The findings of the re-licensure survey, conducted 09/26/23 through 09/28/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily 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

The findings of the revisit to the re-licensure survey of 09/28/23, conducted on 01/23/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 1 of 4 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in September 2018 with dementia.

Review of Resident 3's 9/15/23 service plan, observations, and interviews with staff identified the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Transfers;

* Ambulation; and

* Level of assistance with meals.

On 09/28/23, the need to ensure service plans were reflective of the resident's needs and provided clear direction to staff was discussed with Staff 1 (Regional ED) and Staff 3 (RN/Wellness Director). They acknowledged the findings.

1) Service Plan for resident #3 was corrected to provide clear direction of services and ensure Service Plan is reflective of resident need.

2)All residents Service Plans are to be reviewed to ensure they are reflective of care and provide clear direction to staff.

3)RN and Ed to review at each 90 day service plan update and at time of any Change of Condition.

4) RN and ED.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 4 sampled residents (#3) whose orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2018 with diagnoses including dementia and was receiving hospice services.

Resident 3's current orders and 09/01/23 through 09/26/23 MARs were reviewed.

a. Resident 3 had orders for:

* Senna 8.6 mg daily for constipation;

* Seroquel 25 mg in the morning for anxiety;

* Acetaminophen 325 two tablets twice a day for pain; and

* Refresh liquidgel 1% one drop in each eye thee times a day.  

The medications were documented as not administered in the morning on two days because Resident 3 was sleeping. There was no evidence of staff re-attempting to give the medications.

In an interview with Staff 21 (RCC/MT), she explained each morning Resident 3 woke around 5:00 am and returned to bed around 7:30 am. She acknowledged the medications had not been administered.

b. Resident 3 had orders for coconut oil to be applied to the back.

The coconut oil and the Refresh liquidgel 1% were not documented as administered on 09/14/23.

The coconut oil was documented as not administered on 09/13/23 because Resident 3 was sleeping. There was no evidence staff re-attempted to provide the treatment.

c. Resident 3 had orders for:

* Quetiapine Fumarate 25 mg as needed for anxiety, use as first line of treatment; and

* Lorazepam 0.5 mg as needed for agitation, anxiety, use Quetiapine first.

On 09/18/23 Resident 3 was administered the Lorazepam without first attempting the Quetiapine.

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 3 (RN/Wellness Director) on 09/27/23 and 09/28/23. She acknowledged the findings.

1) All MARS will be reviewed to ensure medication and treatment orders are accurate.

2) RN/RCC will audit MARS not less than monthly to maintain compliance. MT's to be provided training specific to medication administartion including: Rights, procedures, and proper documentation.

3) This will be done no less than monthly.

4) RN/ED monthly review.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 3 of 4 sampled residents (#s 2, 3, and 5) whose MARs were reviewed. Findings include, but are not limited to:

1.  Resident 2 was admitted to the facility in 11/2020 with diagnoses including arthritis and restless leg syndrome.

Resident 2's 09/01/23 through 09/26/23 MARs and current orders were reviewed.

Resident 2 had orders for:

* Acetaminophen 500 mg as needed for mild pain;

* Gabapentin 100 mg as needed for breakthrough pain at bedtime only; and

* Oxycodone HCI 5 mg tablet as needed for breakthrough pain in legs at night.

The electronic medication record was reviewed with Staff 13 (MT) on 09/27/23. There were no specific parameters to guide non-licensed staff on which pain medication to use first.

2. Resident 3 was admitted to the facility in 09/2018 with diagnoses including dementia and anxiety, and was receiving hospice services.

Resident 3's 09/01/23 through 09/26/23 MAR and current orders were reviewed.

a. Resident 3 had the following PRN medications for bowel care:

* Glycerin suppository as needed for constipation;

* Milk of Magnesia 15 ml as needed for constipation, no bowel movement (BM) in three days;

*Polyethylene Glycol 17 gram as needed for no BM in three days; and

* Senna 8.6 mg two tablets as needed for no BM in two days, no BM in three days.

Resident 3 has instructions on the MAR to contact hospice "...when has had NO BM in 4 days. Give Senna per PRN order if no BM in 2 days. If no BM in 3 days give Senna per PRN order."  The MAR was signed daily for this bowel protocol.

The electronic medication record was reviewed with Staff 14 (MT) on 09/27/23. There were no clear parameters to guide non-licensed staff on which bowel medication to use first.

b. Resident 3 had the following PRN medications for pain management:

* Acetaminophen 325 two tablets as needed for pain; and

* Ibuprofen 600 mg one tablet as needed for pain.

The electronic medication record was reviewed with Staff 13 (MT) on 09/27/23. There were no specific parameters to guide non-licensed staff on which pain medication to use first.

The need to ensure MARs were accurate and included clear parameters to direct non-licensed staff when administering multiple PRN medications for the same condition was discussed with Staff 3 (RN/Wellness Director) on 09/27/23 and 09/28/23. She acknowledged the findings.

