The findings of the re-licensure survey, conducted 10/03/23 through 10/05/23, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 revisit to the re-licensure survey of 10/05/23, conducted 02/06/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

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 to staff for 1 of 2 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the memory care community in May of 2023 with diagnoses including vascular dementia with behavioral disturbance.

Observations of the resident, interviews with staff between 10/03/23 and 10/05/23, review of the service plan, dated 09/28/23, and charting notes, dated 07/03/23 through 10/03/23, showed 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:

* Physically aggressive behaviors and interventions; and

* Two person assist with toileting, incontinence care, and showering.

The need to ensure service plans reflected the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN),

Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings.

Template used for service plan has been updated to reflect issues with agitation and aggression during personal care, a new service plan has been developed reflecting his  needs during personal care if agitation and aggression is an issue and addresses how staff should respond in those instances.

The template is used for all facility residents' service planning and will address any potential aggression and agitation concerns in personal care.

These issues will be addressed with every service plan, for every resident, as specified by OAR.

The service plan is updated and implemented by the Service Planning Team which includes the RN and Administrator and may also include the Back-Up Managers and care partners.

Based on interview, observation, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (#2) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 2 moved into the memory care community in July of 2023 with diagnoses including vascular dementia and mood disturbance.

Review of the resident's monthly weight records from 08/02/23 through 09/26/23 showed the following:

The resident experienced an 8.0 pound weight loss from 08/08/23 to 09/19/23, which constituted a 6% weight loss in one month. The resident weighed 132 pounds on 08/08/23 and 124 pounds on 09/19/23.

In an interview with Staff 2 (Officer/RN) on 10/03/23, she reported she was not aware of the weight loss because she was on vacation. She stated she had not been informed of the weight loss upon return.

A current weight and RN assessment was requested and provided on 10/4/23. The resident weighed 124.6 on 10/4/23 and was observed eating 100% of meals during the survey. Staff 2, Staff 6 (CG), and Staff 8 (CG), all reported Resident 2 had a good appetite except for the time period s/he had COVID, which coincided with the weight loss.

On 10/05/23 the need to ensure the facility RN completed an assessment for all residents who experienced significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer). They acknowledged the findings.

ata will be analyzed monthly for changes in weight for each resident.  The Administrator and RN will work in conjuction to analyze and address changes in weight. At the beginning of each month they will review previous month's weights for changes in weight.  Weights reviewed will be previous 30 days, 90 days, and 6 month time span.

An alert from the Facility Calendar will prompt a review of the monthly weights, as will a monthly task in the internal data system.

This will be implemented and monitored by the Administrator and RN.

Weight calculator template designed to help review weight changes.

Providers will continue to be notified for any changes in weight per OAR guidelines.  

Based on interview and record review, it was determined the facility failed to ensure facility management or the licensed nurse were notified of the services provided by the outside provider and ensure recommendations made by outside providers were communicated to staff and the service plan adjusted for 1 of 2 sampled residents (#2) who received services from an outside provider. Findings include, but are not limited to:

Resident 2 moved into the memory care community in July of 2023 with diagnoses including vascular dementia and mood disorder.

During the acuity interview on 10/03/23, Resident 2 was identified as having recently received HH PT and speech therapy services. Staff 1 (Administrator) reported outside service provider notes were contained in the electronic chart notes and entered directly into the computer by outside providers. The resident's 07/31/23 through 10/03/23 progress notes were reviewed and identified the following:

* A HH speech therapy note on 08/10/23 stated, "Supervise (intermittent ok) to cue swallow before talking, use slow rate, swallow bites/sips completely."

* A HH PT note on 08/21/23 stated, "Recommend...PROM program to gently stretch hips and knees (30 second holds, 3-5 repetitions, 2 times per day)."

There was no documentation these recommendations had been reviewed by facility management or the licensed nurse, had been communicated to staff, or the service plan updated.

In an interview on 10/05/23, Staff 3 (Officer/RN) reported the process for informing the Administrator and RN's of outside provider visits involved a staff member logging onto the computer for the outside provider and designating the note as "Important," which would send the note to all the administrative staff. The HH notes on 08/10/23 and 08/21/23 were designated as "Low." Staff 3, Staff 2 (Officer/RN), and Staff 1 confirmed that they would not have seen these outside provider notes because of the designation.

The need for the facility to coordinate on-site health services with outside service providers was discussed with Staff 1, Staff 2 , Staff 3, and Staff 4 (Officer) on 10/05/23. They acknowledged the findings.

Training will take place during Staff meeting to ensure that all staff are marking progress notes as important prior to providing the outside provider the computer to document progress notes in our EMAR system.

All outside provider notes will be reviewed by the Back-Up-Manager, Administrator, or Administrative Designee. They will review all outside provider notes at time of service to ensure they are properly recorded as 'Important'.

The RN will review all outside provider notes and update service plans as necessary.

On-going monitoring will happen by Administrator and RN.

