Footsteps at Happy Valley.

“The findings of the initial survey, conducted 02/12/24 through 02/15/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the initial survey, conducted 02/12/24 through 02/15/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first revisit to the re-licensure survey of 02/15/24, conducted 07/23/24 through 07/25/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first revisit to the re-licensure survey of 02/15/24, conducted 07/23/24 through 07/25/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the second revisit to the re-licensure survey of 02/15/24, conducted 10/16/24 through 10/18/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. The findings of the second revisit to the re-licensure survey of 02/15/24, conducted 10/16/24 through 10/18/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.”

“Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: During the acuity interview on 02/12/24, Staff 5 (RN, Assistant Director of Health Services) and Staff 7 confirmed no residents in the facility self-administered their medications or treatments. During an environmental tour of the memory care community on 2/14/24 the following was noted: a. On 02/14/24 at 11:35 am, Resident 1's unit was toured.  There was barrier cream observed in a nightstand by the bed. The nightstand was unlocked and accessible to Resident 1. The surveyor toured the room with Staff 7 (Memory Care Coordinator) on 02/14/24 at 11:41 am and the barrier cream was removed. b. On 02/14/24 at 11:38 am, Resident 2's unit was toured. There were multiple over-the-counter medications and treatments observed in the second drawer in the bathroom cabinet. The drawer was unlocked and accessible to Resident 2. The surveyor alerted Staff 7 on 02/14/24 at 11:42 am, and she confirmed the medications and treatments were removed from Resident 2's unit and locked in her office at 11:52 am. On 02/14/24 at 11:56 am, the surveyor observed the medications and treatments were removed from Resident 2's unit. The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator) on 02/15/24. They acknowledged the findings. Refer to C 270, example 1c. Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: During the acuity interview on 02/12/24, Staff 5 (RN, Assistant Director of Health Services) and Staff 7 confirmed no residents in the facility self-administered their medications or treatments. During an environmental tour of the memory care community on 2/14/24 the following was noted: a. On 02/14/24 at 11:35 am, Resident 1's unit was toured.  There was barrier cream observed in a nightstand by the bed. The nightstand was unlocked and accessible to Resident 1. The surveyor toured the room with Staff 7 (Memory Care Coordinator) on 02/14/24 at 11:41 am and the barrier cream was removed. b. On 02/14/24 at 11:38 am, Resident 2's unit was toured. There were multiple over-the-counter medications and treatments observed in the second drawer in the bathroom cabinet. The drawer was unlocked and accessible to Resident 2. The surveyor alerted Staff 7 on 02/14/24 at 11:42 am, and she confirmed the medications and treatments were removed from Resident 2's unit and locked in her office at 11:52 am. On 02/14/24 at 11:56 am, the surveyor observed the medications and treatments were removed from Resident 2's unit. The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator) on 02/15/24. They acknowledged the findings. Refer to C 270, example 1c. In order to assure resident rooms are free of potential hazards, a safety check of apartment will be conducted by the Memory Care Coordinator or designee within 24 hours of admission. If hazardous items are located, residents and their families will be notified immediately of items not permitted in memory care and they will be removed, placed in a box in the Memory Care Coordinator office until pickup can be arranged by responsible party. In addition, apartment safety checks were completed by Memory Care Coordinator for both Resident #1 and Resident #2 immediately after findings. Memory Care Coordinator or designee will complete and store safety check logs, this will be implemented in March 2024. Memory Care Coordinator or designee will also train memory care staff on items that should not be in apartments or in lock box. Safety checks will be evaluated by Memory Care Coordinator or designee monthly. Facility will be in compliance by 4/12/2024 In order to assure resident rooms are free of potential hazards, a safety check of apartment will be conducted by the Memory Care Coordinator or designee within 24 hours of admission. If hazardous items are located, residents and their families will be notified immediately of items not permitted in memory care and they will be removed, placed in a box in the Memory Care Coordinator office until pickup can be arranged by responsible party. In addition, apartment safety checks were completed by Memory Care Coordinator for both Resident #1 and Resident #2 immediately after findings. Memory Care Coordinator or designee will complete and store safety check logs, this will be implemented in March 2024. Memory Care Coordinator or designee will also train memory care staff on items that should not be in apartments or in lock box. Safety checks will be evaluated by Memory Care Coordinator or designee monthly. Facility will be in compliance by 4/12/2024 Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were exercised against a condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#4) who had orders for a modified diet of mechanical soft texture and nectar thick liquids. Resident 4 received an inaccurate diet texture and liquid consistency, placing him/her at risk for aspiration, choking and/or death. This is a repeat citation. Findings include, but are not limited to: Resident 4 was admitted to the facility in 02/2024 with diagnoses including dementia and was identified during the acuity interview as having a recent decline, admitted to hospice and placed on a modified diet of mechanical soft textures and nectar thick liquids. Observations of meals, interviews with facility staff, and review of physician orders dated 07/18/24, RN assessment dated 07/19/24, and Temporary Service Plans (TSP's) dated 07/18/24, 07/22/24 and 07/23/24, identified the following: * Resident 4 had physician orders dated 07/18/24 for a mechanical soft diet texture and nectar thick liquids. *A TSP dated 07/18/24 listed mechanical soft foods, add thickener to all fluids, monitor during all meals, needed assistance with meals and safety, and high aspiration risk. * The RN assessment completed 07/19/24 revealed, "diet orders for mechanical soft textures and nectar thick liquids because of high risk for aspiration". * A TSP dated 07/22/24 listed mechanical soft foods, upright position while eating, 1:1 feeding assist for safety, also "thickened liquids", use "Thick-It" for all liquids. During a lunch observation on 07/23/24 at 12:15 pm, the resident was served a regular sandwich and thin liquids. Staff 21 (CG) cut the sandwich into bite size pieces and offered the resident bites. Staff 21 stated Resident 4 was on a regular texture diet cut into small pieces, thin liquids, and was assisted with eating and drinking at all meals. Staff 2 (Health Services Administrator) was informed of the observation, the facility then provided a mechanical soft texture meal with nectar thick liquids. During an observation at 12:30 pm on 07/23/24, the resident demonstrated a wet cough and Staff 21 asked the resident if s/he would like a glass of water. Staff 21 brought the resident a glass of thin water. Staff 2 and Staff 20 (Regional RN) were informed of the observation and the glass of thin water was removed. During an observation at 12:40 pm on 07/23/24, Staff 25 (MT) added t”

