Springs at Tanasbourne

The findings of the re-licensure survey, conducted 07/15/24 through 07/18/24, 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 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 first re-visit of the re-licensure survey of 07/18/24, conducted 12/02/24 through 12/04/24, 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 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 second re-visit to the re-licensure survey of 07/18/24, conducted on 04/02/25 through 04/03/25, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 07/15/24 through 07/18/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations.Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 1 of 3 sampled residents (# 2) whose records were reviewed. Findings include, but are not limited to:During the survey, resident records were reviewed and were found to be missing, inaccurate or incomplete, including signed physicians' orders, onsite provider notes, and temporary service plans. Resident 2 moved into the facility 07/2022 with diagnoses including Parkinson's disease. On 07/15/24 during the acuity interview, Resident 2 was identified as having home health PT, OT and Speech therapy. During an interview with Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator 3rd floor) on 07/15/24 at 2:45 pm, medical records including signed physician orders, onsite and/or outside provider notes and temporary service plans for Resident 2 were unable to be located. Staff 2 and Staff 4 reviewed the resident's physical chart that was located in the first-floor med room. Staff 2 and 4 reported there was another binder that had the [current] clinical information. The binder in the first-floor med room was for purged documents. They reported that they would find the current binder [medical documents] and get it to the survey team as soon as possible. During an interview with Staff 2 on 07/16/24 at 9:00 am, the surveyor was told the binder had not been found. Staff 2 reported the facility's process was to scan the provider-signed 90 day medication reviews into the electronic record. The surveyor requested the signed orders from the electronic record.During an interview on 07/16/24 at 12:36 pm with Staff 8 (Health Services Quality Coordinator), onsite and/or outside provider notes were requested. No information was received. On 07/16/24 at 12:40 pm, Staff 2 reported she couldn't print Resident 2's physician orders because they were not scanned into the system. Staff 2 stated she could call the physician office and the pharmacy to get a copy of the signed orders. On 07/17/24 at 9:00 am a copy of an onsite provider note from home health PT was provided that indicated the resident was discharged from PT on 03/08/24. No further information regarding onsite services for OT or speech therapy was provided. On 07/18/24 at 11:21 am, survey received a copy of a temporary service plan update that included a summary of previous changes in condition, which included information regarding a change in diet texture and the need for two-person transfers. On 07/18/24 at 11:40 am, survey received a faxed copy of the resident's complete signed physician orders from the prescriber. The orders were dated 01/2024. On 07/18/24 at 3:16 pm the need to ensure facility records were accurate and complete was discussed with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8, Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

2. Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease. The resident's service plan available to staff, dated 05/15/24, and temporary service plan updates were reviewed, and interviews with the resident and staff were conducted. The service plan was not reflective of the resident's needs as identified in the evaluation and lacked clear direction for staff regarding the delivery of services in the following areas:* Evacuation status and level of assistance needed;* Mechanical soft diet verses Regular texture diet; * Mental Health/Anxiety and depression;* Two person assist for toileting and incontinent care; and* Two person transfers with a gait belt. The need to ensure service plans reflected the resident's needs as identified in the evaluation and provided clear direction for staff regarding the delivery of services was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 04/2022 with diagnoses including Parkinson's disease. The resident's service plan available to staff, dated 03/10/24, and temporary service plan updates were reviewed, and interviews with staff were conducted.The service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Activity assistance;* Weight monitoring; * Mental health history details, including personality;* Bathing; * Dressing; and* Evacuation assistance.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 2:20 pm. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 05/2021 with diagnoses including cerebellar ataxia and diabetes. The resident's service plan available to staff, dated 05/27/24, and temporary service plan updates were reviewed, and interviews with staff were conducted.The service plan was not reflective of the resident's needs as identified in the evaluation and lacked clear direction for staff regarding the delivery of services in the following areas:* Expression of wants and needs;* Dressing;* HH PT; * HH mental health;* Wheelchair use as a mobility device; * Transfer assistance;* Mood disorder and interventions;* Medication management;* Activities;* Falls;* Weight and weight changes;* Diabetic insulin status;* Bathing preferences; and* Transportation. The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator 3rd Floor), and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, and were reviewed and updated following a significant change of condition for 3 of 4 sampled residents (#s 6, 7, and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 07/2022 with diagnoses including dementia and arthritis. The resident's current service plan dated 09/26/24 was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 12/02/24 and 12/04/24. The service plan had not been updated when the resident experienced a significant change of condition on 11/22/24 when s/he transitioned to hospice. Additionally, the service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Amount of assistance needed with ADLs, including dressing, grooming, mobility, and transfers;* Number of staff to assist with mechanical lift;* Hospice admission;* Responsibility of medication administration; * Preference to eat meals primarily in room;* Use of hospital bed; and* Amount of assistance required for an evacuation. The need to ensure service plans were updated after a significant change of condition was identified, were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 34 (Staffing Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.
3. Resident 6 was admitted to the facility in 03/2022 with diagnoses including major depressive disorder, Parkinson's disease and history of falling.Interviews with the resident and facility staff were conducted. The current service plan dated 10/09/24 was reviewed. Resident 6's service plan was not reflective of the resident's current needs and/or lacked clear instructions to staff in the following areas:* Number of staff needed to assist with activities of daily living and emergency evacuations; * Instructions on what types of skin impairments to report and to whom;* Incorrect reference to use of bed cane;* Incorrect reference to use of wheelchair for mobility;* Instructions to staff on whom to report signs and symptoms of complications while on anti-Parkinson and anti-depressant therapy; * Toileting; * Behavioral problems;* How a person expresses pain or discomfort; and* Personality, including how the person copes with change or challenging situations.The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 7 (Regional RN), Staff 33 (Resident Services Coordinator first floor, MC Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.
