The findings of the re-licensure survey, conducted 02/06/24 through 02/08/24, 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 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

The findings of the first re-visit to the re-licensure survey of 02/08/24, conducted 05/29/24 through 05/30/24, 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.

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 texture. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic obstructive pulmonary disease and was identified during the acuity interview as having a recent decline and hospitalization.

Observations of meals, interviews with facility staff, and review of physician orders dated 01/18/24, service plan dated 01/03/24, RN assessment dated 01/31/24, and the Avamere ALF Standard Diets policy dated 05/2019 identified the following:

* Resident 4 had physician orders dated 01/18/24 for a "modified mechanical soft" diet texture. The resident's current service plan listed "regular easy chew" diet texture. During an interview at 1:00 pm on 02/07/24, Staff 3 (Dietary Services Manager) confirmed Avamere had diet texture guidelines. A copy of "Avamere ALF Standard Diets" was requested and received at 1:00 pm on 02/07/24. Avamere listed four "Avamere textures" that "would replace" standard modified diet textures. There was no equivalent listed for "modified mechanical soft" as ordered.

* The RN assessment completed 01/31/24 stated acknowledged, "diet orders for modified mechanical soft." During an interview at 1:42 pm on 02/07/24, Staff 2 (LPN) stated she did not know what diet orders to enter for the resident using the Avamere diet texture guidelines. During an interview at 1:45 pm on 02/07/24, Staff 4 (RN) also stated she did not know what diet orders to enter for the resident using the Avamere diet texture guidelines. Documentation the facility had communicated with the resident's physician to clarify the diet texture orders was requested at 1:50 pm on 02/07/24. Staff 2 confirmed there was no documentation to provide.

* During a lunch observation at 12:45 pm on 02/07/24, the resident was served cut-up breaded chicken and roasted potatoes covered with gravy. The resident was offered bites of the chicken by his/her spouse. S/he stated, "...it's hard to swallow...tough. I don't like to chew for an hour."

The need to ensure the resident received the appropriate therapeutic diet, as well as the need to clarify therapeutic diet orders with the legally recognized practitioner in order to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of the resident was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RN). They acknowledged the findings.

2. Resident 1 moved into the facility in 03/2023.

The resident's 01/12/24 service plan and interim service plans were reviewed, observations were made, and interviews with staff were conducted. The service plan was not reflective of the resident's current needs, lacked clear direction to staff and/or was not consistently followed by staff in the following areas:

* Use of cushions;

* Use of a Hoyer lift versus 2-person assistance with transfers;

* Use of modified plate for meal intake;

* Use of floor mattress;

* Use of heel protectors; and

* Use of an air mattress.

The need to ensure the service plan was reflective of the resident's current needs, was implemented, and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 02/08/24. The staff acknowledged the findings.

3. Resident 3 moved into the facility in 02/2023.

The resident's 01/25/24 service plan and interim service plans were reviewed, observations were made, and interviews with staff and the resident were conducted. The service plan was not reflective of the resident's current needs and lacked clear direction to staff in the following areas:

* Conflicting directions for ambulation (wheelchair versus stretcher); and

* Use of an air mattress.

The need to ensure the service plan was reflective of the resident's current needs and provided clear direction to staff was discussed with Staff 1 (Administrator),  Staff 2 (LPN), and Staff 4 (RN) on 02/08/24. The staff acknowledged the findings.

4. Resident 2 was admitted to the facility in 07/2019 with diagnoses including Parkinson's disease and Type 2 diabetes.

Observations of the resident, interviews with staff and review of the most recent service plan, dated 11/28/23, and interim service plans, 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 being implemented in the following areas:

* Environmental factors including low lighting;

* Fall interventions including perimeter guard/swim noodle for bed and locking one brake on wheelchair when not in use;

* Skin integrity prevention including foam added to wheelchair; and

* Signs and symptoms of low and high blood sugar.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RN) on 02/08/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and services were implemented for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/2023 with diagnoses including Type 2 diabetes and was identified during the acuity interview as having experienced a recent decline including weight loss. The current service plan dated 01/03/24 and interim service plans were reviewed, observations were made, and interviews with staff, the resident, and the resident's spouse were conducted. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Signs and symptoms of low and high blood sugar;

* Level of assistance for transfers;

* Pain;

* Ability to use call light;

* Cognition;

* Communication;

* Use of compression stockings;

* Level of assistance for wheelchair use;

* Level of assistance for personal hygiene and oral care;

* Bathing needs;

* Toileting;

* Use of supportive devices;

* Eating, including current diet, level of assistance, and aspiration precautions; and

* Recent weight loss.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RN) on 02/08/24. They acknowledged the findings.

