The findings of the re-licensure survey, conducted 10/30/23 through 11/01/23, 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

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 11/01/23, conducted 02/08/24 through 02/09/24, 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 interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and initial evaluations were updated as needed during the 30 days following the resident's move into the facility for 1 of 1 sampled resident (#3) whose evaluation was reviewed. Findings include, but are not limited to:

Resident 3's move-in evaluation, dated 08/08/23, lacked information regarding the following required elements:

* Spiritual, cultural preferences and traditions;

* Recent losses; and

* Environmental factors that impact the resident's behaviors including, but not limited to noise, lighting and room temperature.

The initial evaluation was not updated or modified 30 days following Resident 3's move into the facility.

In an interview with Staff 1 (Health Service Administrator) on 11/01/23, she stated they updated the intake form after Resident 3 was admitted.

The need to ensure the move-in evaluations included all required elements and initial evaluations were updated 30 days after move-in was reviewed with Staff 1 on 11/01/23. She acknowledged the findings.

1: Resident three's current LOC will be updated to address recent losses, spiritual and cultural preferences, and traditions by 12/22/2023.

2: Spiritual and cultural preferences and traditions will be added to the level of care assessment by 12/22/2023. All new admission assessments will be audited in October 2023 and will be corrected if information needs to be included.  

3: HPP will audit one new move in a month and then monthly for a quarter.

4: The RCF Manager, Administrator, and RN will ensure all corrections are in place and monitored.   

Based on observation, interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, ensure the determined actions were made part of the resident's record, and document progress, at least weekly, until resolved for 1 of 2 sampled residents (#1) who experienced changes of condition. Findings include, but are not limited to:

1. The sampled residents' records were reviewed for changes of condition. The facility's system included placing the resident on "alert" or "change of condition" monitoring. These alerts included instructions to staff regarding monitoring and were populated in the facility's medical documentation system in the "Dashboard." The primary "Dashboard" included alert monitoring for all residents, but a resident specific dashboard was available in each individual chart. When appropriate, the alerts were discontinued by the RN or expired automatically after a pre-established amount of time. Following the discontinuation of the alert, the documentation of instructions to staff dropped off both "Dashboards," and were able to be reviewed from the resident's record for only 90 days.

In an interview with Staff 1 (Health Services Administrator) on 10/31/23, she reviewed the alert charting system with the surveyor and confirmed the documentation of interventions and monitoring instructions were available through the resident's electronic chart only through 90 days and then the monitoring dropped off the "Dashboard." Although this information could be pulled from the system when requested, the facility failed to ensure the determined actions and interventions were made part of the resident's electronic record.

The need to ensure the documentation of staff instructions or interventions for a resident's change of condition is made part of the resident record was discussed with Staff 1, Staff 2 (RN) and Staff 6 (RCF Manager) on 11/01/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 12/2017 with diagnoses including muscle spasms of the back and osteoarthritis.

Observations of and interviews with the resident, interviews with staff, review of the resident's service plan dated 09/07/23, and progress notes dated 08/03/23 through 10/27/23 were reviewed.

a. The following short-term change of condition lacked documentation of progress, at least weekly, through resolution:

* 09/15/23 - Not feeling well.

lack

b. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts:

* 10/25/23 - Laceration to the left arm following a fall.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (Health Services Administrator), Staff 2 (RN) and Staff 6 (RCF Manager) on 11/01/23. They acknowledged the findings.

1: Resident 1 change of condition from 9/15/2023 has been resolved, and the RN added a resolution note. Resident 1 change of condition on 10/27/2023 will be monitored weekly until resolved, and a resolution note will be added once resolved. The dashboard alerts can be added to the residents' records when staff select progress notes.

2: Training will be given on alert charting for the RN and RCF manager and expectations on charting by 12/22/2023. Caregivers will be trained on placing someone on alert, documentation expectations, and how to link the alert in the dashboard to the progress notes by 12/22/2023. Change of conditions for residents in October will be audited for compliance.  