“Based on observation, interview, and record review, it was determined the facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse and failed to immediately notify the local SPD office of incidents of abuse or suspected abuse for 2 of 2 sampled residents (#s 1 and 2) who had incidents reviewed. Resident 1 had multiple resident-to-resident altercations which put him/her and others at risk. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 08/2023 with diagnoses including dementia. A review of the resident's record, including progress notes dated 11/14/23 through 02/11/24, incident reports for the same time period, observations of resident care and staff interviews were conducted during the survey. The following reportable incidents were identified: * On 11/19/23 progress notes and an incident report noted a resident-to-resident altercation. * On 11/25/23 at 20:00 progress notes and incident report noted a resident-to-resident altercation. There was no documented follow up action to the investigation. * On 11/25/23 20:30 an incident report noted a resident-to-resident altercation in which Resident 1 was hitting another resident with an open fist repeatedly. The other resident was yelling for help. Emergency services were called. * On 01/27/24 Progress notes and an incident report noted a resident-to resident altercation. Resident 1 was sent to the emergency room. The follow up incident report noted: "resident was not safe for group living at this time due to aggression toward staff and other residents, having other residents fear for their safety." On 02/01/24 resident to staff altercation: Staff were assisting another resident in their room when Resident 1 entered the room and started hitting care staff. Follow up incident report noted, "service plan is clear and appropriate at this time." Resident 1 continues to have agression without clear interventions in place. During the survey from 02/12/24 through 02/15/24 the resident was not observed to display aggressive behaviors towards other residents. During an interview on 02/12/24 at 11:50 am, Staff 11 (CG) reported the resident had behaviors, was aggressive with staff and other residents, often refused care and required two people to assist with care "just in case something happens." During an interview on 02/15/24 at 8:38 am, Staff 17 (CG) reported the resident "gets angry with other residents and is hard to redirect, we change face [approach with a different caregiver] a lot with [him/her]. Sometimes it works, if not we get the MT." There was no documented evidence any of the above incidents of physical aggression were immediately reported to the local SPD office, and measures were taken to protect the resident and others in the community and prevent the reoccurrence of abuse. The resident continued to have physical altercations with multiple residents and staff. The facility was instructed to report all of the above incidents to the local SPD office on 02/14/24. The need to immediately report resident altercations to the local SPD office was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Administrator) on 02/14/24. They acknowledged the findings. A confirmation of the reports to the local SPD office were provided prior to exit. Based on observation, interview, and record review, it was determined the facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse and failed to immediately notify the local SPD office of incidents of abuse or suspected abuse for 2 of 2 sampled residents (#s 1 and 2) who had incidents reviewed. Resident 1 had multiple resident-to-resident altercations which put him/her and others at risk. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services, included a written description of who should provide the services and what, when, how, and how often the services should be provided for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 08/2023 with diagnoses including dementia. Interviews with staff, review of the resident's service plan, dated 01/19/24, temporary service plans (TSP's) and progress notes, dated 11/14/23 through 02/11/24, were conducted during the survey. The service plan lacked a written description of who shall provide the services and what, when, how, and how often the services shall be provided, was not reflective of the residents current care needs and status and lacked clear direction for staff in the following areas: * Hospice services including the tasks they were responsible to provide; * Cognition: including how often services were provided; * Bathing: independent verses staff assistance needed; * Supportive approaches for refusal of care and type of refusals; * Toileting including assistance for incontinent care and hospice provided supplies; * Use of siderails and caregiver instructions; * Fall interventions; * Behaviors and supportive approaches; and * Weight loss including interventions. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator ) on 02/15/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services, included a written description of who should provide the services and what, when, how, and how often the services should be provided for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or interventions were needed for short term changes of condition, and/or failed to monitor residents consistent with evaluated needs or service plan for 2 of 2 sampled residents (#s 1 and 2) related to falls, behaviors, and resident-to-resident incidents.  Resident 1 had multiple altercations and falls which put the resident and others at risk for injury. