Avamere at Albany

Based on interview and record review, conducted during a site visit on 08/26/25, the facility's failure to update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:A review of the facility's ABST indicated the "minimum time needed based on acuity" on the day shift was 4.28 direct care staff, on the swing shift was 3.83 direct care staff, and on the night shift was 0.80 direct care staff.A review of the facility's posted staffing plan indicated the following:· Day shift: five caregivers and one med tech;· Swing shift: four caregivers and one med tech; and· Night shift: two caregivers and one med tech.A review of the facility's staff schedule from 08/20/25 through 08/26/25 indicated the facility had been short-staffed for five shifts. An interview with Staff 1 (Executive Director) indicated the facility had been short-staffed during the timeframe. The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The findings of the investigation were reviewed and acknowledged by Staff 1.

Based on interview and record review, it was determined the facility failed to update the initial resident evaluation during the 30 days following move-in, and/or failed to ensure the most recent quarterly evaluation was relevant to the needs and conditions of the resident for 3 of 4 sampled residents (#s 1, 2, and 3) whose initial or quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the community in 03/2024 with diagnoses including atrial fibrillation, acute kidney failure and shortness of breath.

The resident’s most recent quarterly evaluation dated 01/30/25, MAR dated 02/01/25 through 02/21/25, service plan, and intermediate service plans were reviewed, and staff were interviewed. The evaluation was not relevant to the current needs and conditions of the resident in the following areas:

* Skin issues;

* Treatments; and

* Toileting assistance.

On 02/20/25, the need to ensure quarterly evaluations were relevant to the needs and conditions of the residents was discussed with Staff 1 (ED), Staff 2 (RN), Staff 4 (RCC), Staff 5 (RCC), Staff 6 (Business Office Manager), and Staff 25 (Regional Nurse Consultant). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 05/2023 with diagnosis’s including hypertension.

In interviews with Staff 9 (MT) and Staff 13 (CG), on 02/19/25, it was reported Resident 3 smoked independently off campus.

On 02/19/25, survey requested from Staff 4 (RCC) a copy of Resident 3’s smoking evaluation for their ability to smoke safely. Staff 4 reported she was unable to find a copy of a smoking evaluation since 05/2023.

There was no current documented evidence Resident 3 had been evaluated for the ability to smoke safely.

On 02/19/25 at approximately 1:15pm, Staff 4 provided survey with a smoking evaluation for Resident 3.

On 02/20/25, the need to ensure quarterly smoking evaluations were completed for residents who smoked was discussed with Staff 1 (ED), Staff 2 (RN), Staff 5 (RCC), and Staff 6 (Business Office Manager). They acknowledged the findings.

3. Resident 1 was admitted to the facility in 11/2024 with diagnoses including Amyotrophic Lateral Sclerosis (ALS).

a. During an interview with Staff 3 (Vice President of Operations) on 02/19/25 at 11:35 am, she reported the facility had started to update but did not complete the 30-day evaluation for Resident 1.

b. Resident 1’s quarterly evaluation was completed on 02/02/25. The evaluation was not updated to reflect the resident's current needs and condition in the following areas:

* Bowel and Bladder: Toileting assistance; and

* Adaptive devices for eating/drinking.

On 02/20/25, the need to ensure 30-day evaluations were completed/updated for new admissions, and quarterly evaluations were updated and reflective of the resident's needs and condition was discussed with Staff 1 (ED), Staff 4 (RCC) and Staff 25 (Regional Nurse Consultant). 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 interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition had resident-specific instructions or interventions developed and communicated to staff on all shifts, and/or weekly progress documented until resolution for 3 of 4 sampled residents (#s 1, 2 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2024 with diagnoses including Amyotrophic Lateral Sclerosis (ALS). The resident's 02/04/25 service plan, 11/21/24 through 02/18/25 interim service plans, progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without resident specific actions/interventions developed and communicated to staff, and/or progress noted at least weekly until resolved in the following areas:

* 11/2024 - Admission to facility;

* 12/05/24 - Fungal rash; and

* 01/29/25 - Elevated blood pressure, with instruction to check blood pressure daily and provide a low sodium diet.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, and/or actions/interventions developed and communicated to staff was discussed with Staff 1 (ED), Staff 4 (RCC), and Staff 25 (Regional Nurse Consultant) on 02/20/25. They acknowledged the findings.

2. Resident 2 moved into the community in 03/2024 with diagnoses including atrial fibrillation, acute kidney failure, and shortness of breath.

The resident’s progress notes dated 12/02/24 through 02/19/25, service plan dated 01/31/25, and intermediate service plans were reviewed, and interviews with staff were conducted. The following was identified:

There was no documented evidence the following changes of condition were monitored with weekly progress noted until resolution:

* 12/22/24 – Bed bug infestation;

* 01/03/25 – Sore on bottom;

* 01/11/25 – Scabs on right shoulder; and

* 01/23/25 – Rash under left side of stomach fold.

During an interview at 3:30 pm on 02/19/25, Staff 25 (Regional Nurse Consultant) confirmed there was no evidence these changes of conditions were monitored at least weekly until resolution.

The need to ensure weekly progress was noted until resolution for short-term changes of condition was discussed with Staff 1 (ED), Staff 2 (RN), Staff 4 (RCC), Staff 5 (RCC), Staff 6 (Business Office Manager), and Staff 25 (Regional Nurse Consultant). They acknowledged the findings.

3. Resident 4 was admitted to the facility in 09/2021 with diagnoses including osteoarthritis, skin melanoma, and multiple sclerosis.

