the areas needing correction.
Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observation of the main facility kitchen on 11/01/24, from 12:30 am through 2:00 pm, revealed the following: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:* Interior of microwave;* Interior of commercial toaster;* Range top;* Sides of industrial equipment (oven/range/grill);* Top shelf of service line;* Industrial mixer;* Floors throughout the kitchen had black matter build-up, food debris, and grease in between, and under equipment;* Walk-in cooler racks;* Cook utility cart;* Industrial can opener and housing;* Spice racks;* Speed rack;* Walls by prep and beverage spaces; and* Cabinets storing clean dishes.b. The following areas needed repair:* Blue utility carts with cracks/damage; and* Baseboards and walls near kitchen entry way and dining room beverage area with scrapes, gouges, and other damage.c. Multiple food items/packages/containers found in cold food storage that were not covered or properly closed/sealed and were exposed to potential contamination. Speed rack with lunch side items with all food items not covered and exposed to potential contamination.d. Multiple food items were not dated when opened and/or prepared. Multiple food items found past their use-by dates.e. Single service cups and plates found in dry storage area open/exposed to potential contamination.f. Multiple pans, pots, and/or cutting boards were noted to be heavily worn, stained, scratched, and/or damaged.g. Dirty cleaning rags were found stored on service line and prep areas on counters and not in sanitation buckets. Multiple dirty/used rags were found in a green bucket with no visible liquid. The red sanitation bucket was empty.h. Multiple dishwashing racks were found stored on the floor next to the dirty drain.Staff 2 (Dining Service Director) toured the kitchen with surveyor and acknowledged the findings.At 1:40 pm, the surveyor reviewed identified issues with Staff 1 (Executive Director), and Staff 2 (Dining Services Director). Both acknowledged the areas needing correction.

Based on record review and interview, it was determined the facility failed to ensure 2 of 7 staff (#s 2 and 3) who prepared food had active food handler's certificates. Findings include, but are not limited to:On 08/16/24 at 10:30 am, employee records were requested and reviewed to ensure staff had active food handler's cards. Food cards for Staff 2 (Dining Service Director) and Staff 3 (Cook) could not be located. Staff 1 (Administrator) stated she would continue to look for documents and forward to surveyor if/when found.On 08/16/24 at 3:45 pm, surveyor received copies of Staff 2 and Staff 3's food handler's certificates, which were dated effective 08/16/24. Staff 1 (Administrator) was interviewed and acknowledged that there was no documented evidence located that Staff 2 and Staff 3 had active food handler's certificates upon kitchen survey entrance as required. Staff 1 validated that the duties of Staff 2 and Staff 3 did include food preparation, that the facility should have had current food handler's cards on file, and that both employees obtained their required certificates after surveyor had identified them as missing.

Based on interview, observation, and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.

Based on observation and interview, conducted during a site visit on 06/18/24, it was confirmed the facility failed to keep medical and other records kept confidential. Findings include, but are not limited to:During an onsite visit to the facility on 06/18/24, compliance specialist (CS) observed several stacks of boxes with resident's confidential information lined up against the walls at the base of the stairwell.In an interview, Staff 1 (Executive Director) stated they had just moved them there temporarily while work was being done. The findings were reviewed with and acknowledged by Staff 1 on 06/18/24.It was confirmed the facility failed to keep medical and other records kept confidential.Plan of correction: ED will have them moved back to secure storage by the end of the day.

Based on interview, and record review, conducted during a site visit on 06/18/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#4). Findings include, but are not limited to:During an interview on 06/18/24, Staff 1 (Executive Director) stated there had been an improved training program that went over transfers and gait belts in the last six months since s/he had been at the facility.Compliance specialist was unable to interview Resident 4 as s/he was no longer at the facility as of 03/29/24.A review of Resident 4's service plan dated 10/02/23 and progress notes dated 10/27/23 through 12/02/23, indicated the following:· Progress note dated 11/09/24 at 10:03am reported "caregiver was not following resident care plan and transferring [Resident 4] by [his/her] self. Resident started to slip so [s/he] was assisted to the ground".· Care plan stated, "Staff to use gait belt to assist [Resident 4] for stand-pivot transfer" and "staff to call for a second caregiver for assistance for the safety of [Resident 4] and staff".The findings were reviewed with and acknowledged by Staff 1 on 06/18/24.It was confirmed the facility failed to ensure the implementation of services.Plan of correction: ED had already started and will continue ongoing re-education of the two-person transfer procedures and gait belt use. They ordered more gait belts and were working on making sure all residents had an updated wellness plan.