Process established and implemented for outside provider notes and posted in employee office.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for residents. Findings include, but are not limited to:

On 10/05/23 at 10:00 am, incontinence care for Resident 2 was observed to determine adherence to universal precautions for infection control.

Staff 8 (CG) was observed to don gloves prior to the task. After performing incontinence care, Staff 8 touched the resident's clean brief, 4 bed pillows, bolster pillow, and clean sheets and comforter prior to doffing gloves. After doffing gloves, no hand hygiene was performed and Staff 8 touched wheelchair handles, Hoyer lift handles, inside and outside doorknobs to resident room, and doorknob leading into the laundry room.

The need to ensure staff consistently used universal infection control precautions for the protection of residents was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings.

Established infection prevention protocols and sanitation measures were reviewed and additional training conducted at the monthly all Staff meeting on 10/18/2023.

Infection and Prevention Control training has been re-issued to all staff to be completed by 11/18/2023.

This will be included in our Quarterly Evaluation and Skills Checklist.

This will implemented by the Administrator and monitored by the Administrator and Back-up Managers.

Based on observation and interview, it was determined the facility failed to ensure the grounds were free of litter and refuse, and the exterior pathways were made of hard and smooth material and maintained in good repair. Findings include, but are not limited to:

Observations of the facility exterior on 10/04/23 identified the following:

* Two broken chairs, a dresser, and multiple broken slats from the gazebo were inside the gazebo; and

* The pathway around the gazebo had multiple cracks across the pathway, including drop-offs which created a potential tripping hazard for residents.

These findings were reviewed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings.

1.The upper area including the gazebo had a sign placed at the entrance of the area that states "Authorized Personell Only" and a chain to rope off the parking lot that states "Danger Do Not Enter." This area is for staff use only. All litter and dysfunctional furniture/appliances have been removed from the premises. Staff was informed of these changes at the all staff meeting on 11/18/2023.

2.The upper area including the gazebo had a sign placed at the entrance of the area that states "Authorized Personell Only" and a chain to rope off the parking lot that states "Danger Do Not Enter.". Staff was reminded of this at the all staff meeting on 11/18/2023. Administrator will do weekly walk-throughs of the outside premises to ensure there is no garbage or debris.

3. Administrator will do weekly walk-throughs to ensure there is no garbage or debris outside.

4. The Administrator will be responsible for ensuring all staff is aware that no residents are allowed in the upper areas referred to in POC. The Administrator will also be responsible for making sure there is no garbage or debris on the outdoor premises.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were maintained in good repair. Findings include, but are not limited to:

The interior of the facility was toured on 10/03/23.

Door frames throughout the facility, including resident rooms and common use bathrooms, had scrapes and gouges, exposing bare wood.

This finding was reviewed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the door frames needed repair.

All door frames with gouges will be repaired/replaced. This will be implemented by David Schill, owner and maintained quarterly.

Based on observation and interview, it was determined the facility failed to ensure the soiled linen room or area included a flushing rim clinical sink with a handheld rinsing device and a hand wash sink. Findings include, but are not limited to:

During a tour of the laundry room on 10/03/23 it was observed there was only one standard sink in the laundry room.

In an interview with Staff 7 (Caregiver), she reported that any waste matter on soiled linens, if applicable, was dumped into one of the shared facility bathroom toilets, then soaked in designated tubs in the laundry room sink. She stated they were washed separately from unsoiled linens, with a disinfectant added to the wash. It was observed the sink in the laundry room was also used for hand washing.

The need to install a flushing rim sink in the soiled linen area was reviewed with Staff 1 (Administrator) and Staff 3 (Officer/RN) on 10/03/23. They acknowledged the findings.

1. Sherwood Pines has requested an exception with policy analyst on process for managing potentially infectious materials (PIMs) in lieu of having a hopper.

2. Sherwood Pines' staff will follow the PIMs policy that will be included in the exception as approved by policy analyst.

3. Sherwood Pines' staff will consistently follow the PIMs policy that will be included in the exception as approved by policy analyst. This will be monitored by Management during Quarterly Evaluations.

4. David Schill (owner) and Administrator will create a PIMs policy that will be reviewed by the Infection Control Specialist and will be included in the exception to be approved by the Policy Analyst. Management will be responsible for monitoring employees to ensure this policy is being followed.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 295, C 510, C 513 and C 530.

See Plan of Corrections listed above for C 295, C 510, C 513 and C 530

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 280, and C 290.

See Plan of Corrections listed above for C 260, C 280 C 290.

Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed based on the activity evaluations for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's records were reviewed, and staff were interviewed. There was no documented evidence activity evaluations were completed which addressed the following required components:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations needed to participate; and

* Identification of activities for behavioral interventions.

There was no documented evidence specific activity plans were developed which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings.

Life history form will now be required to be filled out by family prior to admission rather than as an optional form. This will aid RN/Administrator/Activity Director in addressing all required components and individualized activity plans per OAR requirements. Each resident will be evaluated using an established Activities Evaluation. This evaluation and an Activities Plan will be revised with each care plan update. The Administrator will monitor this process.