Review of Resident 4's progress notes, dated 11/19/24 through 02/19/25, revealed the resident experienced the following changes of condition:

* On 1/23/25, a progress note reported a “pressure sore on left big toe;” and

* On 02/05/25, a progress note described a bruise on the resident’s right calf “approx. the size of a baseball and yellow/green/purple in color.”

There was no documented evidence the skin conditions were monitored for progress at least weekly, to resolution.

On 02/20/25, the need to ensure monitoring of skin conditions weekly to resolution was discussed with Staff 1 (ED), Staff 2 (RN), Staff 5 (RCC), and Staff 6 (Business Office manager). They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

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

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. The failure to have adequate staff to meet the residents scheduled and unscheduled needs on night shift placed residents at high risk for harm. Findings include, but are not limited to:

During the entrance conference on 02/19/25 the following was identified:

* The facility had 43 residents;

* Six residents needed two-person assistance with transfers and/or care; and

* One resident was identified to have behaviors, cognitive impairment, a history of multiple elopements and remained a high elopement risk.

The staffing plan posted at the front desk on 02/19/25 was as follows:

* Day shift 1 MT and 3.5 CG's;

* Evening shift 1 MT and 3 CG's; and

* Night shift 1 MT and 1 CG.

Staff and resident interviews completed on 02/19/25 and 02/20/25 between 9:40 am and 4:30 pm showed the following:

A non-sampled resident approached the survey team and expressed concerns regarding the staffing on the weekends and the night shift. The resident indicated there were only two staff on night shift with some occasions when there had been only one. The resident indicated s/he had expressed their concerns to administration but felt ignored. The resident stated the facility “got wild” at night and there were frequently numerous lights going off. Staff did their best and were running to get to everyone. The resident indicated s/he was not the only one with concerns, but s/he was one of the few not afraid to speak up.

An additional non-sampled resident indicated there was not enough staff at night, some weekends and some evenings. The staff did the best they could to get to lights quickly, but they needed more help. She reported that as far as s/he knew there were only three in the evenings and only two at night.

Staff 22 (Housekeeping) indicated the facility had a red slide that looked like a sled to move residents from the second floor to the first floor in case of a fire or other evacuation needs. The staff indicated she was aware of at least two residents that would need to use the slide down the stairs because of their physical conditions. She believed two staff would be safer and more effective to operate the sled and slide residents down the stairs.

Staff 12 (CG), Staff 15 (CG) and Staff 20 (CG) indicated there were multiple residents on the second floor that would require the “slide” to evacuate in the case of an emergency. The staff described the device as a large sled used to slide the residents down the stairs to the first floor when they were unable to walk down the stairs. The staff indicated there were several residents in wheelchairs or with partial paralysis. Additionally, Staff 12, 15 and 20 stated there were several residents who could not stand for long periods who would also need the slide/sled because there would be no guarantee they could stand long enough to get down the stairs. The staff indicated the slide/sled was large and awkward, so two staff were needed to safely maneuver the stairs, ensure the resident did not fall out, and to help transfer the resident from inside the sled at the bottom of the stairs, into a chair and out of the facility as necessary. The staff further indicated night shift had only two staff. They were unsure how two staff could get residents moved down the stairs in the sled and assist the other residents in an emergency.

Staff 12 took the surveyor to the location of the sled. The slide/sled was approximately 6-6.5 feet long by approximately 2.5-3 feet wide. The sides of the slide/sled were a few inches in height and there was no seat belts or other straps connected to the interior or exterior of the device.

Staff 10 (MT), Staff 12 (CG) and Staff 16 (CG) indicated there were six residents that required two-person assistance for transfers and/or care. The staff stated when the call lights go off on night shift a lot of the time, they were the residents who needed two-person assistance. The staff further indicated there was one resident, Resident 5, who required 1:1 when out of his/her room. The staff stated the resident frequently got up on night shift and wanted hot cocoa and to visit. The resident was on the move a lot, staff had to chase Resident 5 often, and s/he had left the building twice in the last few months. The resident had air tags in his/her clothes due to high elopement risk. The staff indicated night shift only had two staff total and sometimes was down to one staff due to call outs. When staff must track Resident 5, only one staff was left to handle the two person assists and everything else on the two floors.

Staff 4 (RCC) indicated Resident 5 was no longer a 1:1 unless s/he left the building then staff had to follow. While in the building the resident was to be kept in line of sight of staff.

Staff 1 (ED) stated Resident 5 was no longer a 1:1 unless s/he left the building. Staff were to follow the resident if s/he left the facility, otherwise staff were to keep the resident in line of sight when s/he was out of their room. Staff 1 acknowledged that depending on the resident’s location in the building the staff monitoring him/her would not be able to take care of any other resident needs and essentially become the resident’s 1:1 while s/he was on the move. Staff 1 confirmed night shift had one medication technician and one caregiver.

Observations of the facility on 02/19/25, at approximately 9:10 am, Resident 5 was noted to have behaviors around the staff work area and was difficult to redirect. The resident was observed pushing through staff at the front desk after s/he had climbed over a closed baby gate at the opening of the reception desk. Multiple attempts by several staff were made before the resident was willing to exit the area and return to the dining room.

Additional observations of the common areas between 02/19/25 and 02/20/25, showed Resident 5 in the dining room or up moving around the halls on the first floor. The resident was intermittently given a walker to utilize but would quickly walk away from the device.

Five sampled residents were reviewed for service planned needs and ABST entries. All five residents had multiple areas which were not reflective of the actual time staff required to provide the care to the individual residents. ADL areas with inaccurate time noted included transfers, toileting, dressing and behaviors.

The need to ensure resident supervision was maintained throughout each shift and to ensure enough staff were available to meet the scheduled and unscheduled needs of the residents to ensure resident care and safety was discussed with Staff 1 (ED) on 02/20/25. He acknowledged the findings.