Based on interview and record review, conducted during a site visit on 06/18/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 3 sampled residents (#s 1, 3, and 6). Findings include, but are not limited to:A review of Resident 6's May 2024 MAR and progress notes, physician orders, and care history, indicated the following:· Order updated 05/23/24 to "monitor weight monthly, PRN and if suspicious of weight gain or weight loss" and;· Resident 6 was getting monthly and PRN weights completed for May 2024.A review of Resident 1's May 2024 MAR and progress notes, physician orders, and care history, indicated the following:· Order updated on 05/07/24 to "monitor daily weights" and;· On 05/25/24, Resident 1 did not get a daily weight documented.A review of Resident 3's May 2024 MAR and progress notes, physician orders, and care history, indicated the following:· Order updated on 05/12/24 to "take weight daily. Call MD if resident experience a weight gain of 3 pounds or more pound gain in 1 week" and;· There were six days for May 2024 missing a daily weight.In an interview, Staff 2 (RCC) stated the daily weights were documented in the MAR and they did not have any concerns about the staff not getting the daily weights.The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 06/18/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: The RCC's will start doing daily monitoring of the weights to make sure they are getting documented and follow up with staff if they are not completed.

Based on observation, interview and record review, conducted during a site visit on 06/18/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated the current census was 70 residents and only 62 residents were entered into the ABST.A review of the ABST and staff schedule for June 2024 indicated the facility was staffing per the ABST.In an interview on 06/18/24, Staff 1 (Administrator) stated the following:· The current census was 70 residents, as they had one resident out of the facility.· The ABST had not been updated with all of the residents.· The posted staffing plan currently exceeded the ABST generated staffing, but it is not accurate.In separate interviews with Resident 1, 2, and 5, they stated their needs were being met.On 06/18/24, findings were reviewed with and acknowledged by Staff 1.It was confirmed the facility failed to fully implement and update an ABST.

The findings of the onsite investigation, conducted 11/02/23 are documented in this report. The investigation 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

Based on interview and record review, conducted during a site visit on 11/02/23, it was determined the facility failed to ensure a system for tracking of controlled substances for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: In separate interviews, Staff 2 (MT), Staff 10 (MT), Staff 19 (MT), and Staff 21 (MT) stated the following: * If a medication error occurs, MTs are to document the error, report to the nurse, and start a temporary service plan (TSP), and monitor the resident. * When a narcotic medication is administered, MT must read the order, read the medication card, read the MAR to confirm it's the correct medication, pop the medication, then document in the Narcotic Book. After administering the medication the MT must confirm the administration in the MAR. * Two MTs are required to count each narcotic card for each resident at shift change, in which the oncoming MT counts out with the MT at the end of their shift. * If a narcotic has to be destroyed, it's one MT and the nurse for a total of two staff to witness. A review of the Resident 1, 2 and 3's clinical records and facility records including the Narcotic Tracking Book, 24-hour communication logs, dated 11/2023, and the policy and procedures for tracking of controlled substances were reviewed during the site visit.a. A review of Resident 1's MAR, dated 10/01/23 through 10/31/23, progress notes, dated 10/06/23 through 10/28/23, and facility's narcotic tracking record indicated the following: * Resident 1 had been prescribed "alprazolam 1 tablet by mouth every night at bedtime." * On 10/25/23 and 10/31/23, staff initialed as having administered the medication on the MAR, however the two doses had not been singed out on the dispostion log. b. A review of Resident 2's MAR, dated 10/01/23 through 10/31/23, progress notes, dated 10/03/23 through 11/02/23, and facility's narcotic tracking record indicated the following: * Resident 2 had been prescribed "morphine sulfate 20 mg/ml SOLN, 0.5ML (10 mg) by mouth every hour as needed for pain or SOB". * On 10/26/23, his/her MAR indicated morphine was administered twice at 7:32 am and 8:05 pm. The narcotic disposition log indicated the medication had been dispensed at 8:00 am, 10:30 am, and 8:00 pm. * Resident 2 had been prescribed "Tramadol, 1 tablet (50 mg) by mouth every 2 hours as needed for pain levels 5 or 6 out of 10".* On 10/29/23, his/her MAR indicated Tramadol was administered once at 3:24 am. The narcotic disposition log indicated the medication had been dispensed twice, at 3:25 am and 9:23 am.* On 10/22/23, his/her MAR indicated Tramadol was administered once at 1:22 pm. The narcotic disposition log indicated the medication had been dispensed twice, at 3:24 (no indication am or pm) and 7:00 am. The 1:22 pm dose was not recorded in the disposition log. * Narcotic Tracking Book indicated tramadol was dispensed once on 10/13/23 and 10/15/23. There was no documentation on the MAR to indicate the medication had been administered on those dates. * On 10/21/23, his/her MAR indicated tramadol was administered twice at 9:36 pm and 10:18 pm. The 10:18 pm dose was not recorded in the disposition log. *On 10/01/23, 10/02/23, 10/05/23, 10/06/23, 10/08/23, 10/10/23, and 10/11/23, the MAR indicated tramadol was administered at 1:28 pm, 12:35 am, 3:20 am, 1:40 am, 3:55 am, 4:13 pm, and 11:33 am respectively. There was no evidence to indicated the medication administered on these days and times were documented in the Narcotic Tracking Book. c. A review of Resident 3's MAR, dated 10/01/23 through 11/02/23, progress notes, dated 10/05/23 through 11/01/23, and facility's narcotic tracking record indicated the following: * Resident 3 was prescribed "oxycodone 5MG tab, 2 tablets (10mg) by mouth at bedtime as needed for pain" and "oxycodone 5MG tab, 1 tablet by mouth 4 hours later as needed for 28 days."* On 10/22/23, Narcotic Tracking Book indicated 1 tablet of oxycodone was dispensed at "11:30". There was no evidence to indicate oxycodone had been administered on Resident 2's MAR. * On 10/27/23, his/her MAR indicated 1 tablet of oxycodone was administered twice at 1:04 am and 11:04 pm. * Narcotic Tracking Book indicated oxycodone was administered only on one occasion on 10/27/23 at "0100". There was no evidence to indicate the 11:04 pm administration of this medication was documented in Narcotic Tracking Book.The facility failed to ensure a system for tracking of controlled substances.On 11/02/23, the findings related to Resident 2's morphine on 10/26/23 and the importance of maintaining accurate records were reviewed with and acknowledged by Staff 22 (RN), Staff 23 (Contracted Nurse), and Staff 3 (BOM). On 11/15/23, via telephone the additional findings were attempted to be reviewed with Staff 1 (Administrator). Staff 1 stated this was outside his/her scope and the regional nurse would call to review.

