The findings of the re-licensure survey, conducted January 24, 2022 through January 25, 2022, 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 C refer to the Residential Care and Assisted Living Facilities 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 survey to the relicensure survey of 01/25/22, conducted 04/13/22 through 04/14/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 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 second re-visit to the re-licensure survey of 01/25/22, conducted on 06/14/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services.

Based on interview and record review, it was determined the facility failed to conduct an investigation of an injury of unknown cause to rule out abuse and/or neglect and report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia.  

Review of incident reports, skin sheets, chart logs, and progress notes from 10/24/21 through 01/24/22 showed the following:

* On 12/29/21, staff documented a large bruise was found on the resident's back right ribcage and the resident was unable to recall how s/he obtained the bruise. There was no further information about the incident or injury; and

* On 12/30/21, Staff 5 (LPN) documented on a skin sheet the resident had "dark purple bruising on right side of back below ribcage," which measured 6 cm x 15 cm, and reported the resident could not remember how it happened. There was no additional information about the injury.

There was no documented evidence the facility immediately investigated the injury to rule out abuse. The facility did not report the injury to the local SPD office as suspected abuse/neglect.

The need to ensure injuries of unknown cause were investigated promptly, and reported if necessary, was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. Staff 2 acknowledged there was no documented evidence the facility had investigated the injury to rule out abuse and/or neglect.

The facility was asked to report the injury of unknown cause to the local SPD. Confirmation of the report was provided on 01/25/22, prior to exit.

1. All injuries will be investigated and documented on either event report or in progress note or both.

2. Injuries are reported by CG or MA via a form labeled skin sheet regardless of the type of injury (this can include fractures and other injuries) which is forwarded to LN. Unless absent, the LPN assigned to either ALF or MC will investigate the reported injury. Documentation of the injury and treatment plan will be on a "wound/skin issue" sheet in EHR. (In the event of assigned LPN's absence, injuries will be investigated by: remaining LPN, RN, or administrator. Injuries without known cause and where abuse has not been ruled out will be reported to the DHS and administrator for forwarding to APS.

3. Each time an injury is reported where, after investigation, a cause cannot be determined and abuse has not been ruled out.

4. Administrator and/or Director of Health Services  

Based on interview and record review, it was determined the facility failed to ensure incidents were promptly investigated to rule out abuse and/or neglect, reviewed by the administrator, and immediately reported to the local Seniors and People with Disabilities (SPD) office if abuse and/or neglect could not reasonably be ruled out for 1 of 1 sampled resident (#7) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in July 2018 with diagnoses including mixed Alzheimer's and dementia.

Review of Resident 7's record identified the following:

* On 04/02/22, Resident 7 had expressed unwanted sexualized behaviors towards another resident. The residents were immediately separated. Further record review indicated the incident was not investigated until 04/05/22 through 04/06/22 and was not reported to the local SPD office until 04/06/22. There was no documented evidence the facility administrator reviewed the incident of suspected abuse; and

* On 04/06/22, a progress note indicated that Resident 7 displayed unwanted sexualized behaviors towards another resident. There was no documented evidence the facility conducted an immediate investigation of the suspected abuse. In an interview on 04/14/22, Staff 1 (ED), reported that the incident was reported by a third party and Adult Protective Services came into the facility and notified them of the suspected abuse.

On 04/14/22, the need to ensure the facility conducted immediate investigations to rule out abuse or suspected abuse, reviewed by the administrator, and to immediately report to the SPD office if abuse and/or neglect could not reasonably be ruled out was discussed with Staff 20 (Administrator). She acknowledged the findings.

Staff to be trained on policy for reporting suspected abuse.  Staff to be informed of what and when to report. All investigations to be completed within 24 hours and if abuse can not be ruled out, a report will be made to the appropriate agency.

Staff training to be held on policy of reporting.  Training will be completed upon hire and reviewed yearlyand as needed.

RN and Administrator will ensure that training is completed.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

The kitchen was toured on 01/25/22. The following areas were in need of cleaning and/or repair:

* Paper signage posted in multiple areas of kitchen, creating an uncleanable surface;

* Loose food debris under and around freezer shelving units;

* Dried food buildup and black matter on base of rolling cart in freezer;

* Black debris on metal transition strip between kitchen and freezer floors;

* Dark gray smudges above and below freezer handle;

* Loose food debris on machinery surfaces beneath warewasher;

* Multiple areas of paint missing on kitchen back door, creating an uncleanable surface;

* Gray smudges on flooring in small dry storage room;

* Large area of ceiling cut out in small dry storage room, with white thread of debris hanging down;

* Black streaks, scratches, and chipped wood on dining room and kitchen entry doors;

* Chipped paint on kitchen and dining room door jambs, creating an uncleanable surface;

* Chipped paint on legs of food warmer cart;

* Chipped paint on large stand mixer;

* Plastic molding detached from base of cabinetry on beverage bar;

* Missing caulking on beverage bar, with black debris on counter/backsplash and backsplash/wall seams;

* Black matter on beveled edges of beverage bar cabinetry; and

* Food debris and black matter inside drawers and cupboards of beverage bar.

