The findings of the re-licensure survey, conducted 06/21/22 through 06/22/22, 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

MCCMemory 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

1) Deep cleaning of the areas noted was conducted on 6/24-7/12.  Repairs will be completed by 7/29/22.

2) Routine kitchen walk throughs and review of cleaning schedules

3)  Weekly

4) Dining Services Director with oversight by Executive Director

The findings of the first re-visit to the re-licensure survey of 06/22/22, conducted 10/19/22 through 10/20/22, are documented in this report. It was determined the facility was in substantial compliance with the the 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 maintain the kitchen clean and in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

During a tour of the kitchen on 06/21/22, the following areas were observed to be in need of cleaning and/or repair:

* There were black smudges, drips, and spills on the walls and doors throughout the kitchen;

* Black matter, smudges, and debris were observed on the floors throughout the kitchen, with increased build-up in corners and bases of the walls, tables, counters, and shelving units;

* There were multiple areas where the seams of the linoleum flooring had separated;

* The utility room mop sink had black matter on the inside and at the base;

* The shelves in the stainless steel freezer had peeling paint;

* There was black matter on the caulking behind the dishwasher and the food preparation sink; and

* The refrigerator in the activity room had holes on the outside of the door.

The need to ensure the kitchen was maintained clean and in good repair was discussed with Staff 1 (Executive Director) on 06/21/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation for 1 of 1 sampled resident (#5) who had recently been admitted. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2022 with a diagnosis of dementia. A review of his/her move-in evaluation, dated 05/21/22, revealed the following required elements were not addressed:

* Cognition, including memory, orientation, confusion, and decision-making abilities;

* Housework;

* Transportation;

* How the resident expresses pain or discomfort;

* List of treatments, including type, frequency, and level of assistance needed; and

* Unsuccessful prior placements.

The need to address all required elements on the move-in evaluation was discussed with Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4 (Chief Operations Officer), Staff 5 (Regional Director of Operations), and Staff 6 (Administrator) on 06/22/22. They acknowledged the findings.

1) Community Pre-move in eval form was updated with missing items as of 6/22/22.  

2)  Education completed with Executive Director and Designee to assure undertanding to completing all sections on this form to be compliant.  Pre-move in evaluations will be reviewed for all new incoming residents to assure completion.

3) Within 48 hours of move in

4) Assisted Living Director with Executive Director oversight

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, were followed by staff, and/or were not updated quarterly for 2 of 3 sampled residents (#s 1 and 4). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 05/2021 with diagnoses including cerebral vascular accident with left side hemiplegia.

Observations of the resident, interviews with staff and the resident, and review of the care plan, dated 06/02/22, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed in the following areas:

* Padding under left arm when in wheelchair;

* Seat belt buckled when in wheelchair;

* Side rails on bed with instructions for monitoring and safety;

* Significant weight change;

* Bed baths;

* Non-pharmaceutical interventions for pain;

* Application of barrier cream with all incontinent cares;

* Call light in reach at all times; and

* Clear cup with straw at bedside.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Executive Director), Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4 (Chief Operations Officer), Staff 5 (Regional Director of Operations), and Staff 6 (Administrator) on 06/22/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2005 with diagnoses including chronic heart failure and diabetes.

Review of the resident's current service plan and an interview with staff revealed the service plan was not updated quarterly.

The current service plan was dated 06/13/22 and indicated the last service plan update was on 01/04/22. In an interview on 06/21/22, Staff 2 (Area Manager) reported the resident's service plan had not been updated between 01/2022 and 06/2022.

The need to ensure service plans were updated quarterly was discussed with Staff 2, Staff 3 (Director of Health Services, Staff 4 (Chief Operations Officer), Staff 5 (Regional Director of Operations, and Staff 6 (Administrator) on 06/22/22. They acknowledged the findings.

1) Service plans for sampled residents #1 & #4 were updated to reflect all care needs and clear direction for staff to follow.  Remaining residents service plans will be reviewed for accuracy and detailed contents.

2)  Routine review of alert charting, occurrence reports, outside provider visit notes and other resident care related documentation to determine the need for any Temporary Care Plans and/or service plan updates.   Resident service plans will be updated routinely in accordance with community policy.  Completion of routine Care Giver Skills observations using the Caregiver Skills Observation tool.

3) Daily review of resident related documentation, service plan updates every 90 days or with a significant change of condition, Caregiver skills observations completed quarterly and Weekly review of upcoming service plan meetings

4) Executive Director and Assisted Living Director.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team which included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 1, 3, and 4 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team.

