The findings of the relicensure survey, conducted 09/12/22 through 09/16/22, 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 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 re-visit to the re-licensure survey of 09/16/22, conducted 04/03/23 through 04/04/23, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of residents' needs for 1 of 3 sampled residents (#4). Findings include, but are not limited to:

Resident 4 was admitted to the facility in 09/2019 with diagnoses including emphysema and COPD.

The resident's quarterly evaluation, dated 09/02/22, was reviewed and interviews with the resident and care staff determined the evaluation was incomplete or inaccurate in the following areas:

* Falls (history and interventions).

On 09/15/22, the need for quarterly evaluations to be complete and accurate was discussed with Staff 1 (Executive Director), Staff 2 (Corporate RN), and Staff 3 (Regional Director). They acknowledged the findings.

1. Res 4's evaluation/service plan was updated to reflect residents fall trends and current interventions.  Evaluations/Service plans for remaining residents with fall trends, behaviors trends and/or wieght loss issues will be reviewed to assure trends and associated interventions are present.

2. ED, RN ALD and MCD have reviewed rules along with community processes regarding completion and expected content of quarterly evaluations/service plans to assure understanding.

3.  Resident evaluations/service plans will be completed upon move in, 30 day and 90 day as per regulation and community policy.  

4.  ALD & MCD will complete reviews of residents care needs as part of the quarterly evaluation/service plan update process to assure content accuracey.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored to resolution, failed to determine, document, and communicate interventions, and/or referred to the facility RN for assessment for 3 of 4 sampled residents (#s 1, 2 and 4) reviewed for changes of condition. Findings include, but are not limited to:

1.  Resident 1 was admitted to the facility in 02/2020, with diagnoses including cancer and hypertension.

a. Resident 1's record was reviewed for changes of condition and identified the following:

* 06/23/22 RN note "seven staples in back of head, right elbow bandaged. Wounds will be monitored weekly by facility nurse until resolved"; and

* 08/25/22 progress note "resident had a cut on the side of his head that was bleeding."

There was not documented evidence the wounds were consistently monitored weekly until resolution.

b. At the acuity interview on 09/12/22, Resident 1 was noted to have experienced weight loss. Review of the resident's record revealed a weight loss of greater than 5% between 05/10/22 and 06/10/22. The weight loss was not evaluated and monitored until the facility RN completed a change of condition assessment on 07/26/22, which confirmed Resident 1's weight loss was intentional and updated the service plan.

2.  Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and CHF.  A home health note dated 09/2/22 noted the discovery of "new wound on R heel", however, there was no documented evidence of evaluation or monitoring of the wound.

In interview on 09/15/22, Staff 1 (Executive Director), Staff 2 (Corporate RN), and Staff 3 (Regional Director) acknowledged the findings.

3. Resident 4 was admitted to the facility in 09/2019 with diagnoses including emphysema and COPD.

Resident 4's record was reviewed for changes of condition and identified the following:

*A progress note on 08/30/22 indicated that the resident was on alert for a fall with injury and staff were doing frequent safety checks. There was no documented evidence the facility evaluated the resident to determine what actions or interventions were needed to minimize further falls.

On 08/04/22, the need to ensure the facility evaluated residents who experienced a change of condition was discussed with Staff 1 (Executive Director), Staff 2 (Corporate RN), and Staff 3 (Regional Director). They acknowledged the findings.

1. Res #1: Wound assessed and documentation placed in the chart.  Resident weight loss assessment completed and SP already updated.  Res #2:  Initial assessment completed and wound added to the weekly skin log for ongoing monitoring.  TCP put in place for additional interventions for staff to follow.      

Res # 4:  Resident falls evaluated and trends and interventions added to the active service plan/TCP.  

Progress notes for remaining residents will be reviewed for the last 30 days to assure short term changes of condition were known and address as well as skins monitored and significant weight loss/gains have been addressed.

2. ED provided re-education to the RN, ALD and MCD regarding the rules/associated community protocols for changes of condition and monitoring to assure understanding.  ED has reviewed with RN/ALD/MCD the expectation of daily progress note auditing to assure timely awareness, assessments as applicable and monitoring via the alert charting process is being completed. During stand up the ED, RN, ALD/MCD will review changes of condition to assure timely awareness and discussion of next steps.

