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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 02/05/24 through 02/06/24, 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, Division 57 for Memory Care Communities, and Division 004 for Home and Community Based Services.

2. Resident 4 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease.

The resident's clinical record from 07/31/23 through 10/30/23, including progress notes, service plan and temporary service plans were reviewed, and interviews with staff were conducted. The following was identified:

* On 08/14/23 the progress notes indicated that the hospice aide had reported a skin discoloration to the resident's right leg. The incident was not investigated to rule out abuse and/or neglect, nor was it reported to the local SPD office.

* On 08/21/23 the progress notes indicated the resident had a skin tear to the left knuckle.  The incident was not investigated to rule out abuse and/or neglect, nor was it reported to the local SPD office.

The surveyor requested Staff 2 (RN) report the incidents to the local SPD on 10/31/23 and received confirmation the facility reported the incidents on 10/31/23.

The need to investigate injuries of unknown cause to rule out abuse and/or neglect, and to report the incidents to the local SPD office if abuse and/or neglect could not be ruled out was discussed with Staff 1 (ED) and Staff 2 on 11/01/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to report physical injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse for 2 of 4 sampled residents (#s 2 and 4) with injuries of unknown cause. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, asthma, anxiety and shortness of breath.

The Service Plan dated 07/31/23 indicated the resident "is not oriented to time, place, date, situations and is only oriented to self, [his/her spouse] and familiar faces such as family and friends."

A review of the resident's clinical record between 07/31/23 and 10/29/23, and family and staff interviews identified the following:

* A Progress Note entry dated 07/31/23 noted: "Being put on alert for skin tear to L [left] leg below knee.";

* A Progress Note entry dated 08/13/23 noted: "Resident is also being placed on alert for skin tear to left outer knee.";

* A Progress Note entry dated 08/16/23 noted: "right wrist skin tear ....Placing on RN skin checks."; and

* A Progress Note entry dated 08/30/23 noted: " ...also added new skin tear alert for resident: skin tear on back of L [left] calf."

The incidents on 07/31/23, 08/13/23, 08/16/23 and 08/30/23 represented injuries of unknown cause.

There was no documented evidence the facility immediately investigated the injuries to rule out abuse, nor reported them to the local SPD office as suspected abuse.

In an interview with Staff 1 (ED) on 11/01/23, she acknowledged the four incidents of injuries of unknown cause were not reported immediately to the local SPD office. On 11/01/23, Staff 3 (RCC) provided documentation that she self-reported the incidents to the local SPD office.

The need to ensure resident incidents were immediately investigated by the facility to reasonably conclude and document that the physical injuries was not the result of abuse, and reported to the local SPD office as needed was discussed with Staff 1, Staff 2 (RN), and Staff 3 on 11/01/23 at 12:45 pm. They acknowledged the findings. No further information was provided.

Incidents pertaining to resident's 2 and 4 were investigated and reported to APS as due to time lapse unable to rule out abuse and neglect. Incident report completed prior to survey exit.

Resident Care Coordinators (RCCs) are responsible for conducting second checks on all orders and outside provider notes daily. While conducting second checks, RCC's will identify if incident reports are in place for new skin issues and will follow facility processes. If not, RCC will follow up with med tech to ensure process is completed in a timely fashion.

Health Services Director (HSD) is responsible for conducting third check of orders during working days and will verify that process has been completed by MT/RCC.

RCC's and HSD will also complete Oregon Care Partners Abuse Reporting and Investigation class to review the investigative process and reportable events.

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

Resident 5 was admitted to the facility on 10/219/23 with diagnoses including Alzheimer's dementia.

The resident's new move-in evaluation was completed on 10/13/23.  The following elements were not addressed in the move-in evaluation:

* Personality, including how the person copes with change or challenging situations;

* Complex medication regimen; and

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

The need to complete move-in evaluations that addressed all required elements was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 11/01/23. The staff acknowledged the findings.

The Functional Evaluation tool that is used by the facility will be reviewed and edited to include the same components as is on the service plan to include "personality, including how the person copes with change or challenging situations, complex medication regimen, and environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, and room temperature."

All residents' current functional evaluations will be reviewed by either RCC, HSD, or ED and components added once tool is updated.

Moving forward, components will be added to the functional evaluation tool which cannot be completed with missing information. This will be reviewed by RCC and/or HSD during initial move in and per service plan schedule/with significant change of condition to ensure all necessary compenents are met.

2. Resident 4 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 10/23/23, temporary service plans, and progress notes dated 07/31/23 to 10/30/23 were completed. The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not implemented by staff in the following areas:

* Meal assistance and adaptive equipment;

* Activity needs, physical limitations and abilities and level of participation;

* Assistance needed for evacuation;

* Current behaviors;

* Non-skid mat next to bed;

* Pacing and wandering;

* Bedtime needs/sleep habits;

* Grooming and hygiene assistance; and

* Barrier cream.

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 (ED), Staff 2 (RN), and Staff 3 (RCC) on 11/01/23. 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' current care needs, provided clear directions to staff regarding the delivery of services, and/or were implemented for 2 of 4 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, asthma, anxiety and shortness of breath.

Observations were made of the resident's care on 10/30/23 and 10/31/23. Interviews with facility staff and the resident's family were conducted. The current service plan dated 07/31/23 was reviewed.