The areas in need of cleaning and/or repair were reviewed with Staff 1 (Administrator) on 01/25/22. She acknowledged the findings.

1. All documentation/signage placed in sheet protectors. Maintainence notified regarding chipped paint and environmental deficiencies. Interior doors leading to the kitchen were removed. The exterior door will be ordered and replaced.

2. Cleaning schedule initiated.

3. Area checked weekly.

4. Dietary manager and administrator.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to:

Resident 3 and 4's move-in evaluations were reviewed on 01/25/22.  There was no documented evidence the following required elements were addressed prior to move-in:

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

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

The need to ensure move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. They acknowledged the findings.

1. Move-in evaluation (Oregon Screening Tool--OST) will have all portions completed prior to resident move-in.

2. Screening tool used prior to Feb. 2022 was missing two sections which have since been added to ensure compliance with regulation.

3. The move-in evaluation system will be evaluated with each move-in, and evaluation is reviewed at 30 days, quarterly, and with any significant change of condition.

4. Administrator  

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 were completed in a timely manner for  3 of 5 sampled residents (#s 1, 3 and 5). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in November 2017 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the care plan dated 11/13/22, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Dressing, toileting and ambulation;

* Behaviors, resistance to care;

* Meal assistance;

* Hoyer lift use and transfers;

* Evacuation ability;

* Repositioning, bed mobility; and

* Pain, making needs known.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff  was discussed with Staff 1 (Administrator), Staff 2 (RN/Director of Health Services) and Staff 4 (LPN) on 01/25/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia.

During the acuity interview on 01/24/22, Resident 5 was identified to have a skin impairment, weight loss and increased confusion.  

Observations of the resident and interviews with staff from 01/24/22 to 01/25/22, review of the service plan, dated 12/10/22, and temporary service plans indicated the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Current activity interests;

* Mental health status and behaviors, including signs and symptoms of depression and effective non-drug interventions;

* Level of assistance required with ADLs;

* Instructions on when and how often to assist with incontinence care;

* Pain status, including interventions;

* Skin condition;

* Fall risk and interventions;

* Frequency of safety checks;

* Assistance with choosing food options and health shakes; and

* Ability to use call light and pendant.

The need to ensure service plans were reflective of resident needs, were accurate, and included clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 12/2022, with diagnoses including Lewy Body Dementia.

Resident 3's initial service plan was dated 12/10/22, and his/her 30-day service plan was due on 01/13/22. The facility was unable to provide documented evidence the service plan had been reviewed within 30 days.

The need to update service plans in a timely manner was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. They acknowledged the findings.

1. Service plans will be completed by due date (upon admission, 30 days, 90 days, and quarterly thereafter).

2. Upon admission to facility, resident will be added to the care plan calendar by RCC to ensure that 30-day assessment and careplan update is not overlooked. All care plan updates will be completed after review of resident, chart notes, and any discussion with family/staff/resident to ensure that care plan accurately reflects resident's current functional ability, care staff are providing, and what interventions are effective, and discontinuing interventions proven to be ineffective.

Changes to care plan will not be done via editing a current intervention but by creating a new intervention/instruction with the date it was started.

Interventions deemed to no longer be effective will be deleted/archived from the care plan. Interventions for assistance (such as safety checks, frequency of toileting) will be measurable and specific indicating number of times per shift and/or what time during a shift the care should occur. Interventions/instructions will be specific to the individual resident.  

3. Each time a care plan requires updating.

4. Administrator and/or Health Services Director

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident and updated the service plan for 2 of 3 sampled residents (#s 1 and 5) who experienced significant weight changes. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in November 2017 with diagnoses including dementia.   

Weight records dated 07/05/21 to 12/05/21 and progress notes and RN notes dated 10/23/21 through 01/24/22 indicated the resident experienced the following:

A 10.6 pound weight gain from 09/05/21 to 10/05/21. This constituted a 10.20% severe weight gain in one month.

The resident's weights were monitored at the beginning of each month from September 2021 through January 2022 and ranged between 98-108 pounds. The resident experienced a severe stroke in mid-January, was placed on hospice, and experienced an ongoing rapid decline.