Staff 1 was asked to increase staffing for night shift to two caregivers and one medication technician. Staff 1 and Staff 5 (RCC) provided names of staff who would be working as the additional staff on night shift beginning 02/20/25 through 02/23/25. They would continue to update the schedule to ensure three total staff on night shift were present going forward.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

(Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (ED) on 02/19/25 and 02/20/25.

Review of Residents 1, 2, 3, 4 and 5’s ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1, Staff 4 (RCC), Staff 5 (RCC) and Staff 25 (Corporate Nurse Consultant) on 02/20/25. They acknowledged the findings. No further information was provided.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING
(b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average.
(c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents.
(d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1).
(e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule.
(f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.
(g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure resident ABST entries were updated at least quarterly. Findings include, but are not limited to:

Review of the facilities ABST entries was completed and showed the following:

* The staffing tool showed there were five residents whose ABST entries were not updated at least quarterly in conjunction with the residents’ service plans.

The need to ensure all residents’ ABST entries were updated at least quarterly was discussed with Staff 1 (ED) on 02/19/245and 02/20/25. He acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

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 02/19/25 showed the following areas in need of cleaning and/or repair:

* Rooms 107, 109, 110, 116, 118, 203, 209, 219 and 224 had scrapes, dings and/or spills to the doors and door frames;

* Common area bathrooms on the first floor had cracked, brown and/or missing caulking around the toilets;

* Carpet stains of varying sizes and colors were noted in the center of the dining room and in the front entryway. Additional significant carpet stains were noted from the doorways to the center of the hallway, of rooms 104 and 107. Tile inserts in the dining room floor near the kitchen and the sliding patio doors, were chipped and dinged with small pieces of tile missing;

* Two armchairs located on the second floor, center hall, had large spills/stains to the seats and a nearby bar stool was torn and worn at the seams which exposed the fabric underneath the vinyl layer;

* Room 117 had significant carpet stains and wall damage. A corner wall in the main living area had large chips, dings and chunks of missing plaster/dry wall. A wall in the bathroom was also dinged, chipped and scrapped with a loose baseboard. The counter top was chipped with missing laminate, and caulking around the toilet was brown and cracked with small missing pieces; and

* The resident laundry room had scrapes and spills to the door, as well as a long scrape to the back wall.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 02/19/25. He 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:

Based on interview and record review it was determined the facility had restricted resident rights to visitors for 1 sampled (#3) and 1 non-sampled resident. Findings include, but are not limited to:

During the facility HCBS interview it was determined the facility had 24/7 visiting hours available for most residents. Two residents were identified to have restrictions in place preventing specific family members from coming to the facility due to concerns regarding the visitors conduct.

Staff 1 (ED) indicated Resident 3 and a non sampled resident both had restrictions in place related to specific visitors. No individually based limitation (IBL) had been completed regarding the restriction of this resident right. Staff 1 indicated he would get IBLs for both residents completed and submitted for review.

The need to ensure an IBL was completed when the need to restrict a residents’ right to visitors at any time, was discussed with Staff 1 and Staff 3 (VP of Operations) on 02/19/25. The staff acknowledged the findings.

OAR411-004-0020(2)(h) Individual Visitors: Any Time

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(h) Each individual may have visitors of his or her choosing at any time.

This Rule is not met as evidenced by:

Based on interview and record review it was determined the facility failed to ensure Individually Based Limitations (IBLs) were completed when the need to restrict a residents’ rights arose. Findings include, but are not limited to:

Refer to H1521.

OAR411-004-0040(1) Limitations: Threats To Health And Safety

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility failed to provide a daily program of social and recreational activities for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:During an interview on 07/30/24, Staff 1 (Executive Director) indicated during the timeframe of the complaint the activities director had to go on leave for surgery. There had been no one covering for activities while s/he was out resulting in the facility canceling activities. Staff 4 (Activities Director) had been out for about 3 weeks. Staff 1 also indicated s/he had been working with Staff 4 to improve the activities program. During separate interviews on 07/30/24, Residents 1 and Resident 2 indicated they do not attend activities at the facility because they are boring and not engaging. A review of Staff 4's performance improvement notifications dated 01/05/24 and 07/15/24 indicated Staff 4 received a verbal and written warning for his/her inability to provide social and recreational activities for the residents. A review of the activities calendar indicated the activities on 07/30/24 we as follows; · 10:00 AM- Morning exercise. · 11:00 AM-Corner Kitchen. · 12:00 PM- Lunchtime trivia. · 2:00 PM- Bingo. · 3:30 PM- Wii Games.On 07/30/24, the findings were reviewed with and acknowledged by Staff 1.It was determined the facility failed to provide a daily program of social and recreational activities.Verbal plan of correction: Staff 1 will continue to work with Staff 4 to improve the activities program.

Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:In an interview on 07/30/24, Staff 1 (ED) indicated no knowledge of the average call light response time, however, indicated the standard was to answer within 5 minutes. A review of call light history from 05/09/24 through 05/13/24 indicated 94 call light response times that exceeded 15 minutes and of those, 61 response times exceeded 20 minutes. The longest response time had been 50 minutes.A review of call light history from 07/26/24 through 07/28/24 indicated 46 call light response times that exceeded 15 minutes and of those, 33 response times had exceeded 20 minutes. The longest response time had been 87 minutes.It was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.On 07/30/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Staff 1 will start auditing call lights and have meetings with staff when call lights have exceeded regular response times.

Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility failed to update an acuity-based staffing tool (ABST). Findings include, but are not limited to:On 07/30/24, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required three staff on day shift, two care staff on swing shift, and one care staff on night shift. There were 36 of 38 residents' profiles that had not been updated quarterly. The posted staffing plan indicated the following staffing levels: · Day shift: two caregivers and one med tech. · Swing shift: two caregivers and one med tech.· Night shift: one caregiver and one med tech.In an interview on 07/30/24, Staff 1 (Executive Director) indicated the facility had been using the ODHS ABST. Staff acknowledged the residents who had not been updated quarterly. It was confirmed the facility failed to update an acuity-based staffing tool.On 07/30/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility does not take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to:During an interview on 07/30/24, Staff 1 (ED) indicated the facility was 98 percent cleaned up of the bed bugs and will continue to have the pest control company to come out until there was no more trace of the bugs. S/he indicated the facility is working hard to eliminate this issue. A review of the pest control invoices indicated the following:· Invoices from 05/09/24 through 07/09/24 had indicated evidence of active bed bugs. · On 07/09/24 pest control inspected rooms 202 through 204 and found no evidence of active bed bugs. Facility requested they look at rooms 205 and 213 where no current bed bugs had been found. · On 07/16/24 and 07/23/24 pest control inspected rooms 202, 203, and 204. No activity of bed bugs had been indicated in rooms 202 or 204. In room 203 pest control found one single juvenile bed bug and removed the bug. · It was determined the facility does take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.It was confirmed the facility does not take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.On 07/30/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The facility has a pest company coming out to treat the bed bugs and will continue the treatments until the facility and resident no longer has them.

Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility did not take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to:During an interview on 04/30/24, Staff 1 (Acting ED) indicated s/he had recently taken over the facility. Once aware of the bed bugs s/he had treated not only the hallway where the bed bugs had been, but the corridors, common areas, dining room, and high traffic areas. The facility had gotten rid of recliner in RM 202 and swapped out the bed frame in RM 213. A review of the pest control invoices from 01/04/24 through 04/19/24, indicated the following; ·01/04/24- indicated live bed bug activity noted on seatbelt on RM 202 electric shooter. ·01/10/24- Bed bug follow-up service completed for rooms 202, 213, and 224. 220 had not been inspected. 202 had minimal activity around baseboards below bed. Room 213 and 224 had no activity of bed bugs. ·01/23/24- RM 202 had minimal activity. ·02/08/24- High activity noted in RM 204, recliner was infested.·02/20/24- inspected rooms 202, 203, 204, 218, 219, and 220 with minimal activaty. RM 203 and 220 had no activity. ·03/04/24- Treated baseboards in common areas. ·03/27/24- RM 204 no activity, RM 202 live activity noted around bed frame. ·04/12/24- Minimal activity in RM 202. ·04/19/24- No activity in RM 202.It was confirmed the facility did not take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.On 04/30/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The facility has a pest company coming out to treat the bed bugs and will continue the treatments until the facility and resident no longer has them.

The findings of the kitchen inspection, conducted 11/17/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 11/17/23, conducted 02/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen was conducted on 11/17/23 from 9:45 am through 1:30 pm and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Vent above reach-in refrigerators in main kitchen;* Interior of reach-in refrigerator in activity space;* Interior of oven; and* Utility carts' corners and edges. b. The following areas were in need of repair: * Utility carts had heavy wear on handles; * Several cooking utensils were observed to have integrity concerns (example: parts of utensils melted, paint chipped, protective coating worn/chipping/flaking off);* Knife holder;* Wood drawers throughout kitchen had integrity concerns (e.g., porous material, chips, missing laminate, etc);* Cupboards throughout kitchen do not have smooth, cleanable surfaces;* Caulking behind dish pit area had sections with dark mold-like substance; and* Calking to left of food prep sink by window had section with dark mold like substance.c. Poor infection control practices observed include, but are not limited to:* Dining room had pre-set tables with food contact surfaces of cutlery exposed to potential contamination;* Ice machine had black mold-like residue on inside of machine;* While kitchen staff was temping a hot dog, the staff member placed the hot dog on a bun. The meat product tempted at 138 degrees F, staff removed the hot dog from bun and placed back on flattop to continue cooking. Staff did not change gloves and continued to touch and prep other ready-to-eat foods, potentially contaminating those items. * While temping hot dog the second time, cook did not replace hot dog bun that touched uncooked hot dog, placed hot dog on bun (again), tempted at 179 degrees F, meal was served to resident;* While prepping salads and sandwiches, the same cutting board was used for multiple foods (lunch meat, cheese, bread, tomato) and was not sanitized in between uses;* When plating meals, cook(s) touched food items with potentially contaminated gloves; * Kitchen staff observed to not wash hands in between handling dirty then clean dishes;* Dry storage had uncovered product with expiration date of 08/05/22;* Frozen food item observed in main kitchen to have broken packaging, creating potential for contamination;* Frozen food items uncovered in main kitchen freezer;* Unlabeled product in activity refrigerator;* Uncovered product in activity refrigerator; * Outdated/expired food products found in activity refrigerator; and* Kitchen staff preparing food without facial hair restraints.At approximately 2:20 - 2:40 pm, surveyors reviewed above areas with Staff 1 (Executive Director) and Staff 2 (Dining Services Director), who acknowledged the identified areas.