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 08/2023 with diagnoses including dementia. A review of the resident's service plan dated 01/09/24, temporary service plans (TSP's), progress notes dated 11/14/23 through 02/11/24, incident reports for the same time period noted the resident had verbal and physical aggression. a. The resident had the following changes of condition related to behaviors: * On 11/15/23 - Resident-to-staff altercation; * On 11/19/23 - Resident-to-resident altercation; * On 11/25/23 - Resident-to-resident altercation; * On 11/25/23 - A second resident-to-resident altercation; * On 01/27/24 - Resident-to-resident altercation; * On 02/01/24 - Resident-to-staff altercation; and * On 02/04/24 - Resident-to-staff altercation. During an interview on 02/12/24 at 11:50 am, Staff 11 (CG) reported the resident had behaviors, was aggressive with staff and other residents, often refused care and required two people to assist with care "just in case something happens." During an interview on 02/15/24 at 8:38 am, Staff 17 (CG) reported the resident "gets angry with other residents and is hard to redirect, we change face [approach with a different caregiver] a lot with [him/her]. Sometimes it works, if not we get the MT." There was no documented evidence the facility evaluated each altercation and determined what actions or interventions were needed for the resident, communicated the action or intervention to staff on each shift and the documentation of staff instructions or interventions made part of the resident record with weekly progress noted until the condition resolved. This put the resident and others in the community at risk for continued physical aggression from Resident 1. On 02/15/24, the facility provided the survey team with a safety plan which detailed a description of what the verbal and physical aggression looked like. Noted the resident "would present with wide eyes, intent pacing and hands in fists. The safety plan further identified specific resident altercations. Interventions for staff to attempt included talk in a low tone and provide verbal cues away from what [s/he] is fixated on, talk about Hawaii, family, hunting, fishing camping. When [s/he] was hitting, kicking, slapping himself or other residents/staff were to avoid touching [him/her], coach and provide verbal cues, redirect away from the scene with a second caregiver, utilize PRN medications, contact community RN or after hours contact [care team]." The need to ensure the facility monitored residents per evaluated condition and service plan, determined resident specific action or interventions needed, the interventions communicated to staff on each shift and the documentation of staff instructions and/or interventions made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator ) on 02/15/24. They acknowledged the findings. b. Resident 1's current evaluation and service plan identified the resident was a high fall risk. Fall interventions included frequent checks and non-skid footwear. The resident experienced the following changes of condition related to falls: * On 11/12/23 - Unwitnessed fall in his/her apartment. The resident was found on the floor in front of his/her bed with a scrape on the knee. A TSP was written on 11/16/23 (four days later). The TSP noted the following: encourage assistive device, pendant, keep environment free of clutter, caregiver to check catheter bag placement. The resident was evaluated as unable to use a call pendant, unable to remember to use assistive device and did not have a catheter, therefore the interventions on the TSP were not resident specific. * On 11/22/23 - Fall in the hallway with his/her head against the wall and lying on the floor; * On 11/24/23 at 7:58 pm - Fall in the resident's apartment in which s/he appeared to be "seizing". Resident had complaints of pain in knees; and * On 11/24/23 at 11:36 pm - A second fall in the resident's apartment. The resident had "complaints of pain in lower back but it's normal pain for him/her." There was no documented evidence the facility evaluated the fall with reported seizure, determine action or intervention needed for the fall or seizure, communicate the action or intervention to staff on all shifts and monitored the residents fall, pain or reported seizure at least weekly through resolution. * On 11/26/23 - Unwitnessed fall from bed. A TSP written on 11/26/23, repeated the same previous interventions noted on a TSP dated 11/16/23. There was no documented evidence the facility monitored the fall interventions for effectiveness or monitored the resident for any pain or latent injuries at least weekly through resolution. * On 11/27/23 - Unwitnessed fall in his/her apartment; * On 11/30/23 - Unwitnessed fall with injury in another resident's room which resulted in two cuts with minor bleeding on the resident's left forearm; * On 12/12/23 - Observed fall in the hallway when resident attempted to self-transfer in the common "TV" area and missed the recliner, no injuries noted; and * On 01/08/24 - Unwitnessed fall in the apartment. There was no documented evidence the facility evaluated the resident's continued falls, determined what action or interventions were needed for the resident, communicated the actions and/or interventions to staff on all shifts and monitored the resident's falls and the skin injuries to the left forearm at least weekly through resolution. Resident 1 continued to have falls with injuries. * On 01/11/24 - Unwitnessed fall, resident called for help and was found on the floor of his/her bathroom. The resident fell off the toilet with injury to right side of forehead and had complaints of right wrist pain; and * On 01/14/24 - Unwitnessed fall, the resident was found on the floor next to the recliner. The incident investigation noted, "falls to be expected at this time." There was no documented evidence the facility evaluated the resident's fall interventions for effectiveness, determined what action or interventions were needed for the resident following the fall, communicated the actions and/or interventions to staff on all shifts, and monitored the resident's skin injuries to the left forearm at least weekly through resolution. Resident 1 continued to have falls with injuries. * On 01/20/24 - Unwitnessed fall in the resident's apartment. A TSP was written on 01/23/24 (three days later) with interventions including: put laundry clothing piles in appropriate places, remove rugs, ensure resident is wearing "pull ups" and check room floors due to incontinence. There was no documented evidence the fall and determined interventions were monitored for effectiveness. * On 02/02/24- Unwitnessed fall with a scratch on the right leg. A TSP was written on 02/06/24 (four days later) instructing staff to "monitor unsteady gait, monitor hourly, use pendant, ensure room is clutter free and report changes nausea, vomiting to MT and hourly checks." The facility failed to evaluate the fall interventions for effectiveness, determine what action or intervention was needed for the skin injury to the right leg and the fall and skin injury were not monitored weekly through resolution. Resident 1 was evaluated as a high risk for falls and experienced multiple falls w”