Based on interview and record review, conducted during a site visit on 11/02/23, it was confirmed the facility failed to carry out medication or treatment orders as prescribed for 1 of 1 sampled resident (#1) whose MAR was reviewed. Findings include, but are not limited to:A review of Resident 1's records including Medication Administration Record, dated 10/01/23 through 10/31/23, physician orders, chart notes, dated 10/01/23 through 10/31/23 and service plan, dated 08/08/23, indicated the following: * Morphine (for pain) 15 mg tab, 1 tablet by mouth twice daily at 8:00 a.m. and 3:00 p.m.* Morphine (for pain) 30 mg tab, 1 tablet by mouth twice daily, take in the morning and at bedtime, 10:00 a.m. and 9:00 p.m.* On 10/07/23, Resident 1 received 15 mg of [pain medication] at 10:00 am instead of 30 mg as ordered. * On 10/25/23, there was no evidence to indicate that 5 medications scheduled for 4:00 p.m. were administered. In an interview, Resident 1 stated s/he had no complaints. In separate interviews, Staff 2 (Medication Technician), Staff 10 (Medication Technician), Staff 19 (Medication Technician), and Staff 21 (Medication Technician) stated when a medication error occurred staff were to document the error, report error to the nurse, start a temporary service plan to monitor for adverse effects. It was confirmed the facility failed to carry out medication or treatment orders as prescribed.On 11/02/23, these findings were reviewed with and acknowledged by Staff 22 (RN), Staff 23 (Contracted Nurse), and Staff 3 (BOM). Staff 3 stated the possible reason for the missed medications on 10/25/23 was due to the internet going out. Verbal Plan of Correction: Within two weeks, the nurse will provide Medication Technicians training, and implement a self-MT audit using the electronic MAR dashboard in which MT will sign off as all medications have been administered, and the nurse will perform weekly audits.