3. Resident 5 was admitted to the facility in 12/2020 with diagnoses including COPD.

Review of Resident 5's 09/01/2023 through 09/26/2023 MAR identified the following PRN medications lacked clear parameters:

* Polyethylene Glycol 17 grams as needed for constipation; and

* Bisacodyl 5 MG as needed for constipation.

The MAR failed to include clear parameters and instructions to unlicensed staff regarding which bowel medications should be administered first.

On 09/26/23, the need to ensure PRN medications included resident-specific parameters was discussed with Staff 3 (RN/Wellness Director) and Staff 4 (Regional RN). They acknowledged the findings.

1) MAR for residents #2, #3 and #5 have been reviewed and corrections made to ensure accuracy of medication orders  and clear, resident specific parameters for PRN medications.

2) All new Orders/MAR will be reviewed by Med tech, RCC and WD for need of PRN parameters.

3) RN and ED will review this process monthly.

4) RN and ED

2.  Resident 4 was admitted to the facility 09/2023 with diagnoses including chronic obstructive pulmonary disease and osteoporosis.

During the acuity interview on 09/26/23, Resident 4 was identified as administering his/her own medications.

The physician orders dated 08/22/23 and 08/24/23, and self medication evaluation dated 09/01/23 were reviewed, and an interview with the resident identified the following:

The resident's signed physician orders from 08/24/23 identified Resident 4 was taking the following prescribed and over the counter (OTC) medications including:

*Albuterol sulfate inhaler PRN (for wheezing);

*Alendronate sodium (for osteoporosis);

*Trelegy Ellipta (for difficulty breathing);

*Tramadol PRN (for pain); and

*Vitamin D3/folic acid (supplement).

A physician order, dated 08/22/23, indicated Resident 4 may not administer his/her own medications including narcotics and OTC medication.

Review of the record indicated the evaluation to determine the resident's ability to safely self-administer medications was completed on 09/01/23.

In an interview on 09/27/23 at 9:50 am, Resident 4 confirmed s/he was administering the medications on his/her own. Resident 4 was able to verbally state from memory all medications s/he was taking, what the medications were for, when to take them, and the precautions s/he followed when taking alendronate. Resident 4 also confirmed that s/he was no longer taking Tramadol "for the last three or four months."  

On 09/27/23 at 9:40 am Staff 3 (RN/Wellness Director) confirmed there was not a signed physician's order for Resident 4 to self administer his/her medication. "We don't have an order. But I did [his/her] assessment and [Resident 4] is cognitively able ....The doctor inadvertently said [s/he] couldn't." Requested Staff 3 contact the physician and obtained an order for Resident 4 to self-administer his/her medications. A confirmation of the fax was received on 09/28/23.

On 09/28/23, the need to ensure residents who self-administered medications had physician's orders in place was discussed with Staff 3. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who self-administered medications had physician's orders in place for 2 of 2 sampled resident (#s 4 and 5) who self-administered medications. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 12/2020 and was evaluated for the ability to safely self-administer their medications. There was no signed physician's order for approval of self-administration of medications.

On 09/27/23, the need to ensure residents who self-administered medications had signed physician's orders in place was discussed with Staff 3 (RN/Wellness Director) and Staff 4 (Regional RN). They acknowledged the findings.

1) Resident #4 and #5 self-administer physicians orders have been obtained, reviewed and updated with corrections made to ensure accuracy of self-administration of meds.

2) All self administration of resident meds will be reviewed and updated by RN/RCC to reflect accuracy of orders provided by the physician.

3)Reviewed, updated and checked accordingly at every 90 day service plan meeting with RN and RCC.

4) RN and ED

Based on interview and record review, it was determined the facility failed to ensure documented, non-pharmacological interventions had been tried, with ineffective results, prior to administering PRN psychotropic medications, for 1 of 2 sampled residents (#1) who were administered a PRN psychotropic.  Findings include, but are not limited to:

Resident 1's MAR, dated 09/01/23 through 09/26/23, was reviewed. The resident was prescribed PRN hydroxyzine 10 mg for anxiety. The medication was administered nine times in September.

In each instance, there was no documented evidence the facility attempted non-pharmacological interventions prior to considering the use of the psychotropic medication.

On 09/28/23, the need to ensure non-pharmacological interventions were attempted, with ineffective results, prior to administering psychotropic medication was discussed with Staff 1 (Regional ED) and Staff 3 (RN / Wellness Director). They acknowledged the findings.

1) MAR for resident #1 has been reviewed and corrections have been made to ensure accuracy of medication orders with clear, resident-specific non-pharmacological interventions to try prior to offering prn psychotropic medication.

2) Orders/MAR will undergo triple review process upon move-in (RN, RCC or MT). All new orders will be undergo the same process.

3) RN and ED will review this process monthly.

4) RN and ED.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents, and included all the required ABST elements.