2. Resident 7 was admitted to the facility in 10/2022 with diagnoses including type 2 diabetes. The resident's current service plan dated 11/20/24 was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 12/03/24 and 12/04/24. The service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Outside service providers including names of the home health and private care agencies and the services being provided;* Preference to eat all meals in room;* Use of side rails, including safety checks; and* Skin conditions, including management of lower extremity edema per HHRN instructions.The need to ensure service plans were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator, second floor), Staff 34 (Staffing Coordinator) and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate significant changes of condition and refer to the facility RN, determine actions or interventions needed for short term changes of condition and document weekly progress through resolution for 2 of 3 sampled residents (#s 2 and 3) reviewed with changes of condition. Resident 3 continued to experience weight loss. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in May 2021 with diagnoses including atherosclerotic heart disease and diabetes.a. During the acuity interview on 07/15/24, Resident 3 was identified as experiencing weight loss. Review of Resident 3's weight records noted the following:*1/12/24: 187 pounds;*02/12/24: 178 pounds.;*03/12/24: 180 pounds.; and*04/12/24: 173 pounds.Between 01/12/24 and 04/12/24, Resident 3 lost 14 pounds or 7.5% body weight in three months resulting in a significant change of condition. There was no documented evidence the significant change of condition was evaluated and referred to the facility RN including documentation of the change and updating the service plan as needed.Additional weight records noted the following:*05/12/24: 168 pounds;*no weight documented for 06/2024; and*07/17/24: 162 pounds, requested by survey.Between 04/12/24 and 05/12/24 Resident 3 lost an additional five pounds. There was no weight identified in June and at the time of the survey, the resident weighed 162 pounds. During the survey, on 07/17/24 and 07/18/24, the surveyor attempted to watch Resident 3 eat a meal but the resident refused. Resident 3 stated they were independent in eating and took all their meals in their room. In an interview on 07/16/24 at 10:25 am, Staff 17 (CG), stated that Resident 3 had lost a lot of weight and that their clothes no longer fit. Resident 3 experienced significant weight loss between 1/2024 and 04/2024, there was no documented evidence the weight loss was evaluated and referred to the facility RN. Resident 3 continued to lose weight.The need to ensure the facility evaluated residents with a significant change of condition, referred to the facility RN, documented the change and updated the service plan was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings.b. Review of Resident 3's progress notes between 04/16/24 and 07/15/24, identified the following changes of condition: On 04/24/24, Resident 3 had three medications discontinued: * Ozempic (for diabetes); * Metoprolol (for high blood pressure); and* Allupirinol (to reduce high blood uric acid levels).There was no documented evidence the facility determined and documented what action or intervention was needed for the resident and they did not monitor this short-term change of condition until resolution. The need to ensure the facility evaluated residents with a change of condition, documented the change and monitored until resolution was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings.
2. Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease. Clinical records, including the current service plan and evaluation dated 05/15/24, and progress notes from 04/15/24 through 07/15/24 were reviewed and interviews with facility staff and the resident were conducted.a. The facility failed to evaluate, determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following changes of condition:* 05/19/24 - Urinary tract infection and new antibiotic; and* 06/24/24 - Change in diet orders. b. The resident had the following significant change of condition:* 07/03/25 - Declined mobility - now requiring two person transfer. This constituted a significant change of condition that required referral to the RN. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and update the service plan as needed. The need to ensure the facility had a system to determine and document what actions or interventions were needed for changes of condition, referred to the RN, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.


Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 1 of 4 sampled residents (# 6) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 03/2022 with diagnoses including major depressive disorder, Parkinson's disease and history of falling.Clinical records, including the current service plan and progress notes, from 09/17/24 through 12/01/24, were reviewed, and interviews with facility staff and the resident were conducted.The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:10/07/24: "Med dose change [anti-Parkinson therapy] and Flu Vaccine";10/10/24: unwitnessed fall, blood pressure 189/96 mm/Hg (outside normal parameters); 10/12/24: "caregiver notice multiple bruises on his/her lower back.";10/13/24: unwitnessed fall;10/15/24: unwitnessed fall;10/21/24: "Per OT recommendation resident is to start using weight wrist on right hand with self-feeding ...";11/06/24: unwitnessed fall;11/09/24: " ...Covid Shot";11/10/24: "there is also a small open area red in color.";11/19/24: blood pressure 170/94 mm/Hg (outside normal parameters);The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 7 (Regional RN), Staff 33 (Resident Services Coordinator first floor, MC Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility 04/2022 with diagnoses including Parkinson's disease.During the entrance conference on 07/15/24, Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator, 3rd Floor) stated the resident had a recent significant decline in health and was recently admitted to hospice services. The resident's clinical record was reviewed and revealed the following significant changes of condition: a. Resident 1 returned to the facility 06/14/24 from a hospitalization followed by a stay at a rehab facility due to a hip fracture. In an interview with Staff 18 (CG) on 07/16/24 at 1:20 pm it was noted upon Resident 1's return from the rehab facility s/he had a significant change in his/her ADLs going from a one person assist to mostly bed bound. The resident's hip fracture constituted a significant change of condition. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.b. On 07/01/24 Resident 1 was admitted to hospice services. The decline in health and admission to hospice constituted a significant change in condition for which an assessment by the facility RN was required. On 07/17/24 at 12:10 pm Staff 7 (Regional RN) stated RN assessments which included documentation of findings, resident status, and interventions made as a result of the assessment had not been completed for the significant changes of condition and no further information was available. The need for an RN to conduct an assessment when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7, Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 2:20 pm. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure the RN assessed significant changes of condition, documented interventions made as a result of an assessment, the service plan was updated, the licensed nurse participated on the service planning team, or reviewed the service plan with date and signature within 48 hours related to significant change of condition related to residents' significant weight loss, hip fracture and hospice admission for 3 of 3 sampled residents (#1, 2 and 3). Resident 3 experienced continued weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in May 2021 with diagnoses including atherosclerotic heart disease and diabetes.The resident's 04/16/24 through 07/15/24 progress notes, physician faxes and weight documentation were reviewed.The resident experienced ongoing weight loss as follows: * 01/12/24: 187 lbs.;* 02/12/24: 178 lbs.;* 03/12/24: 180 lbs.;* 04/12/24: 173 lbs.; * 05/12/24: 168 lbs; and* No weight available for 06/2024.Between 01/1/24 and 04/12/24 the resident lost 14 pounds or 7.5% total body weight. This constituted a significant change of condition for significant weight loss.In an interview with Resident 3 on 07/16/24 at 10:30 am, they stated they ate their meals independently. Resident 3 also stated they ate all their meals in their room. A surveyor attempted to observe Resident 3's meal intake on 07/18/24 but the Resident refused. There was no documented evidence an RN significant change of condition was completed at the time of the weight loss noted in April of 2024. There was no evidence that interventions were put in place, the nurse participated on the service planning team, or reviewed the service plan with date and signature within 48 hours.In an interview on 07/17/24 at 12:20 pm with Staff 7 (Regional RN) indicated he was aware of the weight loss for the resident and acknowledged the RN assessment of the resident's weight loss was overdue and no interventions were implemented. At the time of survey there were no weights available between 06/12/24 and 07/12/24. On 07/17/24 the facility was asked to get a current weight for the resident and it was noted as 162 pounds, this was a decrease of six pounds since the last weight was obtained on 05/12/24. The facility's failure to complete an RN assessment within 48 hours that documented findings, resident status and interventions made as a result of the assessment put the resident at risk for ongoing weight loss. The need to ensure the RN documented interventions made as a result of an assessment, the service plan was updated, the licensed nurse participated on the service planning team, or reviewed the service plan with date and signature within 48 hours related to significant change of condition was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings.
3. Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease.During the entrance conference on 07/15/24, Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator, 3rd Floor) reported the resident required two person transfers and meal assistance. Interviews with staff, the resident and family member and review of the resident's clinical record was conducted during the survey. The following was identified:During an interview with Witness 1 (family member) on 07/17/24 at 12:16 pm, it was reported Resident 2 had "a big change since [s/he] was in the hospital with a pretty bad [urinary tract infection] at the end of June [2024]. [S/he] came back after that and [s/he] really declined with eating and mobility." During an interview on 07/18/24 at 10:15 am with Staff 19 (CG), reported "I asked [Staff 4] for a TSP [temporary service plan] because [s/he] can't bear weight anymore and we can't transfer [him/her] with one person anymore."Review of a temporary care plan update dated 07/03/24 noted Resident 2 required two-person transfers. This constituted a significant change of condition requiring an RN assessment. There was no documented evidence an RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN completed significant change of condition assessments was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside service providers, ensure staff were informed of new interventions, and that the service plan was adjusted if necessary, in order to ensure the continuity of care for 1 of 2 sampled residents (# 3) who received outside services. Findings include, but are not limited to:During the survey, Resident 3's records were reviewed and staff were interviewed about his/her care needs. The following was identified: Resident 3 received home health PT services for strengthening. S/he started home health services on 04/11/24. Resident 3 was discontinued from this home health program on 05/17/24. The resident was then enrolled into a different home health PT program on 06/04/24 until it was discontinued on 07/11/24.Both home health PT agencies made regular recommendations for staff to do the following:* Assist resident into wheelchair daily and encourage propelling in hallway;* Continue with one to two person transfers;* Follow plan of care on transfers and strengthen. In an interview with Staff 2 (Health Services Administrator) on 07/17/24 at 12:20 pm, she agreed there was no follow up from the facility with outside service providers on the care Resident 1 was being provided, if there were any new interventions or if the service plan required adjustment.There was no documented evidence the facility reviewed these recommendations, informed staff of new interventions, and adjusted the service plan if necessary.The need to coordinate care with on and off-site health care providers, staff are informed of new interventions, and that the service plan was adjusted if necessary was discussed with Staff 1 (ED), Staff 2 and Staff 4 (Resident Service Coordinator 3rd Floor) on 07/18/24 at 2:00 pm. They acknowledged the findings.
2. Resident 8 received home health RN, PT, and OT services prior to admitting to hospice on 11/22/24.Home health PT made recommendations for staff to perform the following:* 11/14/24: "Staff advised to do 2x person assist for transfers - walk only if able/use wheelchair as appropriate to avoid falls. Recommendations made to facility staff."During an interview on 12/04/24 at 11:10 am, Staff 2 (Health Services Administrator) confirmed there was no documented evidence the facility informed staff of new interventions and adjusted the service plan if necessary. The need to coordinate care with on and off-site health care providers, staff were informed of new interventions, and the service plan was adjusted if necessary was discussed with Staff 1 (ED), Staff 2, Staff 34 (Staffing Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to coordinate care with outside service providers, ensure staff were informed of new interventions, and the service plan was adjusted if necessary, in order to ensure the continuity of care for 2 of 4 sampled residents (#s 8 and 9) who received outside services. This is a repeat citation. Findings include, but are not limited to:During the survey, Resident 9's records were reviewed and staff were interviewed about his/her care needs. The following was identified: 1. Resident 9 received home health physical therapy (PT) services for strengthening. S/he started home health services on 10/17/24. Home health PT made recommendations for staff to do the following:* 10/17/24: "Reorganize bathroom so that patient can sit at sink in wheelchair and reach sink/needed supplies to clean teeth, brush hair/face, put on makeup"; * 10/23/24: "Patient should still use pendant when needing/wanting to get up"; and* 10/25/24: "Patient should still use pendant when needing/wanting to get up". Resident 9 also started with home health RN on 10/31/24.On 11/04/24, home health RN recommended "practice good position changes to prevent skin injury on the buttocks".In an interview with Staff 7 (Regional RN) on 12/03/24 at 2:38 pm, he agreed there was no follow up from the facility on information obtained from the outside service provider regarding care recommendations, if there were any new interventions or if the service plan required adjustment.There was no documented evidence the facility informed staff of new interventions and adjusted the service plan if necessary.The need to coordinate care with on and off-site health care providers, staff were informed of new interventions, and that the service plan was adjusted if necessary was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 7, and Staff 10 (Regional RN) on 12/04/24 at 11:30 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused to consent to a medication order for 1 of 1 sampled resident (#2) who had medication refusals. Findings include, but are not limited to:Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease and had a history of chronic urinary tract infections (UTI). The resident's current prescriber orders and 06/01/24 to 07/15/24 MARs were reviewed. The following was identified:* The resident was prescribed Nitrofurantion Macro 100 mg capsule every day for recurrent urinary tract infection; and* Staff documented the resident refused the Nitrofurantion Macro medication from 06/25/24 through 07/11/24. There was no documented evidence staff notified the prescriber of the above medication refusals.The need to ensure the physician or other practitioner was notified when a resident refused to consent to a medication order was discussed with with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 3:16 