The findings of the re-licensure survey, conducted 02/20/24 through 02/22/24, 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 revisit to the re-licensure survey of 02/22/24, conducted on 05/13/24, 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.

2. Resident 2 moved into the facility in 11/2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the 01/03/24 service plan, and Temporary Service Plans, dated 01/07/24 through 02/15/24, identified Resident 2's service plan was not reflective of the resident's care needs and lacked clear direction to staff in the following areas:

* Diet status, vegetarian; and

* Use of right eye prothesis.

The need to ensure the service plans were reflective of the residents care needs and provided clear direction to staff was reviewed with Staff 1 (Administrator), Staff 4 (Health Consultant) and Staff 10 (Campus Manager) on 02/22/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services, including a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and/or was implemented for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. The following was identified:

1. Resident 1 admitted to the facility in 01/2024 with diagnosis including dementia.

Observations of the resident, interviews with staff, review of the 02/11/24 service plan, Temporary Service Plans dated 01/18/24 through 02/15/24 and current evaluation identified Resident 1's service plan lacked clear direction to staff and/or was not implemented in the following areas:

* Safety checks related to: falls, diagnoses of dementia, disorientation, wandering, inability to use the facility provided call system, and frequent independent walks on facility grounds;

* Use of GPS tracing device (JioTracker);  

* Resident specific activities to decrease risk for potential elopement; and

* Bathing assistance, four times weekly.

The need to ensure the service plans provided clear instruction to staff and was implemented was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 4 (Health Consultant) on 02/22/24. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan:

General

1. Actions to be taken to correct the rule violation include:

a. TSP was immediately put into place for Resident 1 to detail a clear safety plan to staff, including documented safety checks; plan on who to contact if resident was observed wandering towards the main gate; specific activiy plan to engage resident in meaningful activities and who would be responsible for encouraging activities; and clear plan with direction for use of JioBit tracker. A copy of each tsp were provided to surveyors, and signed by all staff working in license.

b. Adams house shower schedule was updated to reflect Resident 1's bathing assistance 4x weekly, as per the resident's service plan.

c. TSP implemented for Resident 2 to reflect that she no longer has a preference of Vegetarian meals, but is able to decline foods she does not like.

d. TSP implemented to convey plan for nursing and staff monitoring of Resident 2's eye prosthesis, which will also be added to subsequent service plan updates.

e. Education will be provided to staff in case of removal or replacement needed.

2. To ensure the system will be corrected so this violation does not happen again:

a. During service plan reviews and updates, evaluation will be thoroughly reviewed for completeness and clarity of information and staff direction.

b. When reviewing at-risk residents (risk of falls, wandering, elopement, saftey risk, etc) during weekly Clinical Meeting with administrator, nursing staff, and other clinical team memers, the team will ensure there is a clear and concise plan available to staff to ensure resident saftey.

c. Diet requirements and preferences will be reviewed with the Dietary manager and Marketing Director in charge of updating and distributing the dietary binders to ensure accuracy and completeness across staff sources.

d. During move-in and service plan updates, RN/LPN will review and ensure completenss of information regarding prosthesis, braces, and other supportive/assistive devices.

3. To ensure the system will be corrected so this violation does not happen again, evaluations will be reviewed and updated with any acute or significant change of condition, as well as with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the residents' current status per Oregon State Rule. Clinical services and Facility Administrator participate with this process to ensure accuracy.

4. The Facility Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to conduct and record fire drills every other month according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

Fire drill records were reviewed from 08/2023 through 01/2024, on 02/21/24. Fire drill records reviewed within the look back period were dated 11/28/23 and 01/31/24. The following was identified:

a. Fire drills were not conducted every other month or at different times of day. A fire drill conducted on 11/28/23 was not audible, and one or both lacked documentation of the following information:

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Number of occupants evacuated; and

* Alternate exit routes to react to varying potential fire origin points.

b. Fire and life safety instruction was not provided to staff on alternating months between 08/2023 through 01/2024. The fire and life safety instruction reviewed revealed the following:

* 10/27/23 training on how to use a fire extinguisher;

* 11/28/23 training on how to use a fire extinguisher; and

* 12/21/23 training on how to use a med sled.

c. There was no documented evidence the facility made an effort to identify residents who were unwilling or failed to participate in fire drills and/or make changes to ensure the evacuation standard was met.  

In an interview on 02/22/24 at approximately 11:30 am, Staff 1 (Administrator) stated the facility had recently identified the same areas and since has initiated a new system.

The need to ensure fire drills, and fire and life safety training was provided and documented as required was reviewed with Staff 1, Staff 3 (RN), and Staff 4 (Health Consultant). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life

Safety: Safety

1. Actions to be taken to correct the rule violation include:

a. Facility will conduct unannounced fire drills every other month at different times of the day and night. No less than 3 on each shift (day/night) annually.

b. Fire and life safety instruction for staff will be provided on alternate months.

c. Community will implement a fire drill tool that encompasses all required pieces including but not limited to: Evidence alternate escape routes were used; Evidence occupants were evacuated or relocated to the point of safety; problems encountered and comments relating to residents who resisted or failed to participate in the drills; and evidence of immediate changes that were made for residents who were unwilling to participate in the fire drill to ensure the evacuation standard could be met.

2. To ensure the system will be corrected so this violation does not happen again:

a. Facility Administrator and Facilities director or designee will complete a comprehensive review of: current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule; in-service for maintenance staff who are conducting fire and life safety drills and education on process and documentation required.

b. Facility Administrator and Facilities Director or designee will compile a reference for multiple subjects to utilize during staff safety in services.

3. Facility Administrator and Facilities Director will review documentation for fire drills and staff saftey trainings at the end of each month during stand-up to ensure completeness and accuracy of documentation.

4. Facility Administrator or designee will be responsible to ensure the system has been corrected and that the system is monitored.