3. Daily

4. ED, RN, ALD  

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers notes were reviewed, for 1 of 3 sampled residents (#2) who received home health services. Findings include, but are not limited to:

On 09/13/22 a home health provider was interviewed and stated Resident 2 received home health services four times a week for wound care to his/her heels. The home health provider stated they documented information and any wound care recommendations on a home health form and left it at the front desk after each visit.

Review of records showed the only home health notes retained in the resident record were for 08/05/22, 08/12/22, 09/01/22 and 09/02/22.

The 08/05/22 note included the wound protection recommendation "please encourage patient not to rest on heel".  The home health recommendation was placed in a progress note, however, the service plan was not updated and the recommendation was not communicated to caregiving staff.

The 09/02/22 note included the finding "new wound right heel". There was no evidence facility staff had reviewed the note and updated the service plan.

The need to have a system for coordinating on-site services with outside providers, ensure facility staff reviewed home health notes for recommendations, and that the service plan was adjusted accordingly was discussed with Staff 1 (Executive Director), Staff 2 (Corporate RN), and Staff 3 (Regional Director) on 09/15/22. No further information was provided.

1. Outside providers notes have been fully reviewed for each resident in assisted living,  Applicable TCP's are in place for new care recommendations noted. Re-education provided to the MT staff on creating TCP's for new care recommendations made on outside agency visit notes.  .

2. Re-education provided to ALD/MCD and RN on expectations of their review of the visit notes and assuring TCP's have been created for any new care recommendations.   This will be overseen daily and with a 3 person check system. Med Tech to review and write PCP when needed, ED/designee to  provide 2nd check and RN to final check to ensure all records have been reviewed and no changes are missed.

3. Daily when outside providers come into the community.

4. ED/Designee/RN

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented medication refusals. Findings include, but are not limited to:

Resident 4's clinical records and MARs/TARs were reviewed during the survey and identified multiple treatment and medication refusals between 09/01/22 and 09/12/22.

There was no documented evidence the facility notified the physician when the resident refused consent to orders.

On 09/15/22, the failure to notify physicians of the documented multiple treatment and medication refusals were reviewed with Staff 1 (Executive Director), Staff 2 (Corporate RN), and Staff 3 (Regional Director). They acknowledged the findings.

1.An audit will be conducted of the last 14 days of MARs to assure MD notification for all refused meds/treatments has been conducted.  Re-education has been provided to the MT's to assure understanding.

2. Refusals will be checked daily to ensure PCP is aware that resident has refused or missed their medication.

3. Daily

4. ALD/MCD with ED oversight

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed at least quarterly for assistive devices with potentially restraining qualities, the service plan was updated, and staff were instructed in proper use for 1 of 1 sampled resident (#2) reviewed who had a supportive device. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and CHF.

During the entrance conference, 09/12/22, Resident 2 was identified as having a side rail on his/her bed. Observations of the resident and the residents room showed the side rail was in the up position throughout the survey.

There was no quarterly assessment for the side rail completed by the RN, PT or OT for use of the assistive devices with potentially restraining qualities. There were no instructions to staff in the resident's service plan regarding the use or safety precautions of the side rails.

The need to complete assessments of supportive devices with restraining qualities at least quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Corporate RN) and Staff 3 (Regional Director) on 09/15/22. They acknowledged the findings.

1. Assessments are current for all residents utilizing supportive devices with restraining qualities. Service plans are inclusive of the device use and what staff will monitor for (safety precautions).   RN has been re-educated on the requirements for initial and ongoing quarterly assessments for use of such devices.

2. Routine audits will be provided to assure assessments are current.

3.  Audits will be conducted weekly and also quarterly in conjunction with the service plan update schedule.

RN and ALD/MCD with ED oversight

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

Observations, interviews and record review during the survey revealed the following:

*In an interview on 09/12/22, Resident 4 indicated when s/he pressed his/her pendant for assistance, often times response from staff was 20 minutes and sometimes 30 minutes or more. Resident 4's call light times were reviewed from 09/01/22 through 09/12/22 and revealed 17 times staff response was over 20 minutes.   