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#2) who chose to self-administer their medications. Findings include, but are not limited to:Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease. During the acuity interview on 07/15/24, staff reported the resident self-administered some of their medications. Review of Resident 2's 05/15/24 evaluation and service plan noted "spouse will administer medication that keeps [sic] in apartment, staff to administer the rest." During an interview with Staff 2 (Health Services Administrator) on 07/17/24 at 1:05 pm, surveyor requested a self-administration of medications evaluation and a signed physician order. The facility provided an evaluation that was completed on 02/28/23. There was no documented evidence the facility updated the self-administration of medications evaluation quarterly and there was no documented evidence the facility had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.The need to ensure the facility updated the self-administration of medications evaluation quarterly and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following:During the entrance conference on 07/15/24 at 10:05 am with Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator 3rd Floor), the following was identified: * The assisted living was home to 71 residents who resided on three floors;* Four residents required a mechanical lift for transfers. At least one resident who required a mechanical lift resided on each floor of the facility;* Five residents required two-person assist for transfers at all times;* One resident required occasional two-person assist for transfers; and* Sixteen other residents were reported to require high levels of caregiving assistance due to hospice, cognitive decline, need for one-person transfer assistance, need for frequent checks, and/or due to fall risk.The facility's posted staffing plan, the staffing schedule from 07/01/24 through 07/15/24, and the corresponding timeslips were reviewed. The facility's posted staffing plan indicated two caregivers and one medication technician were scheduled to work the 10:00 pm to 6:00 am shift daily. This was confirmed in an interview with Staff 2 (Health Services Administrator) on 07/18/24 at 11:16 am.On 07/17/24 at 1:19 pm, Staff 32 (Staffing Coordinator) reported the two overnight caregivers were assigned to specific floors, but they were expected to assist on other floors as needed. He also reported the one overnight MT provided occasional assistance with two-person transfers or required resident checks, but caregiving was not the focus of the MT's job.The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, and resided on three distinct floors. The need to have a sufficient number of staff in to meet all scheduled and unscheduled needs of residents on the overnight shift was discussed with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 2:32 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated quarterly, addressed the amount of staff time needed to provide care for 1 of 4 sampled residents (#3) and multiple unsampled residents to determine appropriate staffing levels for the facility, and to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: During the acuity interview on 07/15/24, 22 residents were identified as requiring two-person care, two-person transfers with mechanical lift, had falls with injuries, and/or were on hospice. The facility's ABST was reviewed with Staff 4 (Resident Services Coordinator 3rd floor) and Staff 8 (Health Services Quality Coordinator) on 07/16/24 at 11:05 am. The following was identified:* Resident 3's ABST was not accurate for staff time needed to provide care; * Resident 4's ABST was not updated at least quarterly;* Three unsampled residents were not entered into the facility's ABST; and* 19 unsampled residents had not been updated quarterly.The need to ensure the ABST was updated quarterly, addressed the amount of time needed to provide resident care and ensured all residents were entered into the ABST was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8, Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) following a significant change of condition for 1 of 1 sampled resident (# 8), and failed to consistently staff to meet or exceed the posted staffing plan 24 hours a day, seven days a week. Findings include, but are not limited to:Review of the ABST, the 11/24/24 through 11/30/24 staffing schedule, and the posted staffing plan was completed on 12/02/24 through 12/04/24 and the following were found: a. Resident 8, who experienced a significant change of condition on 11/22/24, was last updated on 09/30/24.b. Review of the facility's posted staffing plan indicated the following:* Three MTs and five CGs were scheduled for day and swing shift (6:00 am to 2:00 pm) and (2:00 pm to 10:00 pm), respectively; and* One MT and three CGs were scheduled for the overnight (NOC) shift (10:00 pm to 6:00 am).Review of the facility's staffing schedule from 11/24/24 through 11/30/24 revealed the following:* 1 of 7 days two MT's were scheduled for swing shift; and* 4 of 7 days two caregivers were scheduled for NOC shift.The facility's staffing schedule was reviewed with Staff 2 (Health Services Administrator) on 12/04/24 at 9:05 am and she confirmed she routinely scheduled one MT and three caregivers for NOC shift but acknowledged the facility's staffing plan was not consistently followed.The need to ensure residents' ABST was updated with significant changes of condition, and consistently followed the facility's staffing plan was discussed with Staff 1 (ED), Staff 2, Staff 5 (Resident Services Coordinator), and Staff 34 (Staffing Coordinator) and Staff 10 (Regional RN), who was present via speaker phone, on 12/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and failed to re-instruct residents at least annually. Findings include, but are not limited to:On 07/16/24 at 10:10 am, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 1 (ED). Staff 1 reported that the Resident Services Coordinator met with each new resident within 24 hours of move-in to provide the required fire safety instruction, then documented this within the resident record. Staff 1 also reported that all residents were re-instructed quarterly at each care conference. Documentation was requested for initial fire safety instruction for Resident 5 and the most recent fire safety re-instruction for Resident 6. No documentation was provided.On 07/18/24 at 2:43 pm, the need to ensure fire and life safety instruction was provided to residents upon admission and at least annually was discussed with Staff 1, Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C260, C270, and C290.