Observations of the resident on 01/24/22 and 01/25/22 showed the resident was bed bound and unresponsive. Staff assisted the resident with small sips of water, as well as utilizing a toothette to swab the resident's mouth. No meals were observed.

A current weight was not obtained for January 2022, as the resident was actively dying. The resident passed away during the survey.  

Interviews with staff from 01/24/22 through 01/25/22 indicated the resident was dependent for all care. Staff indicated the resident's intake was very poor since the stroke. The resident was unable to complete any ADLs on his/her own, including food and fluid intake. Staff indicated the resident was more active and able to eat and drink more independently prior to the stroke.

The facility failed to ensure an RN assessment was completed for the severe weight gain with documented findings, resident status, and interventions made as a result of the assessment.

In an interview on 01/25/22 Staff 2 (RN/Director of Health Services) indicated she believed the weight gain was an error. Staff 2 stated they had a period of time when the scale was not operating correctly. She suspected the resident's weight was inaccurate and a re-weight was not obtained. Staff 2 further stated the resident did not have any acute issue going on at the time that would contribute to a gain. The resident did not have any problems with edema that would have affected his/her weight. Staff 2 indicated she was unable to locate any documentation of a significant change of condition assessment completed regarding the weight or any documentation regarding the potential error.

The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (RN/Director of Health Services) and Staff 4 (LPN) on 01/25/22. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia, irritable bowel syndrome, and hypothyroidism.

The resident's 01/01/22 through 01/24/22 MAR, service plan dated 12/10/21, progress notes dated 10/24/21 through 01/24/21, and weight records from 06/10/21 through 01/18/22 were reviewed, Staff 2 (RN/Director of Health Services) and Staff 5 (LPN) were interviewed.

Weight records identified the resident lost 18 lbs. between 9/10/21 - 12/10/21, or 11.9% of his/her total body weight in three months, which represented a significant change of condition and required a timely facility RN assessment.

A facility RN assessment was not completed until 01/20/22.

The facility had obtained orders on 10/21/21 to provide a nutritional supplement between meals. The record indicated the supplement was currently being provided. A progress note dated 12/23/21 noted the resident was seen by her doctor to follow up on chronic diarrhea and weight loss. Interviews with Staff 2 and Staff 5 indicated they were communicating with the resident's doctor frequently and medication changes were made in an attempt to decrease the side effects of diarrhea and weight loss. During the survey, staff encouraged and assisted the resident to the dining room, and when the resident declined the meal offered, staff provided menu alternatives.

On 01/25/22, the need to ensure RN assessments were performed in a timely manner for all residents who had significant changes of condition, interventions were communicated to staff, and service plans were updated was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

1. Significant weight changes will be reviewed and documented via significant changes of condition assessment by the RN.

Significant changes in ADL function and changes to psychosocial status (behaviors) will be reviewed and documented via significant change of condition assessment by RN.

2. Weights are obtained with monthly vitals by the CG.

Weights are reviewed by LPN assigned to unit. Weight variances of 3 or more pounds will generate a re-weight of the resident within 1 business day of discovery of variance which is completed by the LPN.

Once per week, LPNs and DHS will meet to review resident concerns. Each unit LPN will report to DHS upon discovery of significant weight change confirmation so that RN can complete significant change of condition within 24-48 hours (1-2 business days). In the event that the scale is broken or weights appear grossly inaccurate, this information will be documented in the resident's chart. Upon repair (recalibration) of scale, weights will be obtained and reviewed per above instructions.

Potential significant changes in ADL function and/or changes to psychosocial status will be reviewed at weekly meeting and resident placed on two-week observation period. Within 24-48 hours (1-2 business days) of completion of observation period, RN will determine if signficant change of condition occurred and update the plan of care.

3. As the significant change occurs: within 24-48 hours (1-2 business days).

4. Administrator, RN, LPN   

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all elements required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records for 08/2021 through 01/2022 were reviewed on 01/25/22. The fire drill records did not include the following required elements:

* Location of simulated fire;

* Escape route used;

* Problems encountered related to residents who failed to participate in drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

The need to ensure all elements required by the OFC were documented for fire drills was discussed with Staff 1 (Administrator) on 01/25/22. She acknowledged the findings.

1. Fire drill form updated to include required elements.

2. Form updated.

3. Monthly fire drills on alternating shifts.

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all required elements. This is a repeat citation. Findings include, but are not limited to:

The fire drill record for 04/05/22 was reviewed and did not include the following required elements:

* Escape route used;

* Problems encountered related to residents who failed to participate in drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

The need to ensure fire drills included documentation of all required elements was discussed with Staff 20 (Administrator) on 04/14/22. She acknowledged the findings.

A new fire drill procedure will be implemented.  

