The findings of the re-licensure survey conducted 03/27/23 through 03/29/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004.

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 03/29/23, conducted 06/27/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, included determined actions or interventions needed, the determined actions or interventions were documented and communicated to staff on each shift, and had documentation of progress at least weekly until the condition resolved for 1 of 2 sampled residents (#2) who were reviewed for falls. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 04/2019 with diagnoses including Alzheimer's disease and peripheral neuropathy.

Progress notes dated from 12/01/22 through 03/26/23, the service plan dated 02/10/23, Temporary Service Plans (TSP) dated from 12/09/22 through 03/20/23, and incident reports dated from 12/04/22 through 03/20/23 were reviewed. The resident was observed and staff were interviewed.

Resident 2 was observed in common use areas throughout the survey. The resident was either within eye sight of staff or was checked on consistently. Resident 2 appeared calm and friendly with staff and attempts to ambulate independently were not observed.

On 03/28/23 at 11:34 am, two staff members assisted the resident with a transfer with his/her front wheeled walker while reminding him/her it was time for lunch. At 11:42 am, Staff 4 (RCC) verified Resident 2 had not fallen during the day shift during the past three months and the resident had to be checked on four to six times per shift and have his/her walker within reach.

The resident had documentation of falls on the following dates and times:

* 12/04/22 at 8:42 pm;

* 12/09/22 at 5:10 am;

* 01/12/23 at 2:25 am; and

* 03/20/23 at 12:55 am.

The fall interventions in Resident 2's service plan were to ensure the walker was "at the head of [his/her] bed at night" and "staff to provide safety checks 4 - 6 times per shift" to "anticipate [the resident's] needs."

There was no documented evidence the facility evaluated Resident 2 after each fall in order to determine if additional actions or interventions were needed, the actions or interventions were communicated to staff on each shift or had documentation of progress at least weekly until the condition resolved.

The need to ensure changes of condition were evaluated to determine and document what resident specific action or intervention was needed, communicate the determined action or intervention to staff on each shift, and document the progress at least weekly until the condition resolves was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Director of Operations) on 03/29/23. They acknowledged the findings.  

C270

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

1. Immediate actions taken to correct this rule violation include the following:

Resident #2- A root cause analysis and appropriate follow up has been completed related to residents' additional actions or interventions needed related to falls. Focused on review of potential cause of falls, and effectiveness of current interventions due to multiple falls in the past. Nursing to ensure there is a plan in place to minimize risk of falls or severity of injury with falls. Nursing to review for effectiveness on a weekly basis and make changes to plan as necessary.

2. To ensure this system will be corrected so this violation will not happen again, the community will follow the 24-hour communication system.

    a. Shift to Shift Communication Log

    b. Alert Charting Log

    c. Temporary Service Plan

    d. Significant Change of Condition Log

Staff will follow Short Term Monitoring / Communication System for any resident identified to have an acute change of condition such as UTI, missed medication, return from hospital, and / or fall for example. When a change of condition is identified, staff add resident to alert log to ensure monitoring of the resident and identify when to report concerns to the licensed nurse or MD per the temporary service plan (TSP) that has been put in place, which correlates with the resident's change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs / symptoms to report and staff signatures acknowledging they have read and understand the TSP. Staff should monitor resident status until resident condition resolves and they are back at their baseline.

24-hour process will be reviewed daily during stand-up meeting as a means of identification of potential significant change that needs to be assessed by the RN.

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. The Administrator and Registered Nurse will be responsible for ensuring the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were maintained in good repair. Findings include, but are not limited to:

The courtyard of the RCF was observed during survey.

The pathways within the interior courtyard had multiple drop-offs ranging from approximately one to two inches from the sidewalk to the planting bed. The drop-offs created a potential fall hazard for residents who used the courtyard.

On 03/28/23, the drop-offs were shown and discussed with Staff 1 (Administrator) and Staff 3 (Director of Operations). They acknowledged the findings.

C510

OAR 411-054-0200 (3) General Building Exterior

1. Immediate action taken to correct this rule violation includes initiating follow up on area of non-compliance identified during survey to ensure exterior pathways within the interior courtyard are maintained in good repair.

Egress from the sidewalk to the adjacent planting beds have been filled in with gravel and bark mulch.

2. To ensure the system will be corrected so this violation does not happen again by; completing consistent environmental audits and providing all staff with an in-service on identifying and reporting potential hazards.

Any concerns with exterior pathways or outside areas will be identified and followed up in a timely manner.

3. The area needing correction will be monitored and observed daily, weekly, and on a monthly basis with an environmental audit.

4. The Maintenance Director and Administrator will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the design of the RCF supported special resident needs relating to the installation of handrails at one or both sides of resident-use corridors. Findings include, but are not limited to:

The interior of the building was toured on 03/27/23. Corridors to resident rooms from common areas and corridors to side exits of the community were observed without a handrail on at least one side of the corridor.
 

On 03/28/23, the need to ensure handrails were installed along resident use corridors were shown and discussed with Staff 1 (Administrator) and Staff 3 (Director of Operations). They acknowledged the findings.

C511

OAR 411-054-0200 (4) (a-b) General Building Interior

1. Immediate action taken to correct this rule violation include initiating follow up on area of non-compliance identified during survey to ensure corridors to resident rooms from common areas and corridors to side exits of the community have handrails.

Handrails have been installed on the second and third floors.

2. To ensure the system will be corrected so this violation will not happen again by completing consistent environmental audits.

Any areas identified needing corrections will be followed up on in a timely manner.

3. The area needing correction will be monitored and observed weekly and monthly with environmental audits.

4. The Maintenance Director and Administrator will be responsible to ensure corrections are completed and monitored.