The findings of the on-site investigation, conducted on 07/06/2023, 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes on Abbreviations: " The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. " Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate." Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. " If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation, interview, and record review, conducted during a site visit on 07/06/23, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#1). Findings include, but not limited to: During interviews on 07/06/23, Staff 1 (Executive Director) stated in June Resident 1's shower times had been changed because the resident preferred certain staff to assist with his/her showers. Resident 1 had been getting showers during day shift but the staff s/he liked worked swing shift. Before that change, Resident 1 would refuse the service or be moved to a different day or time because of his/her preference of staff. Staff 1 stated Resident 1s nail care had been an issue, and thought staff were not completing the task. On 06/05/23 Staff 1 added the task to Resident 1's MARs to ensure the completion of the service. Resident 1 stated s/he did not have issues with showers being provided but did about his/her nail care. S/he stated his/her family member would come and cut his/her nails because staff did not complete the task.A review of Resident 1's shower sheets indicated the resident received two showers weekly apart from his/ her own refusals. A review of the MARs dated 06/01/23-06/30/23 indicated staff were to cut the residents fingernails every 15 per the service plan. The instructions were placed in the MARs on 06/05/23 and from there to the site visit on 07/06/23, Resident 1 had only gotten his/her nails clipped once on 06/17/23. Resident 1's Service Plan stated resident was to receive a shower and nail trimming two times a month. On 07/06/23, CS observed Resident 1's fingernails were long. Resident 1 showed CS multiple areas where the resident had scratched due him/herself due to his/her nails not being cut regularly.It was confirmed the facility failed to ensure the implementation of services for trimming Resident 1's nails. On 07/06/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility has changed Resident 1's shower schedule to match his/her preferred staff members. Staff 1 added the nail trimming to residents MARs to ensure staff are cutting residents nails every 15 days.

Based on observation, interview, and record review, conducted during a site visit on 07/06/2023, it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to: During interviews on 07/06/23, Staff 1 (Executive Director) stated the facility had an ongoing issue with bed bugs that started in January 2023. Staff 1 identified a group of apartments that continued to be infested with the bed bugs, including apartments 201-204. 213, 215, and 224. S/he also stated they had reduced the bed bugs to only four rooms. Staff 2 (Housekeeper) stated the facility has had bed bugs since s/he started working there in October 2022. S/He stated the bed bugs were only down one hallway and had not extended to other areas of the facility. A review of the pest control company, Sprague, invoices showed the company had been out to the facility multiple times since 01/05/2023. Sprague had returned once or twice a month since then to treat for bed bugs. The last time Sprague came to treat for bed bugs was 07/03/2023, reporting the facility still had bed bugs. It was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.On 07/06/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility will continue with the company Sprague pest control to keep treating the bed bugs. They also use the chemical diatomaceous earth to help stop the spread of the bugs and has staff spraying tea tree oil around their ankles before entering the room.

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 04/27/2023. 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

Based on interview, observation, and record review it was confirmed the facility did not implement a service plan that reflects the resident's needs as identified in the evaluation. Findings include:During separate interviews on 04/27/2023, Staff #1-3 (S-3) stated that the facility does have an issue with cleaning Resident #1 (R1) room. S2 stated that it is difficult to clean R1 ' s room because of their dog who can be aggressive towards staff members. S3 stated that housekeeping should be done on a weekly basis. During an unannounced site visit on 04/27/2023, Compliance Specialist (CS) observed Resident #1 (R1) room to have clutter and multiple Styrofoam containers spread through. A review of R1 service plan states that R1 has requested staff remove trash from apartment three times a week.On 04/27/2023, these findings were reviewed and acknowledged by S1.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate interviews on 04/27/2023, Staff #1-2 (S1-2) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. S1 stated that there was a MT in training that would be working half their shift on day and the other half on swing shift. During an unannounced site visit on 04/27/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working. A record review of the posted staffing plan, staff schedule for April 2023, Resident #1-2 (R1 and R2) service plans dated 02/01/2023 and 03/13/2023, progress notes from 03/26/2023 - 04/27/2023, and the breakdown of their care on the facility's ABST. The exported data in the ABST showed 42 of the 46 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 06/14/2022-10/04/2022. S1 stated that a new resident currently moved into the facility on 04/26/2023 had not yet been added into the ABST. The ABST tool showed the care staff needed for each shift was, day: 5, swing: 4, and NOC: 1, showing the facility is understaffing based on their hours indicated in their tool. On 04/27/2023, these findings were reviewed and acknowledged by S1.

The findings of the kitchen inspection, conducted 11/30/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 11/30/22, conducted 02/07/23, 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 interviews, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 11/30/22 revealed splatters, spills, drips, dust and debris noted on: - Stand mixer; - Interiors of drawers; - Microwave; - Radio by prep station; - Open stainless steel shelving throughout kitchen; - Underneath shelving and equipment; - Floors throughout kitchen; - Walls behind and near the Ice machine and hand washing sink; and - Top of steam table that was storing food delivery containers and service trays.* Fan with visible dust and debris on blades and cage observed blowing directly over food products being prepared for service. This fan was located directly across from range and steam table. * Window seal had multiple personal items and beverage containers of staff, there was dust and debris as well as food splatters along the window edge. This area was directly above a main food prep area.* Unpasteurized shell eggs were found and Staff 2 confirmed were used for soft cooked food items such as over easy, over medium fried eggs. Temperatures for such items were not served at the temperature required to prevent potential food borne illness. * Multiple items were found not dated when opened. Bulk bag of corn meal found open and exposed to potential contaminants in dry storage.* Dish washing rack was observed stored on the floor in ware washing area* Grout in ware washing area by dish machine was worn, missing and/or had black substance throughout a large section. Staff 2 (Director of Dining Services) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings.The areas in need of cleaning, repair and attention were reviewed via phone with Staff 1 (Administrator) and Staff 3 (person in charge while administrator out of facility). They acknowledged the findings.