On 06/22/22, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Executive Director), Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4 (Chief Operations Officer), Staff 5 (Regional Director of Operations), and Staff 6 (Administrator). They acknowledged the findings.

1) The community has reinstated its service planning policy to include creation of the service plan update schedule, resident/responsible party notifications and service plan review process to prepare for upcoming meetings.  Current residents SPs will be reviewed/signed by 8/21/22.

2) Executive Director and Assisted Living Director will meet routinely to assure service plan calendars are maintained/followed, notifications are being sent out timely. verify to assure signatures are present for the attendees of the SP meeting and that the RN has reviewed the serviceplans.

3) Weekly

4) Executive Director, Assisted Living Director, Nurse

Based on interview and record review, 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 MAR and Controlled Substance Disposition log were reviewed for accuracy. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2005 with diagnoses including chronic heart failure and diabetes.

A review of the resident's 06/01/22 through 06/21/22 MAR, physician orders, and Controlled Substance Disposition log and staff interviews identified the following discrepancies:

* The resident had a physician's order, signed on 04/24/22, for oxycodone (a narcotic pain reliever) 10 mg "give 2 tablets by mouth four times daily as needed for pain," which was on the MAR.

* The oxycodone order in the Controlled Substance Disposition log and on the medication card was for "5 mg take 1 tablet by mouth every 6 hours as needed."

* In the Controlled Substance Disposition log, between 06/01/22 and 06/21/22 staff documented removing oxycodone from the medication card as follows:

- 06/06/22: two tablets at 7:41 [a.m. or p.m. is not indicated] and two tablets at "11:22P";

- 06/07/22: two tablets at "12:46p";

- 06/08/22: one tablet at 2:06 [a.m. or p.m. is not indicated];

- 06/14/22: two tablets at "4pm";

- 06/15/22: two tablets at "945AM" and two tablets at 9:57 [a.m. or p.m. is not indicated]; and

- 06/19/22: one tablet at "810pm."

* The 06/01/22 through 06/21/22 MAR indicates the resident was administered oxycodone on the following dates:

- 06/02/22;

- 06/04/22;

- 06/06/22 - twice;

- 06/07/22;

- 06/08/22;

-06/14/22; and

- 06/15/22 - twice.

The documented administration of oxycodone on 06/02/22 and 06/04/22 was not reflected in the narcotic disposition log.

In an interview with Staff 16 (MT), she stated staff "always give [him/her] two pills." Staff 4 (Chief Operations Officer), in an interview on 06/22/22, indicated she thought the order on the MAR for oxycodone 10 mg, "give 2 tablets by mouth four times daily as needed for pain" meant they should administer a total of 10 mg for each dose. She reported she believed staff were administering two 5 mg tablets of oxycodone because the order on the MAR was for two tablets.

Staff 3 (Director of Health Services) reported on 06/22/22 she had spoken with the resident's physician's office; she indicated they were not sure what the resident's oxycodone order was supposed to be.

The number of tablets remaining on the medication card matched the number of tablets indicated in the disposition log.

The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 2 (Area Manager), Staff 3, Staff 4, Staff 5 (Regional Director of Operations), and Staff 6 (Administrator) on 06/22/22. They acknowledged the findings. No additional documentation was provided.

1) Res #1:  Orders have been clarified with the MD and MAR updated.  Remaining residents on narcotics have had records reviewed to assure orders are accurately reflected on the MAR and Narcotic tracking log.  

2) Training has been provided to Med Tech staff on the triple check system for med pouring and steps to take when orders don't match labels.  Oversight will be provided through routine order transcription review and MAR audit processes.

3)Order transcription review occurrs daily.  MAR audits are conducted twice monthly.  Narcotic audits are conducted with sampling weekly.

4) Assisted Living Director/Nurse with ED oversight   

Based on  interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and failed to have written orders in the resident's chart for 1 of 3 sampled residents (#1) whose MAR and physician orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2005 with diagnoses including chronic heart failure and diabetes.

The resident's facility record, including the 06/01/22 through 06/21/22 MAR and physician orders signed 04/24/22, was reviewed and staff were interviewed. The following was identified:

1. The resident had an order for Xarelto (a blood thinner), 20 mg tablet, "give 1 tablet by mouth once daily indefinitely." In a fax dated 04/18/22, the physician indicated "hold Xarelto for 2 weeks."