Based on observation and interview, conducted during a site visit on 11/02/23, it was confirmed the facility failed to keep all interior materials (e.g. floors) clean and in good repair for 1 of 1 sampled resident (#4). Findings include, but are not limited to: At 1:30 pm, the Compliance Specialist observed Resident 4's living room carpet to have multiple black spots and yellow and red stains near Resident 4's dining table. In an interview Resident 4 stated housekeepers clean apartment on Wednesdays and another day of the week. Housekeepers vacuum, mop, does dishes, clean and sanitizes, and washes clothes and linens weekly. In separate interviews Staff 14 and Staff 16 stated shampooing of carpet is not a regular housekeeping service. The facility failed to keep all interior material (e.g. floors) clean. On 11/02/23, these findings were reviewed with and acknowledged by Staff 22 (RN), Staff 23 (Contracted Nurse), and Staff 3 (BOM).Verbal Plan of Correction: Within 1 week, the facility will shampoo Resident 4's carpet and has started to receive bids to replace carpet in response to re-licensing survey findings.

The findings of the re-licensure survey, conducted 10/02/23 through 10/04/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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

Based on observation, interview, and record review, it was determined the facility failed to provide effective oversight to ensure quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the survey, conducted 10/02/23 through 10/04/23, administrative oversight to ensure adequate resident care and quality of services rendered in the facility were found to be ineffective based on the number of citations.Refer to deficiencies in report.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, for 1 of 1 sampled resident (#1) whose evaluation was reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 07/2023.The initial evaluation failed to address the following required elements with sufficient information to develop an initial service plan:* Personality: including how the person copes with change or challenging situations;* Pain;* Treatments;* Fall risk or history;* Emergency evacuation ability;* Recent losses; and* Elopement risk or history.On 10/04/23, the need to ensure the initial evaluation addressed all required elements prior to the resident's admission was reviewed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to have a system which made service plans readily available to floor staff, to provide direction regarding provision of care, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose records were reviewed. Findings include, but are not limited to:During interviews with staff, it was determined the current service plans for Residents 3, 4, 5 and 6 were kept in a locked medication room, which was not readily accessible to floor staff.On 10/04/23, the need for a system which made current service plans readily available to floor staff was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 4 of 4 sampled residents (#s 3, 4, 5 and 6). Findings include, but are not limited to:Resident 3, 4, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.On 10/04/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident, failed to evaluate significant changes of condition and communicate interventions to staff on each shift for 1 of 4 sampled residents (#6) who experienced changes of condition. Findings include, but are not limited to:Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes. Observations of the resident, interviews with staff, and review of the resident's most recent service plan, dated 07/20/23, weight records from 04/01/23 through 10/01/23, interim service plans (ISPs), incident investigations, physician communications and progress notes from 07/01/23 through 10/02/23 were completed. a. The resident experienced the following short-term changes of condition:* 09/27/23: unwitnessed fall and inability to bear weight; * 09/27/23: increased weakness with resident found "hanging half off his bed" with "trouble sitting up on his own"; * 09/30/23: unwitnessed fall with injury to right elbow and bruising on right cheek;* 09/30/23: unwitnessed fall; and* 10/01/23: unwitnessed fall.The facility failed to evaluate, determine interventions or actions needed and communicate to staff regarding Resident 6's changes of condition.In a discussion with Staff 3 (Health Services Director) on 10/02/03, she stated that interventions and instructions to staff would be placed via an interim service plan to address the falls.On 10/02/23, the need to evaluate falls, determine interventions and communicate those to staff was addressed with Staff 3. She acknowledged the findings.b. Review of weight records revealed the following: * 08/06/23 - 160.0 pounds; * 09/10/23 - 151.0 pounds; and* 10/03/23 - 151.0 pounds (weight obtained during the survey).The resident lost 9 pounds, or 5.6% of his/her total body weight, in 30 days, which constituted a significant weight loss and significant change of condition. There was no documentation the facility evaluated the significant change of condition, documented the change, or updated the service plan. The need for the facility to ensure residents who had a significant change of condition were evaluated and resident-specific instructions or interventions were developed and reviewed for effectiveness was discussed with Staff 2 (Regional Director of Operations), Staff 3 and Staff 5 (RCC) on 10/04/23. They acknowledged the findings, and no further information was provided.