Based on observation and interview, it was determined the facility failed to ensure the interior areas were kept clean and in good repair. Findings include, but are not limited to:Observations of the facility on 07/15/24 through 07/18/24 identified the following areas were in need of cleaning or repair:* Laundry rooms located on the 1st, 2nd, and 3rd floors had dirt buildup on the transition strips of the doorways and floors. There was a buildup of lint, dust and debris behind the laundry appliances; * First floor laundry room had walls that were missing paint or drywall and were not cleanable surfaces;* First floor laundry room had a leaking pipe that was discoloring the floor;* The laminate counter on the 3rd floor laundry room was chipped; and* Carpet throughout all three floors of the ALF were stained and soiled. The need to ensure the interior areas of the facility were kept clean and in good repair were discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 3 (Plant Operations), and Staff 11 (Director of Resident Relations) on 07/17/24 at 2:00 pm. They acknowledged the findings.

The findings of the kitchen inspection, conducted 03/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 03/05/24, conducted 05/16/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/05/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills/splatters, debris, dust and/or grease were observed on or underneath the following: * Walk in refrigerator and freezer floors;* Refrigerator #7's interior bottom shelf; * Freezer next to the deep fat fryer's interior bottom shelf; * Lower shelves throughout the kitchen including under the steam table and prep area tables; * Dry storage shelves with pans holding food items and shelves with plastic barriers;* Exterior oven doors; * Hood vents above and walls behind stoves/grills/steam jacketed kettle, tilt pan;* Pan food slicer was sitting on; and* Dishroom wall behind the sink spray hose.Additional observation included: * Improper use of gloves including not washing hands between changes, using same gloves to handle several food items, wearing gloves to retrieve food items from refrigerator and returning to handle food items with same gloves. Not using gloves when preparing ready to eat items. Not using beard restraints while preparing/serving food;* Dishes stored on lowest shelf in the area across from the dishwashing area were stored in a manner that could cause cross contamination;* Food on rolling carts in walk in refrigerator were uncovered/undated/unlabeled; * Three large tubs of food being cooled with frozen wands were not covered tightly; * The freezer next to the deep fat fryer had open bags and uncovered tubs of food; * Garbage cans were not covered when not in use; and * Lack of beard restraints while preparing and serving food. The areas of concerned were discussed with Staff 1 (Executive Chef), Staff 2 (Food & Beverage Director), Staff 3 (Executive Director), Staff 4 (ALF Administrator) and Staff 5 (MCC Administrator) on 03/25/24. The findings were acknowledged.

The findings of the kitchen inspection, conducted on 02/16/23, 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 first re-visit of the kitchen inspection of 02/16/23, conducted 05/01/23, 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 interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:Observation of the kitchen on 02/16/23 at 11:45 am, revealed the following areas were in need of cleaning and/or repair:* Baseboards, ledges and lower wall areas throughout the kitchen perimeter had accumulated food particles, dust and brown matter; * Floors in the walk-in freezer had food particles and dried spills;* Multiple cutting boards had gouges and a build-up of food matter on the surfaces; * Trash receptacles with food debris did not have lids;* The secured cutting board installed along the length of the sandwich prep table had gouges and a build-up of food matter on the surface; and* Multiple open packages in the dry storage area were unsecured or sealed to prevent cross contamination.On 02/16/23 at 1:30 pm the areas requiring cleaning and/or repair were reviewed with Staff 1 (Administrator) and Staff 2 (Culinary Director). They acknowledged the findings.

The findings of the licensure survey, conducted 3/1/21 through 3/3/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 3/3/21, conducted 6/8/21 through 6/10/21 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

3. Resident 4 was admitted to the facility in January 2021 with diagnoses including dementia.Review of the resident's progress notes from 1/16/21 through 3/1/21, new move-in evaluation and an incident investigation were reviewed and indicated the following:* A progress note, dated 2/2/21 identified staff found a skin tear on the resident's "right palm" and Resident 4 was "not sure how [s/he] got it;"* The new move-in evaluation, dated 1/7/21, noted Resident 4 "cannot recall items after [five] minutes;" and* The incident report, dated 2/3/2021, ruled out abuse and/or neglect "per resident statement," although the resident reported not knowing how s/he sustained the injury. An interview with Staff 1 (Administrator) on 3/2/21 at 8:40 am confirmed the injury of unknown cause had not been reported to the local SPD unit. The need to investigate and report incidents to the local SPD unit when abuse and/or neglect could not be ruled out was discussed with Staff 1. She acknowledged the acknowledged the findings. Staff 1 was asked to report the incident to the local SPD office and provided confirmation of the reports prior to survey exit.
Based on interview and record review, it was determined the facility failed to report injuries of unknown cause for which abuse was not reasonably ruled out for 3 of 4 sampled residents (#s 3, 4 and 7) and failed to address a significant change of condition for 1 of 1 sampled resident (#3) who experienced severe on-going weight loss. Resident 3 experienced neglect of care related to severe on-going weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in October 2018 with diagnoses including Parkinson's Disease and Myasthenia Gravis (neurological disorder causing weakness). Review of Resident 3's clinical record revealed the resident lost 36.5 pounds or 21.6% of his/her body weight between 9/23/20 and 11/23/20, which constituted a severe weight loss and significant change in condition. The facility failed to identify the significant change in the resident's condition, evaluate the resident, refer to the RN for assessment, document the change or update the service plan at that time. Failure to properly address Resident 3's significant change in condition constituted neglect of care, which was abuse. The facility was directed to report this incident to local SPD. The facility provided a fax confirmation of the report. The failure of the facility to properly address a significant change of condition was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 6 Resident Services Coordinator (RSC) on 3/3/21. They acknowledged the findings Refer to C270, example 1.2. Resident 7 was admitted to the facility in May 2014 with diagnoses including Parkinson's Disease and dementia. A progress note dated 2/9/21 indicated a CG had found " a little cut on resident's left thigh/butt cheek. Caregiver unsure how resident got the cut."Review of Resident 7's service plan dated 1/22/21 indicated the following: Resident 7 is moderately cognitively impaired, is not oriented to time or place, can occasionally remember things after five minutes and has language impairments in regard to both understanding of language and expression of thoughts and ideas. An investigation dated 2/11/21 indicated the RN spoke to the resident who denied any concerns with "staff performing...toileting needs and pulling up...brief". The RN ruled out abuse and did not report the injury of unknown cause to SPD. During interviews with Staff 9 (MT) and Staff 14 (CG) on 3/3/21, they stated Resident 7 had difficulty with language comprehension, expression and cognition. Based on Resident 7's diminished cognitive and language capacities, the facility was unable to reasonable rule out abuse. The surveyor directed the facility to report the injury of unknown cause to SPD on 3/3/21. A fax confirmation of the report was provided prior to exit. The failure of the facility to report injuries of unknown cause was discussed on 3/3/21 with Staff 1 (Administrator), Staff 4 (RN) and Staff 5 (RSC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4) whose move-in evaluations were reviewed. Findings include, but are not limited to:Resident 4's move-in evaluation dated 1/16/21, failed to address the following required elements:* Customary routines including sleeping and eating times; * Physical health status including list of current diagnosis and list of medications and PRN use; * History of treatment relating to mental health issues; * Personality including how the person copes with change or challenging situations; * Pain including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort; * Environmental factors that impact the resident's behavior including noise, lighting, room temperature; and * Complex medication regimen. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator) and Staff 18 (Resident Services Coordinator) on 3/3/21. They acknowledged the findings.