In an interview on 09/27/23, Staff 1 (Regional ED) stated only the regular ED (Staff 2, who was not available through the entire survey) had access to the ABST information. Staff 1 stated the ODHS model was used by all company buildings, but there was no way to access the required information for this facility.

On 09/28/23, the requirement for use and documentation of an ABST tool was discussed with Staff 1 and Staff 3 (RN / Wellness Director). They acknowledged the findings.

1) ABST for all residents have been reviewed and corrections made to ensure accuracy of care, resident specific needs, time spent for included ADL's. All Current residents have been added to ABST and all past residents removed.

2) Ed or designee will ensure new residents are added to ABST upon move in as well as removing any residents at move-out appropriately. ED or designee will ensure ABST is updated no less than quarterly or as needed.

3)ED and designee will review this at least quarterly or as needed and upon change in Census.

4) ED and/or designee.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months of fire drills and that documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill records from 03/2023 through 09/2023 were reviewed on 09/27/23. The following deficiencies were identified:

* The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills; and

* The facility was not consistently relocating or evacuating residents during fire drills.

The requirements regarding fire drills, fire and life safety instruction for staff, and consistently relocating or evacuating residents during fire drills to identify if any problems were encountered was reviewed with Staff 8 (Maintenance Director) on 09/27/23. He acknowledged the findings.

The need to ensure staff received required fire and life safety training and fire drills included required components according to the Oregon Fire Code was reviewed with Staff 1 (Regional ED) on 09/28/23.  He acknowledged the findings.

1) A fire drill schedule has been created outlining which months will have fire drills and the alternating months fire and life safety instruction for staff. Fire drills moving forward  will include escape route used, evacuation time needed, number of residents evacuated, any problems encountered relating to residents choosing not to participte in drill.

2) Fire drill schedule with alternating month fire and life safety instruction for staff has been created and is kept in Fire and Life safety binder providing a full year's schedule. Each fire drill on alternating months has space included to document escape route, evacuation time, number of residents evacuated, any problems encountered with comments relating to residents choosing not to participate.

3) ED and Maintenance director will review fire and life safety on a monthly basis.

4) Ed and MD will ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to keep all interior and exterior surfaces clean and in good repair. Findings include, but are not limited to:

The interior and exterior of the building was toured on 09/26/23. The following areas needed cleaning or repair:

* Wood deck and railing outside second floor common area showed warping, rough worn areas, and peeling paint;

* Door frame leading to the deck area had damage, with splinters and gouges visible;

* Vertical wood pillars under stairs in dining room showed scratches and gouges;

* Wood doors and door frames of several resident rooms had scratches and chipped paint; and

* Floor of "Whirlpool Room" on second floor, which was accessible to staff and residents, had extensive red stains near sink.

On 09/28/23, the condition of the areas listed above was discussed with Staff 1 (Regional ED) and Staff 8 (Maintenance Director). They acknowledged the findings.

1)Wood deck, railing, door frames, wood pillars, Wood doors and frames, floor in whirlpool room will be repaired by November 27th, 2023.

2) Maintenance Director will make monthly rounds to ensure Wood deck, railing, door frames, wood pillars, Wood doors and frames, and floor in whirlpool room, stays maintained and free of gouges, chipped paint, splinters, and stains.

3)Monthly review will be completed.

4) Maintenance Director and ED.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The facility was toured on 09/26/23. Resident unit windows on the second floor opened by sliding laterally, and window sills were lower than 36 inches. The windows lacked a system which limited how far the window could be opened, to prevent accidental falls.

On 09/27/23, the lack of a window mechanism to prevent accidental falls was discussed with Staff 1 (Regional ED) and Staff 8 (Maintenance Director). They acknowledged the findings.

1) All second floor windows will be checked. Any window missing a system to limit ability to prevent accidental falls will be addressed by adding appropriate hardware.This will be completed by November 27th, 2023.

2) Maintenance director will make monthly rounds to ensure that all hardware on second floor windows is intact to prevent any accidental falls, and make corrections to hardware as needed.

3) Monthly review will be completed.

4) Maintenance director and ED.

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 they were installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

The facility was toured on 09/26/23.  With the exception of several smaller studio units, the resident apartments had wall heaters in the bedrooms, located low on the wall where a resident could come into accidental contact with it. When heaters were turned on and the temperature of the metal grill surface was measured, using the surveyor's digital thermometer, the temperatures exceeded 160 degrees F.

In an interview on 09/27/23, Staff 8 (Maintenance Director) acknowledged the issue with the heaters. He confirmed they were all on the same system throughout the building, but could be adjusted.

On 09/28/23, the temperatures of the wall heater grills was discussed with Staff 1 (Regional ED) and Staff 8 (Maintenance Director). They acknowledged the findings.

1) All cadet -style heaters will be disabled/removed to prevent accidental resident contact or injury.

2) Cadet style heaters will be removed by November 27th, 2023.

3) This will be done by November 27th, 2023.

4) ED/Maintenance Director to review each unit upon completion of project to ensure all units have been safely disabled/removed.