3: All new condition changes for three residents will be audited weekly to ensure compliance in documentation and then monthly for a quarter.

4:  The RCF Manager, Administrator, and RN   will ensure all corrections are in place and monitored.   

2. Resident 1 was admitted to the facility in 12/2017 with diagnoses including osteoarthritis.

The resident's MAR, dated 10/01/23 through 10/29/23, was reviewed and revealed facility staff documented Resident 1 refused the following orders:

* Diclofenac sodium gel 39 times;

* Gabapentin one time; and

* Omeprazole six times.

In an interview on 10/31/23 at 11:10 am, Staff 2 (RN) confirmed there was no documented evidence the facility notified Resident 1's physician of the refusals.

The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (Health Services Administrator), Staff 2 (RN) and Staff 6 (RCF Manager) on 11/01/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for 2 of 2 sampled residents (#s 1 and 2) who had documented medication refusals. Findings include, but are not limited to:

Resident 2's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals on 10/08/23, 10/09/23, 10/11/23 and 10/14/23.

The medications refused included:

* Polyethylene glycol;

* Pravastatin sodium;

* Oxycodone;

* Protonix;

* Vitamin D;

* Memantine;

* Nystatin powder;

* Acetaminophen; and

* Diclofenac sodium gel.

In an interview on 10/31/23 at 1:00 pm, Staff 2 (RN) confirmed there was no documented evidence the facility notified Resident 2's physician of the refusals.

On 11/01/23 the failure to notify physicians or other practitioners of medication and treatments refusals was reviewed with Staff 1 (Health Services Administrator) and Staff 2. They acknowledged the findings. No further documentation was provided.

1 1 1 1:Resident 1 and Resident 2 orders will be updated to MD notification parameters for refusals by 12/22/2023.

2: The RCF Manager, RN, and caregivers will be inserviced on MD notification for refusals by 12/22/2023. One month of medications will be audited for denials for residents to determine MD notification.

3: HPP will audit three residents' charts for a week for a month and then monthly for a quarter.

4: The RCF Manager, Administrator, and RN   will ensure all corrections are in place and monitored.   

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) no less than quarterly or following a significant change of condition for 3 of 3 sampled residents (#s 1, 2 and 4) and multiple unsampled residents whose ABST was reviewed. Findings include, but are not limited to:

On 10/31/23 at 1:30 pm, the ABST was reviewed and revealed the following:

a. Resident 1 was admitted to the facility in 12/2017. His/her ABST had not been documented as reviewed and updated quarterly since 04/25/23.

b. Resident 2 was admitted to the facility in 06/2019 and experienced a significant change of condition related to weight loss on 08/01/23. The significant change of condition indicated the resident's ABST evaluation should have been reviewed and updated at that time. The last documented ABST evaluation review for Resident 2 occurred on 04/25/23.

c. Resident 4 was admitted to the facility in 08/2022. His/her ABST had not been documented as reviewed and updated quarterly since 04/25/23.

d. The ABST for 21 unsampled residents had not been documented as reviewed or updated quarterly.

The need to ensure the facility's ABST was updated no less than quarterly and following a significant change of condition was reviewed with Staff 1 (Health Services Administrator), Staff 2 (RN) and Staff 6 (RCF Manager) on 11/01/23. They acknowledged the findings.

1: Resident 1, 2, and 4 ABST will be updated by 12/22/2023.

2: The RCF manager, Administrator, and RN will be inserviced on the ABST updating requirements by 12/22/2023. The ABST updating requirements will be added to the Level of Care Tracking tool on 12/22/2023.

3: The RCF Manager, RN, and or designee will audit three residents' ABSTs to ensure they have been updated quarterly, then monthly for a quarter.

4:  The RCF Manager, RN, and Administrator will ensure all corrections are in place and monitored.   

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (#8) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 10/31/23 at 2:00 pm revealed the following:

There was no documented evidence Staff 8 (CG/MT), hired 08/30/23, had demonstrated competency in all required areas and within 30 days of hire including:

* General food safety, serving and sanitation; and

* Medication pass, treatments.