*During the group interview, conducted on 09/12/22 at approximately 2:00 pm, multiple alert and oriented non-sampled residents stated staff response to call light times was often 20 minutes or more;

*The facility's posted staffing plan on 09/12/22 indicated two caregivers and one med aide were available for both day and swing shifts. The facilities updated staffing schedule from 09/01/22 through 09/12/22 revealed five occasions on swing shift and one time on day shift the facility failed to meet their posted staffing plan;

*During an interview about resident care needs, a caregiver stated having two caregivers to assist three floors of residents was not enough, and they were sometimes unable to complete all of the tasks on the service plans.
 

Resident 3's service plan, dated 08/17/22, indicated s/he needed assistance with all transfers and would utilize his/her call light when assistance was needed to use the restroom.

*On 09/15/22, Resident 3 stated s/he was incontinent on two occasions after long call light response times on 09/14/22. Resident 3 indicated when s/he pressed their pendent for assistance, it often took staff 30 minutes or more to respond. Resident 3's call light times were reviewed from 09/01/22 through 09/12/22 and revealed 70 occasions of staff response time over 20 minutes.   

On 09/16/22, the need to ensure an adequate number of staff to meet the scheduled and unscheduled needs of residents was discussed with Staff 1 (Executive Director), Staff 2 (Corporate RN), and Staff 3 (Regional Director). They acknowledged the findings.

*Refer to C 361 Acuity Based Staffing Tool

1. ABST has been reviewed to verify accuracy for total census and resident individual care needs.  Schedule has been looked over and all shifts have been covered by community staff or agency to ensure adequate staff are available per our community staffing plan.

2.Additional education has been provided to the ED on the ABST tool to assure accuracey.  

The community will continue with active recruitment efforts to fill open positions.  

Routine oversight will be provided to verify scheduled staff presence during each shift and to  identify any additional staffing needs and/or increased resident needs that might impact staffing.

Routine oversight will also be provided to monitor resident call response times on each shift.

.

3. Daily

4. ED/designee/AED

Based on interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment for each resident and develop the facility's staffing plan based on the ABST, and failed consistently staff to the levels, intensity and qualifications indicated by the tool. Findings include, but are not limited to:

At entrance on 09/12/22 the ABST assessment was reviewed with Staff 1 (Executive Director) and Staff 3 (Regional Director). They confirmed the ABST tool was in use for determining the facility's staff plan.

The ABST tool showed 41 residents had information entered into the system for determine the staffing plan, however, the facility census was 45.

Staff 1 and 3 acknowledged the tool was incomplete, and four residents residing in the facility had not yet had information entered into the ABST.

The facility's posted staffing plan on 09/12/22 indicated two caregivers and one med aide were available for both day and swing shifts. The facilities updated staffing schedule from 09/01/22 through 09/12/22 revealed five occasions on swing shift and one time of day shift the facility failed to meet their posted staffing plan.

The need to complete an accurate assessment of each resident, promptly enter the information into the ABST, and consistently staff to the level indicated by the tool was reviewed with Staff 1 and Staff 3. No further information was provided.

* Refer to C 360 Staffing Requirements

1. ABST has been corrected for total census and for  medication management services (this had previously been directed to be removed). All residents data has been reviewed and corrections have been made to ensure adequate staffing is in the community for our current residents.

2. ABST will be updated with admissions/discharges, signfiicant change of conditions or service plan changes. This will be completed by the ALD after service plan meetings have been held. ED will ensure that the proper amount of hours have been applied to the tool.

3. Weekly upon changes of care plans or TCP's.

4. ED/designee

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled veteran staff completed their Infectious Disease Prevention training prior to the required 07/01/22 date. Findings include, but are not limited to:

There was no documented evidence veteran Staff 11 (Housekeeping), hired 08/31/17, and Staff 12 (Cook), hired 11/27/19, completed the Infectious Disease Prevention training that included the following:

*Transmission of communicable disease and infections;

*Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease;

*Respiratory hygiene and coughing etiquette;

*Standard precautions;

*Hand hygiene;

*Use of personal protective equipment;

*Cleaning of physical environment;

*Disinfecting high-touch surfaces and equipment;

*Handling, storing, processing and transporting linens to prevent the spread of infection;

*Isolating and cohorting of residents during a disease outbreak; and

*Rights and responsibilities of employees to report disease outbreaks.  