New policy will clearly state:

Date/Time

Location

Escape route

Issues with residents during evacuation

Time needed

Staff participation

Number of residents evacuated.

Policy will be reviewed at move in or hire.  Fire drills will be held 6x year.

Administrator to ensure that proper policy is followed.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Fire and life safety records, dated 08/21 through 01/22, were reviewed on 01/25/22. There was no documented evidence alternate escape routes were used during fire drills and no documented evidence residents received annual training which included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting place.

The need to ensure all general fire and life safety requirements were met was discussed with Staff 1 (Administrator) on 01/25/22. She acknowledged the findings.

1 & 2. During fire drills, alternate routes will be included.  Safety procedures, evacuation methods and fire drill responsibility will be reviewed with residents or their designee if resident is cognitively impaired during quarterly care conference.

3. Annually

4. Administrator

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C231, C420 and C613.

The facility will be in compliance with state inspection by 5/29/2022 and ready for re-inspection.

Administrator will be responsible for ensuring that all corrections are completed.

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

Observations of the facility on 01/25/22 showed the following areas were in need of cleaning or repair:

* Black streaks and chipped paint on doors and door jambs throughout the Assisted Living Facility and both MCC units, including resident rooms, dining rooms, and elevator;

* Chipped paint and small gouges on walls throughout facility, including hallways and bathrooms;

* Missing linoleum flooring at seam, approximately 1" x 12", in laundry room, creating an uncleanable surface;

* Deep gouge in wall, approximately 3' x 1½" on wall behind reception desk on second floor;

* Missing caulking around faucet in bathroom by elevator on second floor, exposing unfinished ceramic and creating an uncleanable surface;

* Chipped paint along length of handrail in Memory Care Unit 1 dining room; and

* Food debris, stains, and litter inside drawers and cabinetry of Memory Care Unit 1 dining room.

The areas in need of cleaning and/or repair were shown to and/or discussed with Staff 1 (Administrator) on 01/25/22 and 01/26/22. She acknowledged the findings.

1. All citations turned over to Maintenance Dept.

2. Maintenance will complete repairs and order supplies as needed.

3. Weekly

4. Administrator/maintenance staff

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 04/13/22 and 04/14/22 showed the following:

1. Areas still in need of cleaning or repair from relicensure survey in January 2022:

* Black streaks and chipped paint on doors and door jambs throughout the Assisted Living Facility and both MCC units;

* Chipped paint and small gouges on walls throughout facility, including hallways and bathrooms;

* Chipped wood on dining room entry doors; and

* Food debris, stains, and litter inside drawers and cabinetry of Memory Care Unit 1 dining room.

2. Additional areas in need of cleaning or repair:

* Exposed nails and broken wall seams on 2nd floor reception desk;

* Loose flooring strips in library, creating an uneven surface;

* Stains on library fabric chair seats;

* Acrylic wall sign holders outside resident rooms hanging or broken;

* Food splatters on ceiling in dining area of Memory Care Unit 1;

* Dark debris in fluorescent light fixtures in Memory Care Units 1 and 2;

* Broken and stained ceiling tiles in Memory Care Units 1 and 2;

* Missing ceiling tiles with exposed wires, in Memory Care Unit 2;

* Scrapes and gouges on walls throughout Memory Care Unit 2;

* Chunk missing from wall, with exposed underwall, by window in common area of Memory Care Unit 2; and

* Caulking missing from toilet bases in Memory Care Units 1 and 2, creating an uncleanable surface.

The areas in need of cleaning and/or repair were shown to Staff 20 (Administrator) on 04/14/22. She acknowledged the findings.

Monthly checklist will be implemented for administrator to inspect all enviromental areas for need of repair.  

Areas in need of repair will be reported immediately on maintence log for repair.  

Repairs will be done monthly and as needed.

Administrator and maintenance will be responsible to ensure that all areas are in good repair.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

The building was toured on 01/25/22. Observations and interviews with staff confirmed the two doors leading to the enclosed courtyard from Memory Care Unit 1 failed to have an alarming device to alert staff when residents exited the building.

The lack of exit door alarms was discussed with Staff 1 (Administrator) on 01/25/22. Staff 1 acknowledged the findings.

1 & 2. Alarms for doors have been ordered.

3. Daily

4. Administrator and maintenance

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

Refer to C 231, C 240, C 420, C 422, C 613 and C 655.

See Above

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

Refer to C231, C420 and C613.

All areas of deficiency will be addressed and corrected.  Administrator will oversee areas and ensure that proper changes or repairs are completed.

These areas will be monitored daily until completed, and then ongoing after correction.

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

Refer to C 252, C 260 and C 280.

See Above