The findings of the re-licensure survey, conducted 11/01/21 through 11/03/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 11/3/21, conducted 1/10/22 through 1/11/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 5), whose records were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 09/2021. Resident 1's move-in evaluation failed to address the following required elements:* Personality, including how the person copes with change or challenging situations; and* Recent losses. The facility's failure to complete all required elements for Resident 1's move-in evaluation was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 10/2021.Resident 5's move-in evaluation failed to address the following required elements:* Interests, hobbies, social, leisure activities;* Spiritual, cultural preferences and traditions; * Personality, including how the person copes with change or challenging situations; * Nutrition habits, fluid preferences and weight if indicated; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature. The evaluation was inaccurate in the following areas: * Skin condition; and* List of treatments: type, frequency and level of assistance needed.On 11/02/21, the need to ensure move-in evaluations were accurate and addressed all required elements was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

3. Resident 5 was admitted to the facility in 10/2021 with a diagnoses including diabetes.Observations of Resident 5 during the survey, interviews with staff, and review of the service plan, dated 10/19/21, and the medical record revealed the service plan was not reflective and/or followed in the following areas: * Side rails on the bed;* Preference to sleep in recliner;* Trash removal instructions;* Wheelchair use;* Pressure-relieving cushion in wheelchair;* Use of a urinal; * Outside provider services;* Edema to lower extremities; and* Resistance to assistance with toileting and showers when offered.The need to ensure service plans were reflective and were followed was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (Regional Nurse Consultant) on 11/02/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' current status and were followed for 3 of 5 sampled residents (#s 3, 4, and 5). Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 10/2020 with diagnoses including history of stroke and hemiplegia and hemiparesis of the right side.The resident's 10/13/21 service plan was reviewed during survey. Interviews with staff and the resident revealed the service plan was not reflective of the resident's current status and care needs in the following areas: * Home health services; and* Transfer status.The need for service plans to accurately reflect residents needs and status was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.2. Resident 4 was admitted to the facility in 01/2020 with diagnoses including diabetes.The resident's 10/21/21 service plan was reviewed. Interviews with the resident and staff revealed the service plan was not reflective of the resident's current status and needs in the following areas:* Wound care;* Checking CBGs as needed;* Foot care; and* PRN medications.The facility's failure to ensure the service plan was reflective was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including anxiety and chronic obstructive pulmonary disease.Review of Resident 1's physician orders, 10/01/2021 through 10/31/21 MAR, and progress notes dated 9/13/21 through 11/01/21, the following short-term changes of condition were identified: * 09/30/21: orders were received to discontinue Simvastatin (for cholesterol) and Aspirin. Orders were received to start Urea packets (supplement) daily and to obtain daily weights;* 10/04/21: orders were received for Xanax (psychotropic) to be taken every six hours as needed for anxiety; and* 10/22/21: the resident had a fall and sustained two skin tears to the left arm and a bruise to the forehead.There was no documented evidence evaluations were completed, interventions were developed and communicated to staff, or of weekly monitoring to resolution for the medication changes, daily weights, fall, or skin injuries. The need to ensure changes of condition were evaluated, interventions were developed and communicated to staff on all shifts, and were monitored weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.3. Resident 5 was admitted to the facility in 10/2021 with diagnoses including diabetes. Review of the resident's progress notes, 10/01/21 through 10/31/21 MAR, outside provider notes, and the transfer/discharge summary from Resident 5's previous residence revealed a left great toe deep tissue injury and a wound to the resident's right buttocks. There was no documented evidence an evaluation was completed, that interventions were developed and communicated to staff, or of weekly monitoring of the skin injury and wound to resolution. The need to ensure short-term changes of condition were evaluated, interventions were developed and communicated to staff on all shifts, and were monitored weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure resident changes of condition were evaluated and referred to the facility RN as indicated, resident-specific actions/interventions were determined, documented and communicated to staff on all shifts, and weekly progress was monitored through condition resolution for 4 of 5 sampled residents (#'s 1, 2, 3, and 5) who experienced changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and hypothyroidism.Interviews with staff and review of Resident 2's clinical records (including the current service plan, weight records (05/01/21 - 10/31/21), progress notes, current physician orders, assessments, and evaluations) indicated Resident 2 began experiencing weight fluctuations in 05/2021:* Between 05/07/21 and 06/11/21, Resident 2 experienced a severe weight loss of nine pounds, which constituted 8.25% loss in total body weight over one month. There was no documented evidence the facility evaluated and referred the resident to the facility RN for further assessment, determined what actions or interventions were necessary for the resident, and there was no documented evidence the weight loss was monitored on a weekly basis.* On 07/22/21, the facility RN completed an assessment related to significant weight loss. Interventions included instructions for the facility to provide a nutritional supplement drink three times a day and fortified foods with each meal. A progress note dated 09/01/21, written by the RN, stated the resident lost 12.6 pounds from two weeks prior and stated the resident should be re-weighed for verification. The resident's recorded weights on 09/03/21 and 09/10/21 continued to show a significant weight loss of six pounds which constituted a 5.45% loss in total body weight over one month. There was no documented evidence the facility evaluated and referred the resident to the facility RN, determined what actions or interventions were necessary for the resident, and there was no documented evidence the resident's weight status was monitored after 09/01/21.The need to ensure resident changes of condition were evaluated and referred to the facility RN as indicated, resident-specific actions/interventions were determined and documented, and weekly progress was monitored through condition resolution was discussed with Staff 1 (ED) on 11/03/21. She acknowledged the findings.