2. Resident 3 moved into the facility in 02/2023 with diagnoses including hypertension.

The resident's progress notes, dated 11/06/23 through 02/03/24, and interim service plans (ISPs) were reviewed and showed the following:  

The resident had orders for the following medications:

* Losartan (for high blood pressure); and

* Atorvastatin (for high cholesterol).

Review of the resident's record indicated the medications were not administered on the following occasions:

* Losartan on 22 occasions between 12/11/23 and 01/01/24; and

* Atorvastatin on 38 occasions between 12/22/23 and 01/28/24.

There was no documented evidence the facility determined and documented what action or interventions were needed for the resident, communicated actions or interventions to staff on each shift and monitored the conditions at least weekly to resolution.

On 02/08/24, the need to ensure the resident's conditions were monitored with progress noted at least weekly, consistent with resident's evaluated needs, until resolved was discussed with Staff 1 (Administrator). The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on each shift with weekly progress noted to resolution for 3 of 4 sampled residents (#s 2, 3, and 4) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2019 with diagnoses including Parkinson's disease and Type 2 diabetes.

The resident's current service plan dated 11/28/23, progress notes dated 11/01/23 through 02/05/24, incident reports and investigations were reviewed, and staff were interviewed. The following was identified:

a. The following short-term changes of condition lacked documentation that actions or interventions were determined, documented, and communicated to staff on each shift:

* 11/17/23 - Non-injury fall;

* 12/08/23 - Return from emergency room (ER) for a fall with scalp and facial contusions;

* 01/04/24 - Return from ER with a urinary tract infection;

* 01/04/24 - Start of Cephalexin (for infection);

* 01/05/24 - Non-injury fall;

* 01/06/24 - Non-injury fall;

* 01/07/24 - Non-injury fall; and

* 01/10/24 - Non-injury fall.

b. On 01/14/24 the resident was identified to have numbness in both hands after a fall on 01/12/24. There was no documented evidence actions or interventions were determined, documented, and communicated to staff on each shift including monitoring for continued or additional numbness with weekly progress noted to resolution.   

c. On 12/16/23 the resident was started on Amlodipine for high blood pressure. There was no documented evidence actions or interventions were determined, documented and communicated to staff until 12/20/23 - four days after the change of condition.

d. On 12/30/23 the resident was started on Metoprolol (for high blood pressure) and Amlodipine was discontinued. There was no documented evidence actions or interventions were determined, documented and communicated to staff until 12/20/23 - four days after the change of condition.

e. On 01/18/24 the resident returned from the ER following a fall. The discharge diagnoses included hypoglycemia (low blood sugar).

There was no documented evidence the facility determined, documented and communicated to staff any actions or interventions, including monitoring the resident for further episodes of hypoglycemia.

f. The resident was identified as a fall risk on the service plan and progress notes indicated that s/he experienced twenty-six falls between 11/01/23 and 01/31/24. There was no documented evidence that current fall interventions were consistently monitored for effectiveness.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, fall interventions were monitored for effectiveness and the changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RN) on 02/08/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 08/2023 with diagnoses including hypertension, heart disease, and chronic obstructive pulmonary disease. The resident's 11/01/23 to 02/05/24 MARs/TARs and progress notes were reviewed and revealed the following:

The resident had orders for the following:

* Flonase (for allergies);

* Tamsulosin (for urinary symptoms);

* Wixela (for asthma);

* Pradaxa (for anticoagulation); and

* Metoprolol (for hypertension).

Review of the MAR indicated the medications were not administered on the following occasions:

* Flonase on 31 occasions between 11/05/23 and 12/30/23;

* Tamsulosin on seven occasions between 11/27/23 and 12/09/23;

* Wixela on eight occasions between 11/29/23 and 12/06/23;

* Pradaxa on 13 occasions between 12/01/23 and 12/13/23; and

* Metoprolol on 11 occasions between 12/24/23 and 01/09/24.

There was no documented evidence the facility determined and documented what action or interventions were needed for the resident, communicated actions or interventions to staff on each shift and monitored the conditions at least weekly to resolution.

The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift and conditions were monitored with weekly progress noted to resolution was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RN) on 02/08/24. They acknowledged the findings.