3. Review of Resident 5's service plan, dated 11/17/20, revealed it was not updated quarterly, not reflective of the resident's current care needs and/or lacked clear caregiving instructions in the following areas: * Most recent fall and interventions relating to the fall; * Customary routine including when the resident gets up in the morning; * Blood pressure monitoring; * Detailed instructions on compression hose; * Mobility aid currently used; and * Transfer assistance. The need to ensure service plans are updated quarterly, reflect residents' current care needs and provided clear caregiving instruction was reviewed with Staff 1 (Administrator) and Staff 18 (RSC) on 3/3/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction for staff, and were followed for 5 of 6 sampled residents (#s 1, 2, 3, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2016, had recently began receiving hospice service, had a history of falls and rib fractures.Interviews with staff on 3/1/21 and 3/2/21, and review of the resident's record noted the resident had a significant change of condition related to hospice admission, falls, and fractures with severe pain. The resident was described as "snappy" and refused care at times related to wanting to maintain independence. Staff stated, the resident's door was left open during the day so the resident could be frequently checked on. The current service plan failed to be reflective of the resident's current status related to:*Mental health;*Fall interventions, including keeping the apartment door open; and *Pain.2. Resident 1 was admitted to the facility in 2019 with diagnoses including cancer.Interviews with staff on 3/1/21 and 3/2/21, and review of the resident's record noted Resident 1 had received chemotherapy, experienced weight loss and had difficulty swallowing and required a soft diet.Observations of the Resident on 3/2/21 and 3/3/21 revealed the resident ate in his/her apartment, was served a breakfast sandwich during a morning meal and chicken fajitas during a noon meal. An observation of Resident 1's room on 3/3/21 revealed a bed mobility device in the up position on the side of the bed opposite the wall.Resident 1's current service plan was not reflective of, followed nor provided clear instructions related to diet texture, use of a bed mobility device or mental health and history of chemotherapy treatments. Resident 1 and 2's service plans were discussed with Staff 1 (Administrator) and Staff 6 Resident Services Coordinator (RSC) on 3/2/21 at 3:00 pm. Staff acknowledged the findings.
4. Review of Resident 3's service plan, updated 1/23/21, revealed it was not reflective of the resident's current status and care needs in the following areas: * Depression; * Hallucinations; * Short-term memory loss; * Pain; * Fall prevention interventions; and * OT/PT/SLP recommendations. The need to ensure service plans reflect residents' current status and care needs was reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 4 (RN), Staff 6 (Resident Service Coordinator) and Staff 7 (Corporate RN) on 3/2/21. They acknowledged the findings.5. Resident 7 was admitted to the facility in May 2014 with diagnoses including Parkinson's Disease and dementia. Resident 7's service plan dated 1/22/21, was not reflective or provide clear instruction to staff for the provision of care in the following areas: * Assistance of two people for all transfers;* Inability to use call light;* Assistance to open packages and cut meat at mealtime; * Inability to self-propel his/her wheelchair;* 1:1 assist is required for playing Bingo; * Frequency of safety checks;* Identification of safety interventions; and* Strategies to assist resident with language expression. The failure of the facility to ensure service plans were reflective of the resident's current status and provided clear instruction to staff was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 6 (RSC). They acknowledged the findings.

3. Resident 1 was admitted to the facility in 2019 with diagnoses including multiple myeloma. Resident 1's weight records noted the following:*10/6/20 114.8 pounds; and*11/6/20 97.8 pounds.In one month the resident lost 17 pounds or 14.8% of his/her body weight resulting in a severe weight loss and significant change of condition. The facility RN completed a significant change of condition assessment and noted the resident would be weighed weekly and have twice a day nutritional supplements.Resident 1's record noted a speech evaluation had been completed related to swallowing difficulties and an interim service plan directed staff to continue bite sized textures, thin liquids, medications in pureed food, remind the resident to take small bites and sips of food/liquids, slow rate of intake, chew thoroughly and take drinks after one to two bites. The resident was observed on 3/2/21 during breakfast and lunch meals. Due to potential exposure to the COVID virus all residents were eating in their apartments. Resident 1 received food that was not cut up, not a soft texture and ate independently in his/her apartment. In addition, the resident's MAR revealed the twice daily nutritional supplement was refused the month of February.On 3/2/21 at 12:28 pm, Resident 1 was alert and oriented and was aware of his/her swallowing difficulties and ate only the food s/he felt confident with.The resident's weight was documented weekly between 11/2020 and the time of the survey 3/1/2021 and ranged between 94 and 97 pounds. There was no documented evidence the resident's interventions were being implemented or reviewed for effectiveness. The lack of monitoring Resident 1's weight loss to determine appropriateness and effectiveness of identified interventions was discussed with Staff 1 (Administrator) and Staff 6 Resident Services Coordinator (RSC) on 3/2/31 at 3:00 pm. Staff acknowledged the findings and updated the evaluation for Resident 1's weight and meal monitoring.