“Based on observation, interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 3 of 3 sampled residents (#'s 3, 4, and 5) and multiple unsampled residents. Findings include, but are not limited to: Observations were made during the survey to determine adherence to universal precautions for infection control. 1. Upon entry to the memory care unit on 07/23/24, Staff 2 (Health Services Administrator) confirmed they had several residents who tested positive for COVID. While on survey, observations were made of an unsampled resident not wearing a mask and wandering the facility, checking door handles on resident rooms, offices and exit doors to the courtyard, stepping into multiple resident rooms, sitting down in community areas surrounded by other sampled and unsampled residents in the dining room, television area and courtyard. Prior to interviews with staff about this resident, no observations were made that identified the facility was sanitizing the high touch areas, redirecting the resident to his/her room or away from other residents or encouraging the resident to wear a mask. On 07/23/24, the surveyor observed a sign posted on this unsampled resident's door that stated "Caution COVID-19 QUARANTINE IN PROGRESS" with a start date of 07/20/24 and end date of 07/25/24.  A (Temp) Service Plan Update, dated 07/20/24, instructed staff to "Keep in room if possible" and "encourage mask/distancing".  There were no instructions to staff how to maintain infection prevention and control for this resident if s/he would not adhere to quarantining, wearing a mask or distancing. During an interview with Staff 24 (CG) on 07/24/24 at 11:00 am, he revealed staff were to wipe down the table after someone who was COVID positive and "keep them isolated." When asked what to do for residents who did not want to stay in their rooms, he responded "We just keep bringing them back to their room." At 11:09 am Staff 24 was overheard saying to another caregiver, "I didn't know that [unsampled resident] was positive." During an interview with Staff 28 (CG) on 07/24/24 at 11:10 am, she relayed that for the resident who was COVID positive and wandered the facility, "S/he has not wanted to stay in [his/her] room" and "we just try to get [him/her] to wear a mask". She did not have any additional instruction as to how staff provided infection control for this resident who wandered. On 07/24/24 at 1:25 pm, the surveyor alerted Staff 1 (ED), Staff 2 and Staff 20 (Regional RN) regarding the observations and interviews made with the resident who wandered and was COVID positive. Staff 2 acknowledged the resident wandered throughout the facility including in and out of resident rooms, and the facility needed to be cleaning the high touch areas. She voluntarily completed an updated service plan update that included instructions on how to prevent and maintain infection control for this resident who wandered and was COVID positive. Additionally, Staff 1 provided a "COVID Disinfecting Schedule" for the memory care facility who had a number of other COVID positive residents. The need to ensure staff consistently used universal precautions was discussed with Staff 1, Staff 2 and Staff 20 on 07/25/24 at 2:35 pm. They acknowledged the findings. 2. On 07/24/24 during breakfast and lunch service the following observations were made: * At 8:58 am, a caregiver provided meal assistance for Resident 5, and intermittent cueing and assistance to another unsampled resident. Resident 5 was repositioned in his/her wheelchair and the caregiver provided assistance with Resident 5's lower legs and feet. With gloved hands, the caregiver was observed to touch Resident 5's legs, feet and the wheelchair's armrest and footplates. Following the repositioning and with the same gloved hands, the caregiver cued the unsampled resident to eat his/her breakfast, touched his/her fork and placed the fork in the resident's hand. The caregiver then picked up the resident's link sausage, attempted to place in his/her hand but the resident refused. The surveyor observed the resident consume the sausage link independently about five minutes later. With the same gloved hands, the caregiver returned to Resident 5 and held the cup and straw to his/her mouth. Following repositioning assistance in the wheelchair, the staff member was not observed to change gloves or perform hand hygiene prior to assisting the unsampled resident and Resident 5. * At 12:33 pm a caregiver was seated between Resident 3 and Resident 5 and provided meal assistance to Resident 5. With gloved hands the caregiver picked up half of a sandwich and Resident 5 took a bite.  Resident 3 was observed to ask for assistance from the caregiver after s/he dropped some food into his/her lap. The caregiver reached over, touched Resident 3's pants, picked up the food from his/her lap and placed it on the table. With the same gloved hands the caregiver resumed meal assistance to Resident 5, picked up his/her sandwich and assisted him/her with another bite. The staff member was not observed to change gloves or perform hand hygiene prior to resuming feeding assistance to Resident 5. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator) and Staff 20 (Regional RN) on 07/25/24 at 2:35 pm. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 3 of 3 sampled residents (#'s 3, 4, and 5) and multiple unsampled residents. Findings include, but are not limited to: Observations were made during the survey to determine adherence to universal precautions for infection control.”

“Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 1 sampled resident (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 08/2023 with diagnoses including dementia. Resident 1 had signed physician orders for morphine 0.25 ml (5 mg) sublingually, by mouth every hour, as needed for pain and/or shortness of breath. Resident 1's 01/01/24 through 02/15/24 MARs and the Controlled Substance Disposition Log were reviewed and identified the following: * The Controlled Substance Disposition log showed the morphine was administered on 27 occasions between 01/01/24 through 02/15/24, however, the MAR showed only 10 occasions the medication was administered to Resident 1. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 02/15/24 with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator ). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 1 sampled resident (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 08/2023 with diagnoses including dementia. Resident 1 had signed physician orders for morphine 0.25 ml (5 mg) sublingually, by mouth every hour, as needed for pain and/or shortness of breath. Resident 1's 01/01/24 through 02/15/24 MARs and the Controlled Substance Disposition Log were reviewed and identified the following: * The Controlled Substance Disposition log showed the morphine was administered on 27 occasions between 01/01/24 through 02/15/24, however, the MAR showed only 10 occasions the medication was administered to Resident 1. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 02/15/24 with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator ). They acknowledged the findings. Resident #1 narcotics were reviewed and audited for accuracy by Director of Health Services. Hospice was consulted to rewrite order for better clarity for unlicensed staff such as using one bottle for two orders to avoid error. Log was reviewed for accuracy by Director of Health Services. Director of Health Services or designee to audit all narcotic books monthly to assure count is corrected. This task will be overseen by Health Services Administrator or designee. Medication techicians to receive narcotic inservice training to review matching the MAR with narcotic book and recording administration properly and accurately. This includes introduction of daily narcotic audit performed by the medication technician each shift, and the monthly narcotic audit form to be completed by the Director of Health Services or designee. This will be conducted by the Director of Health Services and Health Services Administrator or designee. This teaching will occur in March of 2024. Facility will be in compliance by 4/12/2024. Resident #1 narcotics were reviewed and audited for accuracy by Director of Health Services. Hospice was consulted to rewrite order for better clarity for unlicensed staff such as using one bottle for two orders to avoid error. Log was reviewed for accuracy by Director of Health Services. Director of Health Services or designee to audit all narcotic books monthly to assure count is corrected. This task will be overseen by Health Services Administrator or designee. Medication techicians to receive narcotic inservice training to review matching the MAR with narcotic book and recording administration properly and accurately. This includes introduction of daily narcotic audit performed by the medication technician each shift, and the monthly narcotic audit form to be completed by the Director of Health Services or designee. This will be conducted by the Director of Health Services and Health Services Administrator or designee. This teaching will occur in March of 2024. Facility will be in compliance by 4/12/2024. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer for 1 of 1 sampled residents (# 5) whose orders were reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 06/2024 with diagnoses including severe vascular dementia and recurrent strokes. The resident's 06/01/24 through 07/23/24 MARs, medical prescriber's orders, and outside provider notes were reviewed and noted the following: 1. A physician's order on 06/03/24 directed facility to "please check blood pressure for 14 days and send to Primary Care Physician". Although the facility faxed the physician on 06/10/24 for blood pressure readings 06/04/24 through 06/10/24, there was no documented evidence provided that the facility faxed the blood pressure results taken 06/11/24 through 06/17/24. 2. A physician's order on 06/03/24 indicated an order for lidocaine 5% patch (for pain) to be applied every 12 hours. There was no documented evidence the medication had been administered. During an interview on 07/25/24, Staff 20 (Regional RN) indicated the medication was not covered by insurance and acknowledged not following up with the primary care physician. No further documentation was provided. 3. The resident had a physician's order on 07/04/24 for triamcinolone acetonide 0.1% topical cream two times per day as needed. The order was not transcribed to the resident's MAR and there was no documented evidence of a physician's order to discontinue the topical cream. During an interview with Staff 2 (Health Services Administrator), she was not sure what the medication was prescribed for and acknowledged the medication was not available. 4. An outside provider form from the hospice RN, dated 07/12/24, noted "I will be faxing over orders to D/C [discontinue] Atorvastatin [for high cholesterol] and the scheduled and prn Tylenol [for pain]." The MAR revealed the resident continued to receive Atorvastatin 07/18/24 through 07/23/24 and routine Tylenol three times a day 07/13/24 through 07/23/24. No further documented evidence was provided that the three medication orders were discontinued or that the facility followed up with hospice for the physician orders. 5. Resident 5 had a physician's order, dated 06/10/24, for escitalopram (for depression) 5 mg daily for four weeks and "If tolerating well, increase to 10 mg daily after four weeks." The MAR revealed Resident 5 began receiving the 5 mg dosage, administered between 6:00 am and 10:00 am daily, on 06/11/24 and the last 5 mg dose was given 07/07/24. The MAR also revealed Resident 5 began receiving a 10 mg dose at 6:00 pm daily on 07/06/24 and 07/07/24, totaling 15 mg of escitalopram per day. During an interview on 07/24/24 at 2:33 pm, Staff 20 acknowledged the end date for the 5 mg dosage was not indicated on the MAR and the resident received an incorrect dosage of escitalopram. 6. On 07/23/24 at 3:10 pm the Controlled Substance Distribution log and the corresponding medication was reviewed with Staff 27 (MT) and the following was identified: * The MAR indicated tramadol 50 mg 1 tablet was to be administered every six hours as needed for pain. Staff 27 indicated "I know tramadol is on [his/her] MAR but [s/he] doesn't have any tramadol here." She removed all of the controlled substances from the drawer in the medication cart and confirmed there was no tramadol identified for Resident 5. She also did not have a Controlled Substance Distribution log for tramadol for Resident 5. Who alerted?? On 07/25/24 the surveyor alerted Staff 20 of the observation and he confirmed Resident 5 had tramadol ordered prior to moving from assisted living to the memory care and they were waiting for hospice to reconcile his/her medication list and then will request the tramadol if needed. * The MAR indicated haloperidol 0.5 mL was to be administered every two hours as needed for nausea or restlessness/agitation. Staff 27 indicated Resident 5 did not have the medication available to administer. On 07/24/24 at 2:55 pm Staff 2 confirmed Resident 5 did not have this medication and she would request the medication be delivered. The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed and available in the resident's facility record was discussed with Staff 1 (ED), Staff 2 and Staff 20 on 07/25/24 at 2:35 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer for 1 of 1 sampled residents (# 5) whose orders were reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 06/2024 with diagnoses including severe vascular dementia and recurrent strokes. The resident's 06/01/24 through 07/23/24 MARs, medical prescriber's orders, and outside provider notes were reviewed and noted the following:”

“Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-pharmaceutical interventions to attempt prior to administering the medication for 1 of 1 sampled resident (#1) who was prescribed PRN psychotropic medication. Findings include, but are not limited to: Resident 1 moved into the facility in 08/2023 with diagnoses including dementia. A review of the resident's 01/2024 through 02/12/24 MARs identified s/he was prescribed PRN lorazepam 1 mg every hour as needed for anxiety, restlessness, and dyspnea. The MAR lacked instruction related to non-pharmacological interventions for staff to attempt prior to administration of the medication, and failed to identify how each of the resident's symptoms were displayed. Resident 1 was administered PRN lorazepam on 11 occasions from 01/01/24 through 12/12/24. There was no documentation that non-pharmacological interventions had been attempted with ineffective results prior to administration of the medication. The need to include resident-specific parameters were included on the MAR for all PRN psychotropic medications and staff were instructed to attempt and document non pharmacological interventions prior to administration was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator ) on 02/15/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-pharmaceutical interventions to attempt prior to administering the medication for 1 of 1 sampled resident (#1) who was prescribed PRN psychotropic medication. Findings include, but are not limited to: Resident 1 moved into the facility in 08/2023 with diagnoses including dementia. A review of the resident's 01/2024 through 02/12/24 MARs identified s/he was prescribed PRN lorazepam 1 mg every hour as needed for anxiety, restlessness, and dyspnea. The MAR lacked instruction related to non-pharmacological interventions for staff to attempt prior to administration of the medication, and failed to identify how each of the resident's symptoms were displayed. Resident 1 was administered PRN lorazepam on 11 occasions from 01/01/24 through 12/12/24. There was no documentation that non-pharmacological interventions had been attempted with ineffective results prior to administration of the medication. The need to include resident-specific parameters were included on the MAR for all PRN psychotropic medications and staff were instructed to attempt and document non pharmacological interventions prior to administration was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator ) on 02/15/24. They acknowledged the findings. Resident #1 and Resident #2 service plans were audited to assure they were resident specific immediately by Health Services Administrator. Assistive device use, non-pharmacological interventions, and psychotropic use were highlighted and appropriately captured in service plan. All service plans will include resident specific non-pharmacological interventions prior to giving psychotropic medications by 4/12/24. The MAR will reflect which intervention was attempted and was unsuccessful to determine the need to give PRN psychotropic medication. The use of this PRN medication will be monitored with any acute changes or monthly by Director of Health Services and Health Services Administrator or designee. Psychotropic medications will have a clear, accurate indication in order, common side effects, when to contact the RN or MD, and resident-specific parameters. This will be part of the RN "third check" of orders to assure all pieces are present. Facility will be in compliance by 4/12/2024. Resident #1 and Resident #2 service plans were audited to assure they were resident specific immediately by Health Services Administrator. Assistive device use, non-pharmacological interventions, and psychotropic use were highlighted and appropriately captured in service plan. All service plans will include resident specific non-pharmacological interventions prior to giving psychotropic medications by 4/12/24. The MAR will reflect which intervention was attempted and was unsuccessful to determine the need to give PRN psychotropic medication. The use of this PRN medication will be monitored with any acute changes or monthly by Director of Health Services and Health Services Administrator or designee. Psychotropic medications will have a clear, accurate indication in order, common side effects, when to contact the RN or MD, and resident-specific parameters. This will be part of the RN "third check" of orders to assure all pieces are present. Facility will be in compliance by 4/12/2024. 2. Resident 5 was admitted to the facility in 06/2024 with diagnoses including severe vascular dementia and recurrent strokes. Review of Resident 5's MAR, dated 06/01/24 through 07/23/24, indicated the resident was prescribed the following PRN psychotropics: * Haloperidol 0.5 ml by mouth every two hours as needed for nausea or restlessness agitation; and * Lorazepam 0.5 mg by mouth every two hours as needed for anxiety. Review of Resident 5's MAR, dated 06/01/24 through 07/23/24, indicated the resident was prescribed the following PRN psychotropics: * Haloperidol 0.5 ml by mouth every two hours as needed for nausea or restlessness agitation; and * Lorazepam 0.5 mg by mouth every two hours as needed for anxiety. There was no documented evidence of non-pharmacological interventions listed for staff to attempt prior to considering administering the medication. Additionally, the facility lacked documented evidence the staff knew when to contact a health professional regarding side effects of the medication. In an interview on 07/25/24 at 12:55 pm, Staff 25 (MT) confirmed she was not aware of the non-pharmacological interventions she needed to try prior to administering PRN lorazepam or haloperidol. She also confirmed that she was not aware of any instructions when to contact a health professional regarding side effects. The need to ensure PRN medications given to treat a resident's behaviors had written non-pharmacological interventions which had been tried with ineffective results prior to administration and when staff were to contact a health professional with side effects was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator) and Staff 20 (Regional RN) on 07/25/24 at 2:35 pm. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2024 with diagnoses including severe vascular dementia and recurrent strokes. Review of Resident 5's MAR, dated 06/01/24 through 07/23/24, indicated the resident was prescribed the following PRN psychotropics: * Haloperidol 0.5 ml by mouth every two hours as needed for nausea or restlessness agitation; and * Lorazepam 0.5 mg by mouth every two hours as needed for anxiety. Review of Resident 5's MAR, dated 06/01/24 through 07/23/24, indicated the resident was prescribed the following PRN psychotropics: * Haloperidol 0.5 ml by mouth every two hours as needed for nausea or restlessness agitation; and * Lorazepam 0.5 mg by mouth every two hours as needed for anxiety. There was no documented evidence of non-pharmacological interventions listed for staff to attempt prior to considering administering the medication. Additionally, the facility lacked documented evidence the staff knew when to contact a health professional regarding side effects of the medication. In an interview on 07/25/24 at 12:55 pm, Staff 25 (MT) confirmed she was not aware of the non-pharmacological interventions she needed to try prior to ad”

“Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility. Findings include, but are not limited to: Upon review of the ABST on 02/13/24, the ABST did not include data for Resident 2. During an interview on 02/13/24 at 9:33 am, Staff 1 (ED) and Staff 2 (Health Services Administrator) stated they did not realize Resident 2 had not been entered into the ABST. The need to ensure the ABST was updated before a resident moved in to the facility was discussed with Staff 1 and Staff 2 on 02/13/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility. Findings include, but are not limited to: Upon review of the ABST on 02/13/24, the ABST did not include data for Resident 2. During an interview on 02/13/24 at 9:33 am, Staff 1 (ED) and Staff 2 (Health Services Administrator) stated they did not realize Resident 2 had not been entered into the ABST. The need to ensure the ABST was updated before a resident moved in to the facility was discussed with Staff 1 and Staff 2 on 02/13/24. They acknowledged the findings. Health Services Administrator immediately added missing resident (Resident #2) to Footsteps ABST and highlighted all unique care needs. Upon admission, all residents will be entered in the Acuity-Based Staffing Tool on the DHS website by the Resident Service Coordinator(s) or designee. This ABST will be updated on each admission, or discharge as applicable, and will be monitored by Health Services Administrator, or Resident Service Coordinator or designee weekly and as needed for significant change of condition. The ABST will be resident specific. Weekly meeting/check was initiated on 2/23/24 and will be weekly thereafter. Facility will be in compliance by 4/12/2024. Health Services Administrator immediately added missing resident (Resident #2) to Footsteps ABST and highlighted all unique care needs. Upon admission, all residents will be entered in the Acuity-Based Staffing Tool on the DHS website by the Resident Service Coordinator(s) or designee. This ABST will be updated on each admission, or discharge as applicable, and will be monitored by Health Services Administrator, or Resident Service Coordinator or designee weekly and as needed for significant change of condition. The ABST will be resident specific. Weekly meeting/check was initiated on 2/23/24 and will be weekly thereafter. Facility will be in compliance by 4/12/2024. Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to have an accurate number of minutes for 2 of 3 sampled residents (#s 4 and 5) whose ABST was reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 02/2024 with diagnoses including dementia. The resident's 06/14/24 service plan, RN Assessment dated 07/19/24, Temporary Service Plans dated 07/18/24, 07/22/24, and 07/23/24 and Resident 4's ABST data was reviewed. Staff were interviewed and observations were made of the resident. The following areas were not reflective of the resident's current ADL assistance: * How much time was spent supervising, cueing, or supporting while eating; and * The resident was identified as having a significant change of condition on 07/19/24 and the ABST was not updated to reflect the change. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator) and Staff 20 (Regional RN) on 07/25/24 at 2:50 pm. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2024 with diagnoses including severe vascular dementia and recurrent strokes. The resident's 07/12/24 service plan and Resident 5's ABST data was reviewed. Staff were interviewed and observations were made of the resident. The following areas were not reflective of the resident's current ADL assistance: * How much time was spent supervising, cueing, or supporting while eating. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator) and Staff 20 (Regional RN) on 07/25/24 at 2:35 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to have an accurate number of minutes for 2 of 3 sampled residents (#s 4 and 5) whose ABST was reviewed. This is a repeat citation. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 10/2023 and 01/2024, revealed the following: a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas: * The escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * The number of occupants evacuated. b. Staff 14 (CG) and 16 (CG) were interviewed on 02/12/24 and 02/13/24. Neither staff member was able to state the designated point of safety as determined by the Fire Authority having jurisdiction. The need to ensure fire drills were conducted according to the OFC and to provide fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Administrator) on 02/15/24. He acknowledged the findings. Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 10/2023 and 01/2024, revealed the following: a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas: * The escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * The number of occupants evacuated. b. Staff 14 (CG) and 16 (CG) were interviewed on 02/12/24 and 02/13/24. Neither staff member was able to state the designated point of safety as determined by the Fire Authority having jurisdiction. The need to ensure fire drills were conducted according to the OFC and to provide fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Administrator) on 02/15/24. He acknowledged the findings. Resident #1 and Resident #2 were informed of protocol, and service plans updated immediately by Health Services Administrator to highlight evacuation status. All Footsteps resident service plans will be updated to reflect evacuation status on or before April 12, 2024. Fire drills in Footsteps will be conducted every other month starting in February on by the Plant Operations Director or designee. They will be unannouced across day, evening, and night shift. The fire drill document will include date, time of day, location of "fire", escape route used, any issues with residents resisting to evacuation, current staff members participating and number of occupants evacuated. These documents will be completed by the Plant Operations Director or designee. Administrator or designee will evaluate system and implementation of system for effectiveness monthly. Facility will be in compliance by 4/12/2024. Resident #1 and Resident #2 were informed of protocol, and service plans updated immediately by Health Services Administrator to highlight evacuation status. All Footsteps resident service plans will be updated to reflect evacuation status on or before April 12, 2024. Fire drills in Footsteps will be conducted every other month starting in February on by the Plant Operations Director or designee. They will be unannouced across day, evening, and night shift. The fire drill document will include date, time of day, location of "fire", escape route used, any issues with residents resisting to evacuation, current staff members participating and number of occupants evacuated. These documents will be completed by the Plant Operations Director or designee. Administrator or designee will evaluate system and implementation of system for effectiveness monthly. Facility will be in compliance by 4/12/2024.”