There was no documented evidence the physician had discontinued Xarelto, and it was not on the 06/01/22 through 06/21/22 MAR.

In an interview on 06/22/22, Staff 3 (Director of Health Services) reported she was unable to find an order to discontinue Xarelto and was not sure why it was not on the MAR.

2. The 06/01/22 through 06/21/22 MAR indicated the resident was supposed to be administered cephalexin (an antibiotic) 500 mg, one capsule three times a day, and metronidazole (an antibiotic) 250 mg, two tablets twice daily.

There were no signed physician orders for these medications in the resident's chart.

The need to follow physician or other legally recognized practitioner orders as prescribed and to have written orders in the resident's chart for all medications the facility was responsible to administer was discussed with Staff 2 (Area Manager), Staff 3, Staff 4 (Chief Operating Officer), Staff 5 (Regional Director of Operations), and Staff 6 (Administrator) on 06/22/22. They acknowledged the findings. No additional information was provided.

1) Res #1:  Clarification on noted orders was obtained from PCP.  Requests sent to PCP for signed orders for the two noted medications. A review of remaining residents orders was conducted to assure accuracy and presence of signed orders.

2) Re-education provided to Med Techs on the need for signed orders for all medications given to a resident.  Routine order transcription review will be used to track new/changed orders and verify reciept of MD signature.

3) Order transcription review will be conducted daily

4) Med Techs, Assisted Living Director/Nurse with ED oversight

Based on interview and record review, it was determined the facility failed to ensure the MAR was accurate for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2005 with diagnoses including chronic heart failure and diabetes.

A review of the resident's 06/01/22 through 06/21/22 MAR, physician orders, and progress notes dated 03/24/22 through 06/17/22 was completed, as well as interviews with staff.

Documentation on the MAR between 06/07/22 and 06/20/22 for cephalexin and metronidazole (both antibiotics) was inconsistent related to availability and administration of the medications.

The need to ensure MARs were accurate was discussed with Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4 (Chief Operations Officer), Staff 5 (Regional Director of Operations), and Staff 6 (Administrator) on 06/22/22. They acknowledged the findings.

1) Res #1:  Clarification of doses given was completed for the two noted medications.  A MAR audit was completed for all remaining residents to verify meds were being given as per MD orders.

2) Re-education provided to MT's on following MD orders with a focus on short term/time limited medications along with the order transcription process.  Routine order transcription review, daily review of medication pass exceptions and routine MAR audits will be conducted for oversight.

3)  Daily order transcription review, daily med pass exceptions review and twice  monthly MAR audits

4) Med Tech, Assisted Living Director and Nurse with ED oversight.  

Based on interview and record review, it was determined the facility failed to ensure there was a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 2 sampled residents (#2) who self-administered medications. Findings include, but are not limited to:

Resident 2 was discharged from the hospital to the facility in 06/2022.

During the acuity interview, Resident 2 was identified as self-administering his/her medication. The facility provided a copy of the self-administration of medication evaluation, completed 06/12/22, but was unable to provide a written order for self-administration.

In an interview with Staff 4 (Chief Operating Officer), she stated they did not have a physician's order for the resident to self-administer medications.

The need to have a written order from a physician or other legally recognized practitioner for a resident to self-administer medications was discussed with Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4, Staff 5 (Regional Director of Operations), and Staff 6 (Administrator). They acknowledged the findings.

1) Res #2:  Orders obtained from the PCP as of 6/24/22.  A review was conducted of all other residents who self administer medications to verify presence of signed order.

2) Routine reviews will be conducted for residents self admininstering medications to verify presence of signed MD orders.

3) Upon move in and at least monthly thereafter

4) Assisted Living Director/Nurse with oversight of Executive Director.

Based on interview and record review, it was determined the Administrator failed to have 20 hours of documented, Department-approved continuing education credits each year. Findings include, but are not limited to:

On 06/22/22, the facility provided the administrator's license and continuing education documentation. A review of the documents revealed the administrator did not have 20 hours of continuing education credits.

In an interview on 06/22/22, Staff 6 (Administrator) verified she did not have enough continuing education credits.

The need to ensure the Administrator had documented evidence they had completed the required amount of continuing education credits was discussed with Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4 (Chief Operating Officer), and Staff 6 (Administrator) on 06/22/22, and with Staff 1 (Executive Director) on 06/23/22. No additional information was provided.

1) Missing CEU's completed as of 6/29/22.

2) Routine audits of ED or Designee employee file to assure CEU's are done timely for each annual time period.