Resident 2's service plan was not implemented and lacked clear instructions to staff in the following areas:

* Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; and

* Use of barrier cream with toileting changes.

The need to ensure the service plan was implemented and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 11/01/23. They acknowledged the findings. No further information was provided.

RCC will update resident 2 and 4's service plans to reflect current needs and remove historical information that is no longer relevant that may be unclear for staff reviewing service plans.

RCCs, HSD, and ED will review all current resident service plans and update accordingly to reflect current plan of care.

Service plans will be reviewed per the regulation at initial move in, 30 day review, quarterly, and upon significant changes in condition by RCCs.

HSD will be responsible for reviewing service plans to ensure they reflect current plan of care once completed by RCCs. If descrpancies are noted, HSD will bring to RCCs to correct.

ED will conduct final review once corrections have been made.

2. Resident 4 moved into the facility in 10/2021 with diagnoses including Alzheimer's dementia.

The resident's service plan, temporary service plans, progress notes dated 07/31/23 through 10/30/23, RN assessment dated 08/01/23 and the ABST report was reviewed and revealed the resident had a significant change of condition in 08/2023 and required increased assistance in mobility, transfers and ADL tasks. Resident 4 was observed during survey on multiple occasions receiving two person assist with bed mobility, transfers and wheelchair positioning.

The ABST report for Resident 4 had not been updated quarterly since 10/19/22, was not updated after the significant change of condition, and failed to reflect his/her current care needs and level of assistance in the following areas:

* Repositioning in bed/chair; and

* Transfers.

The need to ensure the ABST tool was updated quarterly and following a resident's significant change of condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 11/01/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated no less than quarterly and with changes of condition. Findings include, but are not limited to:

1. On 11/01/23, the facility ABST was reviewed with Staff 1 (ED). Multiple sampled and unsampled residents lacked documented evidence their ABST had been reviewed and updated quarterly.

On 11/01/23, the need to ensure resident ABST's were updated quarterly was discussed with Staff 1 (ED). She acknowledged the findings.

Residents 2 and 4 will be reviewed by RCCs on the ABST once service plans are updated as aforementioned.

RCC's will audit all service plans for current residents and update ABST accordingly.

When RCC's have completed service plans and they have been reviewed by HSD, ED will conduct final review and compare service plan to ABST to ensure all needs are reflected.

ED will pull ABST report monthly to ensure residents are all updated in accordance with aforementioned service plan schedules.

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exited the MCC. Findings include, but are not limited to:

The facility was toured 10/30/23 through 11/01/23. The four exit doors leading to the secure courtyard areas in the north and south hall units did not have working door alarms or other acceptable system that alerted staff when a resident exited the neighborhood.

Staff 1 (ED) reported there was an audible alarm on each door. However, when the doors were opened there was no audible sound or other system to alert staff of a resident exiting to the courtyards.

The need to provide an alarm or other system on the exit doors for each unit was reviewed with Staff 1 on 11/01/23. She acknowledged the findings.

New audible operating system for interior courtyards will be ordered and installed by Maintenance Director. (MD)

Maintenance Director will be responsible for ensuring functional operation of alert system weekly. This task has been added to weekly TELs task list. If not working properly, MD will take the necessary steps to correct.

ED will conduct audit monthly to ensure devices are operational.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 231, C 361, C 555.

Refer to C231, C361, and C555

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 16 and 17) completed all required pre-service training prior to beginning job duties independently, and 1 of 2 sampled long-term direct care staff (#15) completed a total of 16 hours of annual in-service training, including six hours of dementia care training. Findings include, but are not limited to:

Training records were reviewed on 10/31/23, and the following was identified:

Staff 15 (Resident Assistant) was hired 04/20/21, Staff 16 (Resident Assistant) was hired 09/27/23, and Staff 17 (Resident Assistant) 08/22/23.

a. There was no documented evidence Staff 16 and Staff 17 completed the required pre-service training prior to providing personal care independently in the use of supportive devices with restraining qualities in memory care communities.

b. There was no documented evidence Staff 15 completed the required annual in-service training, including six hours of dementia care training.

The need to ensure newly hired direct care staff completed all pre-service training topics prior to beginning any job duties, and long-term direct care staff completed a total of 16 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 11/01/23. They acknowledged the findings. No further information was provided.

ED will review Relias platform and identify a course that meets the description of the use of supportive devices with restraining qualities in memory care communities. This coarse will be added to the Relias new hire onboarding module.

Current staff will be inserviced on supportive devices with restraining qualities at staff meeting and/or one on one in-service as applicable.

New hires will be expected to complete all Relias training modules prior to being permitted to train on the floor. Business Office Manager BOM will pull Relias transcript once new hires indicate completion to ensure all classes completed before being permitted to train on floor.

Ongoing dementia CEUs: BOM will conduct audit of all staff that have been employed longer than 1 year to identify which staff have not completed 6 dementia CEU's.

BOM will provide list of staff not currently meeting this rule to RCC. RCC will be responsible for ensuring staff are scheduled to complete CEUs to meet this requirement.

BOM will conduct monthly audit to identify which staff are in need of CEUs. BOM will provide list to RCC for RCC to schedule completion of monthly CEUs.

For staff that fail to meet their annual CEU's, BOM will notify RCC. RCC and/or ED will remove staff from schedule until CEUs are completed.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 252 and C 260.

Refer to C252 and C260