Based on interview and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition and documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (#6) who experienced significant changes. Findings include, but are not limited to:Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes.A review of the Resident's clinical record, including the current service plan, dated 07/20/23, progress notes 07/01/23 through 10/01/23, and weight records from 04/01/23 through 10/01/23 was completed, and staff were interviewed. The following was identified:a. Review of weight records revealed the following: * 08/06/23 - 160.0 pounds; and* 09/10/23 - 151.0 pounds.The resident lost 9 pounds, or 5.6% of his/her total body weight, in 30 days, which constituted a significant weight loss and required an RN assessment. At time of survey, 10/03/23, resident weighed 151.0 pounds.There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. b. Progress notes from 09/23/23 through 09/27/23 indicated that the resident had multiple trips to the ER, increased confusion, increased weakness, increased need for ADL assistance, and falls. Progress notes from 09/28/23 indicated the resident had been admitted to hospice. Based on the resident's 7/20/23 service plan and interviews with staff, prior to the dates listed above the resident did not have confusion, was independent with all ADLs, did not have a history of falls, and ambulated independently.The changes above constituted a significant change of condition and required an RN assessment. During an interview on 10/04/23, Staff 3 (Health Services Director) stated the RN assessment had not yet been completed.The need to ensure an RN assessed all significant changes of condition including findings, resident status, and interventions made as a result of the assessment within 48 hours was discussed with Staff 2 (Regional Director of Operations), Staff 3 and Staff 5 (RCC) on 10/04/23. They acknowledged the findings, and no additional documentation was provided.