The need to ensure all staff completed the required Infectious Disease Prevention training was discussed with Staff 1 (Executive Director) on 09/15/22 at 11:30 am. No additional information was provided.

1. Audit has been completed with all current verteran staff members. Staff members have been asigned the infection control course and will be completed.

2. All new staff members coming on will complete the infection control training at new hire orientation to ensure they have the proper training before starting on the floor.

Staff training records will be routinely audited to assure completion of all required items during pre-service training.

3. Audits will be conducted upon completion of the new hire/general orientation process and at least twice monthly to assure ongoing compliance.

4. ED/AED

Based on interview and record review, it was determined the facility failed to have documented evidence the required 6 hours of annual dementia care in-service training was completed for 3 of 3 veteran staff (#s 5, 8 and 9). Findings include, but are not limited to:

The annual in-service training records were reviewed on 09/14/22 and revealed the following:

* Staff 5 (CG) hired 03/23/21, Staff 8 (MA) hired 12/09/20 and Staff 9 (CG) hired 02/19/20 lacked documentation of a minimum of 6 hours annual dementia care in-service training.

On 09/15/22 at 11:30 am, the above findings were reviewed with Staff 1 (Executive Director) who acknowledged the findings.

1. Audit has been completed with all current verteran staff members. Staff members have been asigned the 6 hour dementia course and will be completed.

2. ED/AED have reviewed the rules regarding staff initial and annual training to assure understanding of requirements.  ED/AED will audit employee training files twice monthly to assure ongoing complaince.

3. Twice Monthly

4. ED/AED

Based on interview and record review, it was determined the facility failed to ensure fire drills were being conducted every other month and fire drill documentation reflected all required elements. Findings include, but are not limited to:

On 09/13/22, fire drill and fire and life safety records were reviewed from 03/2022 through 09/2022. The following deficiencies were identified:

1. There was no documented evidence the facility was conducting unannounced fire drills every other month; and

2. Fire drill records failed to consistently include the following required elements:

* The escape route used;

* Evidence of alternate escape routes used;

* Residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* The number of occupants evacuated.

On 09/13/22, the need to ensure fire drills were being conducted every other month and all required elements were documented was reviewed with Staff 1 (Executive Director), Staff 3 (Regional Director), and Staff 13 (Maintenance). They acknowledged the findings.

1.Fire drill was held for this month to get back into proper rotation of fire drills.  A new calendar of fire drills/fire drill training has been created for the community to follow.  Fire drill form has been updated to assure all elements are represented.  

2. ED has reviewed rules regarding fire drill/fire drill training with the Maintenance Director and AED to assure understanding.  

ED/Designee will provide oversight weekly of the calendar to assure proper forms and drills/trainings are provided.  

ED/Designee will review completed fire drill/training documents monthly to assure accuracey.

3. Weekly/monthly as stated above

ED/Maintenance Director

Based on interview and record review, it was determined the facility failed to provide fire safety instruction for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records from 03/2022 through 09/2022 were reviewed on 09/13/22. The facility lacked documented evidence Resident 4 was being instructed on fire and life safety procedures, including designated meeting places inside or outside of the building in the event of an actual fire, at least annually.

During a group interview on 09/12/22, multiple unsampled residents indicated they had not been re-instructed, at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside or within the building in the event of an actual fire.

On 09/13/22 the need to provide and document annual fire safety instruction for residents, in accordance with the OFC was discussed with Staff 1 (Executive Director), Staff 3 (Regional Director), and Staff 13 (Maintenance). They acknowledged the findings.

1.  Residents have been provided instruction following this survey to suffice for the 2022 calendar year.  

2.  ED has reviewed requirements for annual Resident training to assure understanding.

3.  ED/Designee will review calendar of monthly fire drills and annual trainings with the Maintenance director every week to assure timely completion and verify completed documentation of both.

3. Weekly

4.ED/Maintenance Director