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 2 of 2 sampled residents (#s 1 and 3) who received incontinent care and meal assistance from staff. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 02/2023.

Observations and interviews with staff during the survey identified the resident was unable to transfer from bed and relied on staff for incontinence care needs.

On 02/07/24, at approximately 11:38 am, the surveyor obtained permission from the resident and observed Staff 7 (CG) and Staff 8 (CG) provide incontinent care for Resident 3.

During the observation, Staff 7 and 8 had gloved hands. During the observation, Staff 8 failed to change gloves after removing a soiled incontinent product and wiping fecal matter from Resident 3's perineum. Staff 8 touched a clean brief, a shirt, and blankets while wearing the same soiled gloves.

The above observation was discussed with Staff 1 (Administrator), Staff 2 (LPN) and Staff 4 (RN) on 02/08/24 at 11:45 am. The staff acknowledged appropriate infection control practices were not implemented.

2. Resident 1 moved into the facility in 03/2023.

Observations and interviews with staff during the survey identified the resident was unable to transfer from bed, relied on staff for incontinence care needs and required meal assistance.

a. On 02/07/24 at 1:00 pm, the surveyor obtained permission from the resident and observed Staff 7 (CG) and Staff 8 (CG) provide incontinent care.

During the observation, Staff 7 and 8 had gloved hands. During the observation, Staff 8 failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 1's perineum. Staff 8 touched the resident's barrier cream and applied the barrier cream to the resident's bottom then Staff 8 touched the resident's clean brief, blanket and pillows while wearing the same soiled gloves.

b. Lunch service was observed on 02/06/24 through 02/08/24. During the observation, caregiving staff provided 1-on-1 meal assistance to Resident 1. The caregiving staff were not wearing aprons or other type of barrier to prevent the potential for cross contamination when providing meal assistance.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Administrator), Staff 2 (LPN) and Staff 4 (RN) on 02/08/24. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 02/2023 with diagnoses including hypertension.

The resident's 09/26/23 physician orders, 01/01/24 to 02/06/24 MARs/TARs and 11/06/23 to 02/03/24 progress notes were reviewed.

The resident had orders for the following:

* Atorvastatin 10 mg daily "for prevent heart attack and stroke"; and

* Losartan 50 mg daily for high blood pressure.

The MAR showed the medications were not administered and noted "See Nurse Notes." The progress notes revealed Atorvastatin was not administered for 38 days, from 12/22/23 to 01/28/24 and Losartan for 22 days, from 12/11/23 to 01/01/24. Staff documented on the progress notes "waiting for med to arrive."

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (LPN) and Staff 4 (RN) on 02/08/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 4 sampled residents (#s 2, 3, and 4) whose orders were reviewed.

1. Resident 2 was admitted to the facility in 07/2019 with diagnoses including Parkinson's disease and Type 2 diabetes.

Review of the resident's physicians orders and 01/01/24 through 02/06/24 MARs identified the following:

The resident had an order for losartan potassium for elevated blood pressure and to notify the physician:

* Each time his/her blood pressure was greater than 190/100;

* Each time his/her blood pressure was greater than 160/90 two times in one week; or

* Each time his/her blood pressure was less than 100/60.

The resident's blood pressure was:

* Greater than 190/100 on five occasions between 01/12/24 and 02/06/24;

* Greater than 160/90 two times in one week on 24 occasions between 01/01/24 and 02/06/24; and

* Less than 100/60 on one occasion on 01/23/24.

During an interview on 2/07/24 at 12:30 pm, Staff 6 (MT) confirmed the facility's process was to alert the primary care physician via fax according to the parameters on the order.

There was no documented evidence the physician was notified of the blood pressure readings according to the parameters listed on the order.

The need to ensure physician's orders were followed as prescribed was discussed with Staff 1 (Administrator), Staff 2 (LPN) and Staff 4 (RN) on 02/08/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic obstructive pulmonary disease, heart disease, and hypertension. The resident's 11/01/23 to 02/05/24 MARs/TARs and progress notes were reviewed and revealed the following:

The resident had orders for the following:

* Flonase 50 mcg for allergies;

* Tamsulosin 0.4 mg for urinary symptoms;

* Pradaxa 110 mg for anticoagulation; and

* Metoprolol 25 mg for hypertension.

Staff marked the medications as "not given" on the following occasions:

* Flonase on 31 occasions between 11/05/23 and 12/30/23;

* Tamsulosin on seven occasions between 11/27/23 and 12/09/23;

* Wixela on eight occasions between 11/29/23 and 12/06/23;

* Pradaxa on 13 occasions between 12/01/23 and 12/13/23; and

* Metoprolol on 11 occasions between 12/24/23 and 01/09/24.