2. Observations made during the survey, 10/02/23 through 10/03/23, determined the facility failed to establish and maintain infection prevention and control protocols including protocols to prevent the development and transmission of communicable diseases: * On 10/02/23, a caregiver was observed entering an unsampled resident's room, who was positive for Covid-19, without first donning full PPE including a disposable gown; and* On 10/03/23, two caregivers were observed entering an unsampled resident's room, who was positive for Covid-19, without first donning full PPE including a disposable gown. Upon interviews with staff, it was noted that the facility had run out of disposable gowns and caregivers had been told they should utilize trash bags to cover their clothing. The need to establish and maintain infection prevention and control protocols, including protocols to prevent the development and transmission of communicable diseases, was discussed with Staff 2 (Regional Director of Operations), Staff 3 (Health Services Director) and Staff 5 (RCC) on 10/04/23. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols and have a designated "Infection Control Specialist." Findings include, but are not limited to:1. In an interview on 10/02/23, Staff 1 (Executive Director) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols, qualified by education, training and experience or certification, and who had completed specialized training in infection prevention and control protocols.On 10/04/23, the need to ensure the facility had a qualified "Infection Control Specialist" was discussed with Staff 2 (Regional Director of Operations). She 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 and written and signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 3, 5 and 6) whose MARs and orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 05/2020 with diagnoses including diabetes.Resident 3's MARs, dated 09/01/23 through 09/30/23 and physician orders were reviewed and revealed the following:Resident 3 had physician orders for staff to check the resident's blood sugars four times a day, and an order instructing staff to administer five units of Humalog insulin for blood glucose levels over 390. This was in addition to the scheduled insulin ordered. There were five occasions between 09/14/23 and 09/30/23 when Resident 3's blood glucose levels were greater than 390 with no documented evidence that the additional five units of insulin was administered. Staff 3 (Health Services Director) on 10/03/23 acknowledged the additional insulin was not documented as administered for the blood glucose levels greater than 390.The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Regional Director of Operations) on 10/04/23 and Staff 3 and Staff 4 (RN Consultant) on 10/03/23. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 11/2018, with diagnoses including diabetes, hypertension, and congestive heart failure. Review of Resident 5's MARs, dated 09/01/23 through 09/30/23, and signed physician orders dated 09/22/23, indicated the following:Resident 5 had a physician's order for weekly weights. The MARs revealed the weight was not taken on 09/19/23, as ordered.On 10/04/23, the need to ensure all treatment orders were carried out as prescribed was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.
2. Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes. The resident's physician orders and 09/01/23 through 10/01/23 MARs were reviewed.a. There were no signed physician orders in Resident 6's chart for the following medications:* Ondansetron 4 mg (for nausea); * Nitroglycerin 0.4 mg (for chest pain); * Loperamide 2 mg (for loose stools); * Epinephrine 0.3 mg/0.3 ml (for anaphylaxis);* Docusate sodium 100 mg (for constipation); and* Tamsulosin 0.4 mg (for urinary retention). In an interview with Staff 3 (Health Services Director) on 10/04/23, she verified there were no signed orders in the resident's chart for the above medications. b. On 09/30/23, hospice faxed signed orders to the facility with instructions for wound care for the resident's right arm, including "Change Telfa [sic] dressing and roll gauze 2 times weekly and PRN." During an interview on 10/04/23, Staff 18 (MT) stated the treatment order was not transcribed to the MAR/TAR, and there was no documentation the facility was providing wound care as ordered.The need to have signed physician orders in the resident's record and ensure all treatment orders were carried out as prescribed was discussed with Staff 2 (Regional Director of Operations), Staff 3 and Staff 5 (RCC) on 10/04/23. 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 2 of 3 sampled residents (#s 3 and 6) who had medication refusals. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2020 with diagnoses including diabetes and insomnia.Resident 3's 07/04/23 through 10/02/23 progress notes, physician communications, and 09/01/23 through 09/30/23 MAR/TAR were reviewed. The resident had an order for Trazodone 50 mg, one tablet every night for insomnia. There were 13 occasions between 09/01/23 and 09/30/23 when the resident refused the medication. There was no documented evidence the facility notified the physician/practitioner of the medication refusals.On 10/03/23 Staff 3 (Health Services Director) reported there was no documentation the facility staff notified the physician each time the resident refused the medication. There was no evidence the facility had a system for notifying prescribers when a resident refused to consent to orders.The need to ensure the facility notified the physician/practitioner of medication refusals as ordered was discussed with Staff 2 (Regional Director of Operations) and Staff 3 on 10/03/23 and 10/04/23. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes. On 10/01/23, the resident refused five medications including:* Glipizide ER 10 mg (for diabetes);* Docusate sodium 100 mg (for constipation); * Jardiance 25 mg (for diabetes); * Isosorbide mono ER 30 mg (for heart disease); and* Preservision (for supplement). During an interview on 10/03/21, Staff 14 (MT) stated when a resident refused medication, the facility contacted the physician or hospice. This could happen via phone call, fax, or in-person communication. They were unable to provide documentation that confirmed the physician or hospice was notified of the above refusals. The need to notify the physician/practitioner when a resident refused to consent to orders was discussed with Staff 2 (Regional Director of Operations), Staff 3 (Health Services Director) and Staff 5 (RCC) on 10/04/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 11/2018, with diagnoses including diabetes, hypertension, and congestive heart failure.Review of the resident's MAR, dated 09/01/23 through 09/30/23, identified the following:The MAR lacked reasons for use for the following medications:* Ferrous Sulfate 325 mg;* Folic Acid 1mg; and* Gabapentin 100 mg.On 10/04/23, the need to ensure MARs were accurate and included reasons for use for all medications was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.
3. Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes. Resident 6's 09/01/23 through 10/01/23 MAR was reviewed and the following PRN medications lacked resident-specific parameters for administration: * Acetaminophen 325 mg tablet, acetaminophen 650 mg suppository, hydromorphone 10 mg/ml liquid, and hydromorphone 2 mg tablet were prescribed to treat pain; * Acetaminophen 325 mg tablet and acetaminophen 650 mg suppository were both prescribed to treat fever; * Haloperidol 2 mg/ml and ondansetron 4 mg were both prescribed to treat nausea; and* Hydromorphone 10 mg/ml liquid, hydromorphone 2 mg tablet, and lorazepam 0.5 mg were prescribed to treat dyspnea (difficulty breathing). The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 2 (Regional Director of Operations), Staff 3 (Health Services Director) and Staff 5 (RCC) on 10/04/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications and treatments ordered by a legal prescriber and administered by the facility, and included reason for use, medication-specific instructions, and resident-specific parameters for PRN medications for 3 of 4 sampled residents (#s 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 05/2021 with diagnoses including chronic ischemic heart disease and diabetes.Review of the resident's 09/01/23 through 09/30/23 MAR, 07/05/23 through 10/01/23 outside provider notes, and signed physician orders revealed the following:* The resident had a physician order for Lidocaine 4% cream "for catheter related pain". A hospice RN removed the resident's catheter on 07/02/23 and s/he refused to let the nurse put it back in; and* The 09/01/23 through 09/30/23 MAR indicated the resident refused the Lidocaine on 25 occasions and staff administered the cream on five occasions.In an interview on 10/04/23, Staff 14 (MT) stated she didn't think the Lidocaine had been administered at all in 09/2023 and thought the pain medication should have been discontinued when the resident's catheter was removed.The need to ensure MARs were accurate was discussed with Staff 3 (Health Services Director) on 10/03/23 and with Staff 2 (Regional Director of Operations) on 10/04/23. No additional documentation was provided.