“Based on interview and record review, it was determined the facility failed to ensure residents were instructed 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. Findings include, but are not limited to: On 02/13/24, Staff 2 (Health Services Administrator) was asked to explain the facility's process for providing fire safety training to residents upon admission. Staff 2 stated the training was provided to the resident and family/power of attorney within their Residency Agreement and Resident Handbook. This documentation was provided however, it lacked instruction regarding the required elements. The need to ensure residents were instructed in the facility's fire and life safety procedures per OFC upon admission and at least annually was reviewed with Staff 1 (Administrator) and Staff 2 on 02/15/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure residents were instructed 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. Findings include, but are not limited to: On 02/13/24, Staff 2 (Health Services Administrator) was asked to explain the facility's process for providing fire safety training to residents upon admission. Staff 2 stated the training was provided to the resident and family/power of attorney within their Residency Agreement and Resident Handbook. This documentation was provided however, it lacked instruction regarding the required elements. The need to ensure residents were instructed in the facility's fire and life safety procedures per OFC upon admission and at least annually was reviewed with Staff 1 (Administrator) and Staff 2 on 02/15/24. They acknowledged the findings. Each resident's POA will be notified of Fire & Life Safety requirements and individualized evacuation needs for resident upon admission, quarterly and with significant changes during care conference. Residents who moved in prior to implementation of this system will receive a Fire & Life Safety Document that details how we will evacuate, where we will evacuate in the event of a fire or other emergency requiring evacuation. This will be given to resident and POA for signature by administrator or designee and will be completed on or before 4/12/2024.  Completion of this task will be overseen by adminstrator or designee. The person-centered transfer status for evacuation will be detailed in the service plan for staff. Signatures of consent will be scanned into the resident record. A new resident will receive a Fire & Life Safety Document that details how we will evacuate, where we will evacuate in the event of a fire or other emergency requiring evacuation. This will be given to resident for signature by care coordinator or designee upon admission within 24 hours. Completion of this task will be overseen by adminstrator or designee. The person-centered transfer status for evacuation will be detailed in the service plan for staff. Signatures of consent will be scanned into the resident record. Residents will participate in the fire drills every other month to educate them on our process and provide reassurance.  Documentation of resident participation will also be recorded and scanned into the resident record. Facility will be in compliance by 4/12/2024. Each resident's POA will be notified of Fire & Life Safety requirements and individualized evacuation needs for resident upon admission, quarterly and with significant changes during care conference. Residents who moved in prior to implementation of this system will receive a Fire & Life Safety Document that details how we will evacuate, where we will evacuate in the event of a fire or other emergency requiring evacuation. This will be given to resident and POA for signature by administrator or designee and will be completed on or before 4/12/2024.  Completion of this task will be overseen by adminstrator or designee. The person-centered transfer status for evacuation will be detailed in the service plan for staff. Signatures of consent will be scanned into the resident record. A new resident will receive a Fire & Life Safety Document that details how we will evacuate, where we will evacuate in the event of a fire or other emergency requiring evacuation. This will be given to resident for signature by care coordinator or designee upon admission within 24 hours. Completion of this task will be overseen by adminstrator or designee. The person-centered transfer status for evacuation will be detailed in the service plan for staff. Signatures of consent will be scanned into the resident record. Residents will participate in the fire drills every other month to educate them on our process and provide reassurance.  Documentation of resident participation will also be recorded and scanned into the resident record. Facility will be in compliance by 4/12/2024. There are no detail notes for this visit.”

“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 C 330, and C 361. 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 C 330, and C 361. Refer to C330 and C361 Refer to C330 and C361 There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to: Facility laundry rooms were observed from 02/12/24 through 02/13/24, and identified the following: 1. Interviews with Staff 14 (CG) and 16 (CG) indicated they used the flushing rim clinical sink to rinse soiled linens and soiled clothing, then items were placed in washer. They stated detergent was automatically released into washer from wall units, and no additional agents were added. They stated they were not instructed on which wash cycle to select and if any chemical disinfectant was to be added to the washer. 2. During an interview on 02/13/23, Staff 4 (Plant Operations Director) was unable to confirm whether there was a chemical disinfectant in the detergent or whether the machines being used provided a minimum rinse temperature of 140 degrees F. The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (Administrator) on 02/14/24. He acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to: Facility laundry rooms were observed from 02/12/24 through 02/13/24, and identified the following:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to: Refer to C 160, C 231, C 361, C 420, C 422, and C 530. Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to: Refer to C 160, C 231, C 361, C 420, C 422, and C 530. See above plan of correction plan, for C 160, C231, C361, C420, C422, and C530. See above plan of correction plan, for C 160, C231, C361, C420, C422, and C530. Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. The facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety or welfare of residents. Resident 4 received inaccurate food textures and liquid consistencies which placed them at risk for aspiration, choking, and/or death. This is a repeat citation. Findings include, but are not limited to: Refer to: C 160, C 295, and C 361. Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. The facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety or welfare of residents. Resident 4 received inaccurate food textures and liquid consistencies which placed them at risk for aspiration, choking, and/or death. This is a repeat citation. Findings include, but are not limited to: Refer to: C 160, C 295, and C 361. Refer to C 160, C 295 and C 361. Refer to C 160, C 295 and C 361. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 302, and C 330. Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 302, and C 330. See above plan of correction for C 260, C 270, C 302, and C330. See above plan of correction for C 260, C 270, C 302, and C330. Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 303 and C 330. Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 303 and C 330. Refer to C 303 and C 330. Refer to C 303 and C 330. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Resident 1 and 2's service plans and evaluations were reviewed. There was no documented evidence the facility had fully evaluated the residents': * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions, if necessary. On 02/15/24, the failure to ensure all residents had individualized activity plans developed and implemented, based on their activity evaluations, was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator) on 02/15/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Resident 1 and 2's service plans and evaluations were reviewed. There was no documented evidence the facility had fully evaluated the residents': * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions, if necessary. On 02/15/24, the failure to ensure all residents had individualized activity plans developed and implemented, based on their activity evaluations, was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (RN, Assistant Director of Health Services), and Staff 19 (Health Services Quality Coordinator) on 02/15/24. They acknowledged the findings. Resident #1 and Resident #2 service plans were reviewed and updated to highlight individualized life enrichment needs by Health Services Administrator immediately after findings. Resident service plans will be updated to highlight specific activities of choice during waking hours. This will cover physical and emotional information. Each resident will be evaluated upon admission, and quarterly thereafter by Life Enrichment team, and overseen by Health Services Administrator or designee. This information will be transposed into service plan by resident service(s) coordinator or designee. Resident #1 and Resident #2 service plans were reviewed and updated to highlight individualized life enrichment needs by Health Services Administrator immediately after findings. Resident service plans will be updated to highlight specific activities of choice during waking hours. This will cover physical and emotional information. Each resident will be evaluated upon admission, and quarterly thereafter by Life Enrichment team, and overseen by Health Services Administrator or designee. This information will be transposed into service plan by resident service(s) coordinator or designee. There are no detail notes for this visit.”

“The findings of the kitchen inspection, conducted 11/07/23, 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. The findings of the kitchen inspection, conducted 11/07/23, 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.”