4. Resident 3 was admitted to the facility in 10/2020 with diagnoses including history of stroke with hemiplegia and hemiparesis of the right side.Progress notes for the resident, dated 08/04/21 through 10/28/21, 01/17/21 through 10/29/21 weight records, and physician correspondence were reviewed during survey, and interviews were conducted with staff and the resident.The resident experienced the following changes of condition:* 08/05/21: the resident's transfer assistance needs changed from a one-person assist to a two-person assist;* 08/29/21: weight records revealed a severe weight loss of 18 lbs. in one month (from 171 lbs. to 153 lbs.), a 10.52% loss of his/her total body weight;* 08/17/21: weight records revealed a significant three month weight loss of 18.3 lbs., or 10.76% of his/her total body weight; and* 10/17/21: a progress note indicates the resident complained of pain related to not having a bowel movement for three days, and staff discovered s/he had hemorrhoids.There was no documented evidence those changes of condition were evaluated, interventions were developed or communicated to staff, a referral was made to the RN, or they were monitored with at least weekly documentation through resolution. The need to evaluate changes of condition, develop actions or interventions and communicate them with staff when indicated, refer to the RN when necessary, and monitor through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and hypothyroidism. Interviews with staff and review of Resident 2's clinical records (including the current service plan, weight records (05/01/21 - 10/31/21), progress notes, current physician orders, assessments, and evaluations) indicated Resident 2 began experiencing the following significant weight fluctuations in 05/2021:* Between 05/07/21 and 06/11/21, Resident 2 experienced a severe weight loss of nine (9) pounds, which constituted 8.25% loss in total body weight over one month. There was no documented evidence the facility's RN completed an assessment to address the resident's weight loss. * Between 06/11/21 and 07/22/21, Resident 2's weight fluctuated with one (1) to 10 pound weight gains and losses. On 07/22/21, the facility RN completed an assessment related to significant weight fluctuations. Interventions included instructions for the facility to provide a nutritional supplement drink three times a day and fortified foods with each meal. * Weekly RN progress notes dated 09/01/21 stated the resident lost 12.6 pounds from two weeks prior and stated the resident should be re-weighed for verification. The resident's recorded weights on 09/03/21 and 09/10/21 continued to show a significant weight loss of six pounds, which constituted a 5.45% loss in total body weight over one month. There was no documented evidence the facility's RN completed an assessment to address the resident's continued significant weight fluctuations. *Resident 2's weight was obtained on 11/02/21, per the surveyor's request, and showed a significant weight gain of eight (8) pounds or 6.8%. Staff 3 (Regional Nurse Consultant) completed an assessment on 11/02/21 to address the resident's weight fluctuations.The need to ensure an RN assessment was completed for all significant changes of condition was discussed with Staff 1(ED), Staff 2 (Regional Director of Operations), and Staff 3 on 11/03/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for a significant change of condition, including findings, resident status, and interventions made as a result of the assessment, in a timely manner for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 10/2020 with diagnoses including history of stroke and hemiplegia and hemiparesis of the right side. The resident's 10/13/21 service plan, 08/04/21 through 10/28/21 progress notes, and 01/17/21 through 10/22/21 weight records were reviewed during survey. Staff and the resident were interviewed. The following changes of condition were identified:*07/23/21 - 171 pounds;*08/29/21 - 153 pounds; and*10/22/21 - 151.2 pounds.The resident lost 18 pounds, or 10.52% of his/her total body weight, in one month (07/23/21 to 08/29/21), which constituted a severe weight loss.The resident lost 19.8 pounds, or 11.58% of his/her total body weight, in three months (07/23/21 to 10/22/21), which constituted a significant weight loss.In a progress note dated 09/08/21, the RN wrote it was "unlikely resident lost 18# in 1 mos [sic], will have staff recheck weight tomorrow." There was no documentation of the resident being weighed on 09/09/21, nor was there any additional documentation about the resident's weight loss by the RN. On 11/02/21 the surveyor requested a current weight for the resident. Staff 1 reported the resident weighed 168 pounds, which was three pounds less than the resident weighed on 07/23/21, and a gain of 16.8 pounds since 10/22/21.The resident stated in an interview on 11/03/21 s/he was able to eat any time s/he wanted, s/he liked the food served by the facility, and s/he had plenty of snacks available in his/her room.There was no documented evidence the RN had completed a significant change of condition assessment which included findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN assessment was completed, which documented findings, resident status, and interventions made as a result of the assessment, for all significant changes of condition was discussed with Staff 1 and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and hypothyroidism.Interviews with staff and review of Resident 2's clinical records (including the current service plan, progress notes, current physician orders, the MAR for 10/2021, hospital emergency department visit records, assessments, and evaluations) indicated the following:On 10/19/21, Resident 2 was sent to the emergency department for evaluation of oral swelling. Resident 2 returned to the facility with instructions to continue taking numerous medications, including Augmentin (an antibiotic) and hyrochlorothiazide (a blood pressure medication). Review of Residents 2's 10/2021 MAR indicated the resident was not administered either of the medications. There was no documented evidence the facility clarified the medication instructions with the resident's physician.On 11/02/21, Staff 1 (ED) stated the medications had previously been discontinued so it was unclear why the medications were included with the ER's visit summary instructions.The need to ensure the facility coordinated care with outside providers in order to ensure continuity of care was discussed with Staff 1 (ED) on 11/03/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 2 of 2 sampled residents (#s 2 and 5) who received services from an outside provider. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 10/2021 with diagnoses including diabetes. The resident's 10/11/21 through 11/01/21 progress notes, MAR, and outside provider visit summaries were reviewed. In a 10/18/21 visit summary, the instructions provided were for staff to "apply iodine to left big toe and cover with bandaid [sic] twice daily, as well as apply barrier cream to coccyx every morning and night." There was no documented follow-up to the recommendation for the left great toe until it was added to the MAR on 10/28/21. There was no follow up documentation regarding the barrier cream to be applied morning and night. The need to ensure the facility coordinated care with outside providers in order to ensure continuity of care was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease.a. During the acuity interview on 11/01/21 it was reported the resident received continuous oxygen.Resident 1 was observed with oxygen being administered via nasal cannula on 11/01/21 and 11/02/21. Resident 1's physician orders and 10/2021 MARs were reviewed. The records failed to include signed orders for oxygen administration.On 11/02/21 Staff 1 (ED) reported there was no signed order for oxygen administration. b. Resident 1's progress notes, physicians orders, and 10/01/21 through 10/31/21 MAR were reviewed and revealed orders dated 09/30/21 for daily weights. There were no weights documented on seven occasions in October 2021, which indicated the weight was not obtained daily as ordered.The need to ensure signed physician orders were documented in the resident's facility record for all medications the facility was to administer and that orders were followed was reviewed with Staff 1 and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure signed physician orders were documented in the resident's facility record for all medications and treatments administered by the facility and medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose physician orders were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and multiple mental health diagnoses. Review of Resident 2's current physician orders and 10/01/21 through 11/01/21 MARs indicated the following:An order for Trazodone (for insomnia) 1 tablet at bedtime and 0.5 tablet at midnight was not administered to the resident on 14 occasions in October 2021.On 11/03/21, Staff 1 (ED) stated issues with the pharmacy was the reason the medication was not administered. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 on 11/03/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear instruction and parameters for administration of PRN medications for 2 of 5 sampled residents (#s 1 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease. Resident 1's 10/1/21 through 10/31/21 MAR was reviewed and noted the following respiratory and anti-anxiety medications:* Albuterol Sulfate HFA inhaler, two puffs every four hours as needed for wheezing; * Ventolin HFA inhaler, two puffs every four hours as needed for wheezing; * Alprazolam (psychotropic) 0.25 mg up to two times a day as needed for anxiety; and* Lorazepam (psychotropic) 1 mg every six hours as needed for anxiety.The MAR lacked clear instruction and parameters for administration of the PRN respiratory and anxiety medications.The need to ensure MARs included clear parameters and instructions to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings2. Resident 5 was admitted to the facility in 10/2021 with a diagnosis of diabetes.Resident 5's 10/11/21 through 10/31/21 MAR was reviewed and noted the following pain and bowel care medications: * Acetaminophen 650 mg every four hours as needed for pain or fever greater than 100 degrees F; * Acetaminophen 650 mg every six hours as needed for pain or fever greater than 100 degrees F; and* Tramadol HCL 50 mg every 12 hours as needed for pain.* Bisacodyl Laxative Suppository 10 mg as needed for no bowel movement four hours after Milk of Magnesia. (There was no order for Milk of Magnesia on the MAR.); and* Sennosides-Docusate Sodium tablet, one as needed for constipation. The MAR lacked clear parameters and instructions for administration of the PRN pain and bowel care medications.The need to ensure MARs were accurate and included clear parameters and direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behaviors had written, resident-specific symptoms for how the resident expressed anxiety and non-drug interventions for staff to attempt prior to administering the medications for 1 of 2 sampled residents (# 1) who was prescribed PRN psychotropic medications for anxiety. Findings include, but are not limited to:Resident 1 was admitted to the facility in 09/2021 with diagnoses including anxiety.Review of the resident's 10/01/21 through 10/31/21 MAR and current physician orders showed the following psychotropic medications:* Lorazepam 1 mg every six hours as needed for anxiety; and* Alprazolam 0.25 mg up to two times a day as needed for anxiety.The facility administered the Alprazolam on 49 occasions between 10/04/21 and 10/31/21.The MAR stated the medications were for "anxiety" and did not include resident-specific symptoms of anxiety. Additionally, there was no documentation of what non-drug interventions to attempt prior to administration of the medications. The need to ensure there were resident-specific symptoms of how anxiety was expressed and non-drug interventions were available, attempted, and documented as ineffective prior to administration of the PRN psychotropic medication was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN, PT, or OT completed a thorough assessment of a supportive device with potentially restraining qualities prior to use, document other less restrictive alternatives prior to use of the device, and provide instruction to caregivers on the correct use of and precautions for the device for 1 of 2 sampled residents (#5) who had side rails on their bed. Findings include, but are not limited to:Resident 5 was admitted to the facility in 10/2021. On 11/01/21, Resident 5's bed was observed to have two half length side rails in the up position. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the use of and precautions related to the device.The lack of assessment and instructions provided for use of supportive devices with potentially restraining qualities was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 11 and 15) completed required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to:Staff training records were reviewed on 11/03/21 and revealed the following:a. There was no documented evidence Staff 11 (MT), hired 9/11/21, completed orientation to fire safety and emergency procedures.b. There was no documented evidence Staff 11 or Staff 15 (CGs), hired 7/11/21, completed the required pre-service dementia training prior to providing care to residents.The need for staff to complete all required pre-service orientation and dementia training before beginning their job responsibilities and providing care to residents was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to verify 2 of 3 newly hired staff (#s 10 and 11) demonstrated satisfactory performance in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 11/03/21.There was no documented evidence Staff 10 (MT/CG), hired 09/29/21, or Staff 11 (MT), hired 09/11/21, had demonstrated competency in one or more of the following required areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions that require assessment, treatment, observation, and reporting;* General food safety, serving, and sanitation; and* First aid/abdominal thrust.The facility's failure to ensure newly hired staff had demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure long-term staff completed the required minimum 12 hours of in-service training annually for 1 of 1 long-term staff (#5) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed on 11/03/21.There was no documented evidence Staff 5 (CG), hired 08/16/19, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care.The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all elements required by the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire drill records for 05/2021 through 10/2021 were reviewed on 11/02/21, and revealed documentation of fire drills did not include the following elements;* Escape route used;* Evacuation time period needed; and* Number of occupants evacuated.The need to ensure all elements required by the OFC were documented for fire drills was discussed with Staff 6 (Maintenance) on 11/02/21 and with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.