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications at least quarterly and obtain a physician or other legally recognized practitioner's written order of approval for self-administration of medications for 1 of 1 sampled resident (#2) who administered their own medication. Findings include, but are not limited to:Resident 2 was admitted to the facility in 07/2021. Resident 2 was identified as administering his/her own medications during the acuity interview on 10/02/23. Review of Resident 2's record identified the following:* An evaluation to determine Resident 2's ability to safely self-administer medications was completed on 08/16/21. There was not an updated evaluation for the resident to safely self-administer their medications.* There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer their medications.On 10/04/23, the need to ensure the facility obtained a physician order for residents who chose to self-administer their own medications and residents were evaluated at least quarterly for their ability to safely self-administer medications was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the use of a supportive device with restraining qualities was thoroughly assessed by an RN, PT, or OT prior to use, instruct caregivers on the correct use of and precautions related to the supportive device, document use of the device in the resident's service plan, and/or evaluate the device on a quarterly basis for 1 of 1 sampled resident (# 5) who used a supportive device. Findings include, but are not limited to:Resident 4 was admitted to the facility in 05/2021 with diagnoses including chronic ischemic heart disease and diabetes.During an interview with the resident on 10/03/23, the surveyor observed half side rails in the up position on both sides of the resident's bed. The rails were securely attached.A review of the resident's current service plan, dated 07/10/23, indicated the resident had a "right-sided bed cane." The service plan did not have instructions to caregivers on the correct use of the side rail and precautions related to the supportive device.There was no documented evidence an assessment of the side rails was completed by an RN, PT, or OT.The lack of an assessment of the resident's side rails was discussed with Staff 3 (Health Services Director) on 10/03/23 and with Staff 2 (Regional Director of Operations) on 10/04/23. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 21 and 22) demonstrated competency of skills in all assigned job duties within 30 days of hire and 1 of 3 newly hired staff (# 22) was trained in first aid and abdominal thrust. Findings include, but are not limited to:Training records were reviewed on 10/04/23 and revealed the following:a. Staff 21 (CG), hired on 07/20/23, lacked documented evidence of competency within 30 days of hire in the following required topics: * Role of service plans in providing individualized care;* Providing assistance with ADLs;* Identification, documentation, and reporting changes of condition;* Conditions that require assessment, treatment, observation, and reporting; and* General food safety, serving, and sanitation.b. Staff 22 (CG), hired 07/13/23, lacked documented evidence of competency within 30 days of hire in the following required topics: * Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting changes of condition;* Conditions that require assessment, treatment, observation, and reporting; and* General food safety, serving, and sanitation.Additionally, there was no documented evidence Staff 22 had completed first aid and abdominal thrust training within 30 days of hire.On 10/04/23, the need to ensure staff had documented evidence of competency demonstration within 30 days of hire and completion of first aid and abdominal thrust training, was discussed with Staff 2 (Regional Director of Operations), She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 17, 18, and 20) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:Staff training records were reviewed on 10/04/23.There was no documented evidence Staff 17 (MT), hired 08/17/22, Staff 18 (MT,) hired 09/14/22, and Staff 20 (CG/MT), hired 06/16/22, had completed a minimum of 12 hours of annual in-service training, basesd on hire dates, related to the provision of care, at least six of which needed to relate to dementia care.On 10/04/23, the need to ensure all required in-service training hours were completed annually was reviewed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills were being conducted every other month, all required components of fire drills were documented, and fire and life safety instruction was provided on alternate months to staff. Findings include, but are not limited to:1. On 10/04/23, fire drill records were reviewed from April 2023 through October 2023 with Staff 2 (Regional Director of Operations). Fire drill records revealed the facility failed to conduct fire drills every other month and failed to document the following required components:* Date and time of fire drill;* Location of simulated fire origin;* Escape route used;* Problems encountered;* Evacuation time-period needed;* Staff members on duty and participating; and* Number of occupants evacuated.2. The facility failed to provide documented evidence fire and life safety instruction was being provided to staff on alternating months from fire drills. On 10/04/23, the need to ensure documentation that fire drills were being conducted every other month, all required components of fire drills were documented, and fire and life safety instruction was provided on alternate months to staff was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures annually. Findings include, but are not limited to:On 10/04/23, facility fire and life safety records were reviewed and lacked documented evidence the following required elements were completed:* A written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.On 10/04/23, the need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:The exterior of the facility was toured on 10/02/23 and 10/03/23. The following deficiencies were identified:* Exterior pathways around the perimeter of the building contained drop-offs up to two inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents; and* The exterior of the facility had an excess of cobwebs throughout. On 10/03/23, the building's exterior was toured with Staff 1 (ED). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:Observations of the facility on 10/02/23 and 10/04/23 identified the following areas in need of cleaning and repair:* Multiple areas of the carpet in the dining room and corridors throughout the facility had stains and black spots;* Vinyl flooring in laundry rooms had cracks and/or tears; * Multiple dining room chairs had stains;* Multiple dining room tables had exposed wood; and* Handrails near the front desk were worn, with exposed wood.On 10/03/23, the areas in need of cleaning and repair were reviewed with Staff 1 (ED). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:During the survey, the exit doors from the ALF to the exterior of the building failed to have a working alarm or other acceptable system to alert staff when residents left the building.On 10/04/23, the lack of alarms on exit doors was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 04/14/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 9/27/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview, observation and record review, it was confirmed that the facility failed to provide three daily, nutritious, palatable meals to the residents, including fresh fruits and vegetables. Findings include: Review of Uniform Disclosure Statement (UDS), Food menu for 9/25/22-10/01/22, Chef ' s Chat meeting minutes for 09/27/22, and always available menu. The meeting minutes included multiple complaints regarding cold food, lack of fresh fruits and vegetable, and being served food they didn ' t order. The menu does not include vegetarian options and does not always include fresh fruits and vegetables in each meal. CS requested food temp logs for 09/09/22-09/15/22, however, the facility did not have any completed logs to provide. They are not documenting food temps, or documenting follow up from menu chat meeting. The UDS states that vegetarian diets are included, however, the facility is not providing it. On 09/27/22, CS observed lunch service. The food being served was what was listed on the menu. The portion sizes were normal and filled the plate. No concerns from residents that they were still hungry or didn't get enough food. In separate interviews with Staff #1 and #4 on 09/27/22, they stated that staff should be temping the food and documenting it. They have not heard of any frozen fish being served. They have their monthly chef chat meeting today. They currently do not provide a vegetarian diet. They haven't heard of residents going hungry. Staff #4 stated that sometimes staff don't use the temp log and will write it on a sticky note and throw it away. Interviews with residents #1-2 and #4 stated that the food is served late, served cold, they do not always serve what they request or ordered off the menu/anytime menu, they do not provide vegetarian diets, and the food is carb heavy without fruit and vegetable options. CS shared the above information with Staff #1 on 09/27/22. Plan of correction: Facility will provide vegetarian meals per their UDS, training for kitchen staff on documenting and keeping food temperature logs, hiring additional dietary staff, keep minutes at menu chat meetings, talk about modification in the meeting to make sure staff are paying attention to what residents are ordering.