3) MOnthly

4) Executive Director or Designee

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 10, 11, and 15) completed all required pre-service orientation and pre-service dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:

Review of training records on 06/22/22 revealed the following:

1. There was no documented evidence Staff 10 (MT), Staff 11 (CG), or Staff 15 (MT), hired 03/16/22, 04/03/22, and 05/12/22, respectively, completed one or more of the following required pre-service orientation topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures; and

* Written job description.

2.  There was no documented evidence Staff 10 or Staff 11 completed one or more of the following required pre-service orientation topics:

* The dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses;

* Strategies for addressing social needs of persons with dementia and engaging them in meaningful activities; and

* Specific aspects of dementia care, including addressing pain, providing food/fluids, preventing wandering, and using a person-centered approach.

The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1 (Executive Director), Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4 (Chief Operations Officer), Staff 5 (Regional Director of Operations), and Staff 6 (Administrator) on 06/22/22. They acknowledged the findings.

1) Staff #10, 11 & 15:  MIssing items will be obtained by 7/22.  An audit will be conducted of remaining staff to verify presence of required training and associated documentation.

2) ED has reviewed current training requirements to assure understanding.  Routine ongoing audits of employee training files will be completed for oversight.

3) Employee training files will be reviewed upon completion of the new hire process and at least monthly thereafter.  

4) Executive Director or Designee.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 10, 11, and 15) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records reviewed on 06/22/22 revealed the following:

There was no documented evidence Staff 10 (MT), Staff 11 (CG), or Staff 15 (MT), hired 03/16/22, 04/03/22, and 05/12/22, respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLS;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

* Conditions that require assessment, treatment, observation, and reporting:

* Medication pass; and

* First aid/abdominal thrust.

Staff 4 (Chief Operations Officer) reported that Staff 15 (MT) no longer worked at the facility. Review of Resident 1's MAR revealed Staff 15 had administered medication as recently as 06/20/22 without documentation she was competent to do so.

The need to ensure  newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 2 (Area Manager), Staff 3 (Director of Health Services), Staff 4 (Chief Operations Officer), Staff 5 (Regional Director of Operations), and Staff 6 (Administrator) on 06/22/22. No further documentation was provided.

1) Staff #15 is no longer employed.  Staff # 10 & 11:  Skills checklists (compentency) will be completed as of 7/27 when they return from leave .  An audit was conducted of remaining staff to verify completion of competencies (aka skills check lists) in conjunction with their job title.  

2) Routine audits will be conducted of employee training files to verify completion/complaince.

3) Employee training files will be audited upon completion of the initial training process and at least monthly thereafter.

4) Executive Director/Designee.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 06/22/22 identified the following deficiencies:

There was no documented evidence Fire and Life Safety instruction was provided to staff on alternating months.

On 06/22/22 the need to provide fire and life safety instruction to staff, in accordance with the OFC, was discussed with Staff 1 (Executive Director), Staff 2 (Area Manager), and Staff 3 (Director of Health Services). They acknowledged the findings.

1) New Maintenance Director and ED have created the monthly Fire Drill schedule to assure compliance.

2) Routine review of fire drill documentation to verify completion.

3)  Fire Drill documentation will be reviewed monthly

4) Executive Director and Maintenance Director  

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 06/22/22 identified the following deficiencies:

There was no documented evidence annual training on fire safety was provided to residents.

On 06/22/22 the need to provide and document fire safety instruction to residents at least annually, in accordance with the OFC, was discussed with Staff 1 (Executive Director), Staff 2 (Area Manager), and Staff 3 (Director of Health Services). They acknowledged the findings.

1) Training will be provided to all current residents by 8/21/22.  Annual training will be added to the Fire Drill calendar for ongoing scheduling.  

2) ED has reviewed expectations and scheduling of such with the Maintenance Director to assure understanding.  ED and Maintenance director will provide routine reviews to assure annual training is completed.

3) Weekly

4) Executive Director and Maintenance Director

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

During a tour of the environment on 06/21/22, multiple drop-offs of up to 2-4 inches were observed along exterior pathway edges.

The need to ensure pathways were maintained and did not present a potential tripping hazard for residents was discussed with Staff 1 (Executive Director) on 06/6/21/22. She acknowledged the findings.

1) Bark dust was brought in and issues corrected on 6/22/22.  

2) Routine walk throughs will be conducted of the exterior grounds to identify any needed corrections/repairs.

3) Monthly

Executive Director/Maintenance Director.