During an interview at 1:40 pm on 02/07/24, Staff 2 (LPN) stated MTs were responsible for ordering Resident 4's medications and they were not ordering them timely. She also stated the pharmacy was late in delivering medications. Confirmation the physician was notified of the missed medications was requested during that interview. Documentation of physician notification regarding a missed Pradaxa dose on 12/12/23 and a missed Metoprolol dose on 01/06/24 was received. No other physician communication was provided.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RN) on 02/08/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code and staff were instructed as to the designated point of safety outside the building. Findings include, but are not limited to:

Fire and life safety records, reviewed between 09/2023 and 01/2024, revealed the following:

1. 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.

2. Staff 6 (MT), 8 (CG) and 13 (MT) were interviewed on 02/08/24. None of these staff knew the designated point of safety for meeting outside the building in an evacuation.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 02/08/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed at least annually 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 and a written record of fire safety training was kept. Findings include, but are not limited to:

In an interview on 02/08/24, Staff 1 (Administrator) was asked how the facility provided periodic re-training on fire safety to residents in the Assisted Living Facility. She stated the re-training was provided at quarterly service plan meetings, however, acknowledged the facility did not currently have a process for documenting the training.

The need to ensure the residents were re-instructed at least annually on safety procedures, and the re-instruction was documented, was discussed with Staff 1. She acknowledged the findings.

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

The facility was toured on 02/06/24 at 10:50 am. The following issues were identified:

* The popcorn machine in the lower level activities room had greasy build-up and was in need of cleaning;

* Several benches in the lower level hallway had spots or stains;
* The area around the floor drain in the resident laundry room was damaged, baseboard was not attached to part of a wall, and an electrical outlet on the east wall under the window was exposed;

* Outlet covers were missing in the first floor private dining room, second floor hallway across from room 207, and exercise room;

* Weatherstripping was detached from the door frame of room 201; and

* There was debris in a ceiling light in the second floor hallway near the elevator.

The areas needing cleaning or repair were reviewed with Staff 1 (Administrator) on 02/08/24. She acknowledged the areas needed cleaning or repair.

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, and a lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident's small valuable items and funds. Findings include, but are not limited to:

1. The interior of the facility was toured on 02/06/24 and was observed to have windows with sills lower than 36 inches in all resident units and common areas on the first floor (east facing windows are above basement level) and second floor. The facility used a small metal device which attached to the window frame with a thumb screw to limit how much a window could be opened.

One of the two windows in resident room 101 lacked a limiting device on the window. In 2 of 5 additional rooms that were reviewed, the locking devices had slid all the way up to the top of the window, allowing the windows to be fully opened.
 

During a tour on 02/08/24 at 9:30 am, Staff 9 (Plant Operations) acknowledged there was no process in place to ensure the limiting devices were installed properly.

2. During a group interview on 02/06/24 at 1:30 pm, five non-sampled residents stated they did not have a lockable storage space in their apartments. Review of several random apartments and the apartments of the residents in group indicated several apartments appeared to have had new cabinets installed that did not include a locking space and resident rooms 218 and 219 had locks that appeared broken. None of the residents interviewed were able to provide a key to their locking storage space.

On 02/08/24 at 2:15 pm, the facility was toured with Staff 1 (Administrator) and windows and locking storage was discussed. She acknowledged the design of windows on the first and second floors were not consistently modified with limiting devices to prevent accidental falls and the need to ensure residents had a lockable storage space with a key.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

From 02/06/24 through 02/08/24, the surveyor measured water temperatures at the bathroom sink in ten unoccupied and occupied resident units. Water temperatures in two of the rooms were 122 and 124 degrees Fahrenheit.

During a tour on 02/08/24 at 9:30 am with Staff 9 (Plant Operations) he acknowledged the high-water temperatures and stated the facility recently completed a plumbing upgrade to increase water temperatures throughout the facility. He noted the two rooms with the elevated water temperatures were the rooms closest to the facility water heaters. When asked about safety precautions to ensure residents were not injured by hot water, he explained that every resident apartment had a thermostatic shower valve that limited the temperature of water in the shower to 114 degrees F. He stated he would contact the plumbing contractor to make additional adjustments.

On 02/08/24, the need to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 (Administrator). She acknowledged the findings.