Based on interview and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:In review of staffing schedules for September 2022, posted staffing plan, Acuity Based Staffing Tool (ABST), service plans for Residents #1-3, and call light response times for 09/10/22. There were multiple response times between 20 and 50 minutes. The facility is not responding to call lights timely.In an interview on 09/27/22, Staff #1 stated that they are not aware of any needs being missed. Meals are being served timely with the exception of the weekend before last. They just hired 2 new cooks. Staff #4 stated they have heard that dinner has been served late most nights. Staff #3 stated that they are responding to call lights within 2-4 minutes, but there have been some complaints about long wait times.In separate interviews with Residents #1-2 and #4, they stated that there is not enough staff. Weekends and nights are the worst. Call lights can take more than 20 minutes, sometimes 45 minutes.Plan of Correction:Hiring kitchen and care staff, re-training staff, auditing call light response times when complaints received, using agency staff, ISP for call light response times, and discuss in shift to shift.

Based on interview and record review, it was confirmed that the facility failed to directly supervise staff until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable. Findings include: In review of the facility's policy and procedures for transfers and an incident report from 09/11/22, it was determined that the staff was not following policy and had not completed training. The staff member transferred a 2-person transfer alone. On 09/27/22, Compliance Specialist (CS) requested the staff member's training records however, this information was not provided. In separate interviews with Staff #1-2 on 09/27/22, they stated that the incident did occur. A new staff member was told not to do a transfer alone as it was their 1st and 2nd day of training, and they did not follow the policy and procedures, which resulted in the resident and staff member falling. This staff member is no longer working at the facility. Plan of correction: Staff member quit and is no longer working at the facility. Reminders to staff regarding safe transfers. ISP to remind staff about transfers and supervised training for new staff.

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 8/10/2022. 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

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 8/10/2022. 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