Based on observation, interview and record review, it was determined the facility failed to evaluate changes, refer significant changes of condition to the facility nurse, determine actions or interventions needed for the resident, document weekly progress notes through resolution and/or failed to monitor residents consistent with evaluated needs and service plans for 3 of 6 sampled residents (#s 1, 2 and 3) with changes related to weight, falls and skin. Resident 3 experienced a severe weight loss without evaluation or monitoring and continued to lose weight. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in October, 2018 with diagnoses including Parkinson's Disease and Myasthenia Gravis (Neurological disorder which causes weakness).a. Review of Resident 3's weight records revealed the resident weighed 168.5 pounds on 9/23/20. The next recorded weight on 11/23/20 was 132 pounds (2 months later), a weight loss of 36.5 pounds or 21.6% of the resident's body weight. This represented a severe weight loss and a significant change of condition. The facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. Resident 3's additional weight records noted continued weight loss: *12/11/20 130.1 pounds; *12/23/20 128.5 pounds; *12/25/20 127 pounds; *1/1/21 124 pounds; *1/8/21 123.8 pounds; *1/15/21 120.7 pounds; and *1/22/21 118 pounds.Between 11/23/20 and 1/22/21, Resident 3 lost an additional 14 lbs or 11.3% of his/her body weight. On 1/22/21, Staff 3 (RN) completed a significant change of condition assessment. Resident 3's total weight loss from 9/23/20 to 1/22/21, when the significant change of condition assessment was completed, equaled 50.5 pounds or 29.97% of his/her body weight. The RN indicated that possible contributing factors might include hallucinations, exacerbation of Resident 3's myasthenia gravis and Parkinson's disease, as well as medication changes. A service plan update was implemented on 1/22/21 to reflect the RN recommendations, which included the addition of two nutritional shakes to the resident's diet and continued weekly weight monitoring. A subsequent significant weight change assessment 14 day follow-up was completed by Staff 3 and indicated the resident's weights were "holding between 117-119 pounds" and that service planned interventions of weekly weights and two nutritional supplements a day were effective and would remain in place. Resident 3's weight record noted continued loss:*2/5/21 119 pounds;*2/12/21 116.5 pounds;*2/19/21 116.5 pounds; and*2/26/21 114.5 pounds.During the month of 2/2021, Resident 3 lost 4.5 pounds or 3.78% of his/her body weight, which is considered a significant change of condition. Review of the February 2021 MAR revealed the resident had been administered two nutritional supplements daily. There was no documented evidence of any contributing factors, additional interventions or monitoring for the effectiveness of the current interventions. During an interview on 3/3/21, Staff 13 stated that Resident 3 ate approximately 10% of his/her meals and drank his/her nutritional supplements. Staff 13 indicated it was about 6 months ago that the Resident 3 stopped eating and that when his/her hallucinations were bad s/he would forget to eat. Staff 13 reported that she verbally informed the RSC about the resident's weight loss, but did not indicate when. During an interview on 3/2/21, Staff 16 indicated that resident sometimes ate 50-75% of his/her meals, but that s/he often preferred shakes. Resident 3 was observed on 3/2/21 at 2 pm lying in bed independently eating from a to go box. The failure of the facility to identify Resident 3's significant change of condition, evaluate the resident, refer to the RN, document the change and update the service plan as needed imposed significant risk to the resident. The findings were discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 6 (Resident Services Coordinator) on 3/3/21. They acknowledged the findings. Prior to exit, Staff 4 initiated a comprehensive assessment of the resident, which he emailed to this surveyor upon completion. b. Resident 3's service plan dated 12/28/20 noted the resident as a high fall risk and instructed staff to provide safety checks every two hours and keep the resident's floor free of clutter. Resident 3's record identified 15 falls from 12/1/20 through 3/1/21. Review of resident records indicated the facility had identified interventions with each subsequent fall the resident sustained. There was no documented evidence if previous fall interventions were in place and/or continued to be effective in minimizing further falls with each subsequent fall the resident sustained.In an interview on 3/2/21 with Staff 13 (MT), s/he reported Resident 3 had not fallen in three weeks. On 3/3/21, the failure of the facility to monitor the effectiveness of the fall interventions was discussed with Staff 1 (Administrator) and Staff 4 (RN). They acknowledged the findings.