The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Health Services Administrator) on 10/31/23. She acknowledged the findings.

1: Staff 8 will be re-trained on medication management and complete a general food safety, serving, and sanitation course by 12/22/2023.

2: All staff records will be audited for food safety training, and food and safety training will be added to relias by 12/22/2023. Staff medication management training for completion and signatures by 12/22/2023.

3: The RCF Manager, RN, or designee will review new hire medication packets and food safety courses for new hires that month and monthly for a quarter.

4: The RCF Manager, Administrator, and RN  will ensure all corrections are in place and monitored.     

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled staff (#9) completed 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours on dementia care. Findings include, but are not limited to:

Staff training records were reviewed on 10/31/23. Staff 9 (CG/MT), hired 10/04/19, lacked documentation of completing six hours of annual dementia care in-service training in the most recent calendar year.

In an interview with Staff 1 (Health Services Administrator) on 10/31/23, she stated Staff 9 had been working on the second floor as an in-home caregiver and only recently moved to the third floor assisted living facility.

On 11/01/23 the need to ensure all direct care staff completed 12 hours of annual required training including six hours on dementia care was discussed with Staff 1. She acknowledged the findings.

1: Staff 9 will complete six hours of dementia training by 12/22/2023.

2: HPP annual training will be audited to ensure compliance with dementia training; if not, we will add additional training. Staff training will be audited to ensure yearly training has been completed.

3: The RCF manager, RN, and designee will audit one employee's relies weekly and then monthly for a quarter to ensure compliance.

4:  The RCF Manager, RN, and Administrator will ensure all corrections are in place and monitored.     

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

On 10/31/23, fire and life safety records, dated 04/2023 through 10/2023, were reviewed and revealed the following:

* Fire and life safety instruction was not consistently provided to staff on alternating months.

* Fire drill records lacked the following components:

- Escape route used;

- Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

- Evacuation time-period needed;

- Staff members on duty and participating; and

- Number of occupants evacuated.

* Due to the escape route not being documented, there was no evidence alternative routes were used during fire drills.

In an interview on 10/31/23 at 1:05 pm, Staff 1 (Health Services Administrator) acknowledged the facility failed to consistently provide fire and life safety instruction to staff on alternating months and to document all required components for fire drills.

The need to ensure the facility provided staff in fire and life safety instruction every other month and fire drills included documentation of all required components was discussed with Staff 1 and Staff 6 (RCF Manager) on 11/01/23. They acknowledged the findings.

1: HPP will have two additional trainings for fire and life safety instruction for November and December.   

2: HPP will convert the fire drill form to the state fire drill form to ensure all components are being met and documented by 12/22/2023. Facility services staff, RCF manager, RN, and caregivers will be serviced on fire drill requirements by 12/22/2023. HPP will develop a training schedule for fire and life safety instruction for alternating months and a form to document the training.

3: Fire drill forms and life safety training will be audited monthly to ensure compliance with documentation for a quarter.

4: The Facility Services Director, RCF Manager, Administrator, and RN will ensure all corrections are in place and monitored.      

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

Facility laundry rooms were observed on 10/30/23. The following was identified:

The washing machines were a commercial type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent.

On 10/31/23 at 9:00 am, in an interview with Staff 10 (CG/MT), she stated staff used each resident's supplied laundry detergent and there was not any additional chemical disinfectant available.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (Health Services Administrator) on 10/31/23. She acknowledged the findings.

1: HPP will supply detergent that has a disinfecting agent.

2: Caregivers will be trained on using a disinfecting agent for detergent. HPP residents and families who want to supply their own detergent will be educated on the best products to use on 12/22/2023.

3: The laundry detergent will be audited weekly for a month and then monthly for a quarter to ensure the proper detergent is used.

4: The RCF manager, Administrator, and RN will ensure all corrections are in place and monitored.