2. Resident 2 was admitted in February 2016. The current service plan dated 1/11/21 noted the resident as a high fall risk and to provide safety checks every two hours. a. Review of Resident 2's record identified 10 falls from 12/1/20 through 3/1/21. The investigations determined the facility had identified interventions with each subsequent fall the resident sustained. There was no documented evidence if previous fall interventions were in place and/or continued to be effective in minimizing further falls with each subsequent fall the resident sustained.In an interview on 3/2/21 with Staff 13 (MT), Staff reported Resident 2 had seen an increase in independence and had a decrease in falls since being admitted to hospice. On 3/3/21, the need to ensure the effectiveness of the fall interventions was discussed with Staff 1 (Administrator) and Staff 6 (Residential Services Coordinator). They acknowledged the findings.b. Resident 2 experienced a significant change of condition related to an injury fall and admission to hospice and required extensive assistance with ADL care.Outside provider notes dated 1/22/21 and 2/5/21 noted changes to the resident's skin condition. Bruising was identified to the left forearm and redness was noted on the resident's coccyx and bilateral heels.An interview on 3/2/21, Staff 13 (MT) stated the resident was dependent on staff for a period of time and currently was more independent. Staff 13 stated the resident did not have any skin breakdown.There was no documented evidence the facility evaluated and determined what actions or interventions were to be implemented. There was no documented evidence the changes had been monitored weekly through resolution.The need to identify changes of condition, determine actions and resolve short term changes of condition was discussed with Staff 1 (Administrator) and Staff 6 (Resident Services Coordinator) on 3/3/21 at 11:00 am. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was conducted for 1 of 3 (#3) sampled residents who experienced a significant change of condition. Resident 3 experienced severe and ongoing weight loss. Findings include, but are not limited to: Between 9/23/20 and 11/23/20, Resident 3 experienced a 21.6 percent weight loss of total body weight, or 36.5 pounds resulting in a severe weight loss constituting a significant change of condition.There was no documented evidence the RN assessed the significant change, documented findings, resident status and interventions made as a result.The failure of the facility to ensure residents who experienced significant changes of condition were assessed timely by the RN was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 6 (Resident Services Coordinator) on 3/3/21. They acknowledged the findings. Prior to exit, Staff 4 initiated a comprehensive assessment of the resident, which he emailed to this surveyor upon completion. Refer to C270, example 1.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were added to the service plan and communicated to staff for 1 of 4 sampled residents (# 3) who were receiving services from outside providers. Findings include, but are not limited to: Resident 3 was admitted to the facility in October 2018 with diagnoses including Parkinson's Disease and Myasthenia Gravis (Neurological disorder which causes weakness). Review of Resident 3's clinical record revealed the resident received home health occupational, physical and speech therapies between 12/8/20 and 1/14/21. The facility failed to ensure the following home health recommendations were reviewed in a timely manner, communicated to staff and added to the service plan: *Lower clothing rod in closet or add second rod at lower height. To help resident see and reach;*Bring resident's food directly to his/her tray table instead of leaving on counter. Resident had a difficult time carrying food and retrieving utensils;*Provide applesauce or other puree with medications to increase swallow safety and ease;*Resident to use only wheelchair while in room, only walk in hallway with red walker and someone with (him/her). Caregivers to walk with resident in hallway for exercise as time allows;*Orient resident daily; and *Remind resident to use calendar and to check white board for appointments. The need to ensure outside provider care was coordinated, with recommendations implemented, communicated to staff and added to the service plan was reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 4 (RN), Staff 6 (Resident Service Coordinator) and Staff 7 (Corporate RN) on 3/3/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication-specific instructions for 1 of 4 sampled residents (# 2) whose medications were reviewed. Findings include, but are not limited to:Review of Resident 2's MAR from 2/1/2021 through 3/1/2021 identified the following deficiencies:*PRN morphine for shortness of breath and pain lacked clear direction and instructions to staff related to when to administer the medication and failed to completely transcribe the physicians orders to the MAR. In an interview on 03/03/21, Staff 13 (MT) acknowledged the facilities MAR did not have the written physician order instructions and parameters transcribed completely. On 3/3/21, the need to ensure MAR's were accurate and included clear parameters and direction to staff for medication administration was discussed with Staff 1 (Administrator) and Staff 6 (Residential Services Coordinator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medication were evaluated for safety and ensure physician's order were in place for 1 of 2 sampled residents (#5) who were reviewed for self-administration. Findings include, but are not limited to: Resident 5 was identified during the acuity interview on 3/1/21 as having their spouse, who lived in the same apartment, administer his/her medications. Review of Resident 5's clinical records revealed the following:*There was no documented evidence Resident 5 was evaluated for safety to have medications in the unit shared with his/her spouse; and*There was no signed physician's order stating the spouse could administer medications to Resident 5.The need to ensure residents who chose to self-administer medications when two or more people live in the same apartment/unit were both evaluated for safety and had a physician's order reflective of who was administered medications was discussed with Staff 1 (Administrator), Staff 18 (Resident Service Coordinator) on 3/2/21. 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 9 and 17) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 3/2/21 indicated the following:Staff 9 (CG) hired 8/26/20, Staff 17 (MT) hired 7/6/17, lacked documented evidence of demonstrated competency for all required components within the first 30 days of hire for topics including: * The role of service plans in providing individualized resident care;* Providing assistance with the activities of daily living;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and* Medication pass and treatments administered.The need to ensure the facility had documentation of demonstrated competency in job duties within 30-days of hire was discussed with Staff 1 (Administrator). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure Fire and Life Safety including drills and instruction were conducted in accordance with Oregon Fire Code. Findings include, but are not limited to:Review of Fire and Life safety records on 3/1/21, from October 2020 through March 2021 identified the following deficiencies:*Fire drills were not being conducted and recorded every other month; and*Fire and life safety instruction to staff were not being conducted and recorded on alternate months.In an interview with Staff 1 on 3/3/21, staff reported not having any records for Fire drills or Life Safety instruction for months prior to February 2021.On 3/3/21, the need to ensure fire drills and fire and life safety instruction are completed on alternate months was discussed with Staff 1 (Administrator) and Staff 6 (Residential Services Coordinator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide evidence that alternating evacuation routes were used during fire drills and resident evacuation levels were met. Findings include, but are not limited to:Review of Fire and Life Safety Records on 3/1/21, for October 2020 through March 2021 identified the facility lacked documented evidence of the following: * Alternate exit routes were used during fire drills; and* A written record of fire safety training, including content of the training sessions and the residents attending. On 3/3/21, the need to ensure alternate exit routes are used during fire drills and fire and life safety instruction was provided to residents upon admission and at least annually was discussed Staff 1 (Administrator) and Staff 6 (Residential Services Coordinator). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:On 3/2/21, a fireplace was observed in the common area on the first floor. The fireplace was located where residents could come into incidental contact with it. The fireplace surface temperature, measured with the surveyor's thermometer, was 256 degrees Fahrenheit.On 3/3/21, the need to ensure wall heaters and associated heating elements did not exceed 120 degrees F was discussed with Staff 1 (Administrator) and Staff 6 (Residential Services Coordinator). They acknowledged the findings. Staff stated the fireplace would remain off until they are able to obtain a fireplace cover.

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 outside court yards failed to have a working alarm or other acceptable system to alert staff when residents left the building.On 3/3/21, the lack of alarms on exit doors was discussed with Staff 1 (Administrator) and Staff 6 (Residential Services Coordinator). They acknowledged the findings.