The findings of the re-licensure survey, conducted 03/28/22 through 03/30/22, 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 03/30/22, conducted on 08/15/22, 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.

Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably ruled out abuse for 1 of 1 sampled resident (# 2) with a reportable incident. Findings include, but are not limited to:

Resident 2 was re-admitted to the facility in 02/2022, following a hospitalization and stay at a skilled nursing facility related to a broken ankle.

The resident's facility record, including Resident Service Notes dated 12/09/21 through 03/28/22, Incident Report & Investigations dated 12/07/21 through 03/02/22, Temporary Service Plans dated 12/08/22, Change in Service Plans dated 02/10/22 and 03/28/22, and interviews with staff identified the following:

* An Incident Report & Investigation dated 02/16/22 indicated the resident had a skin tear on his/her "inside shin of left leg."  The report stated s/he did "not know the origin of skin tear." In their documented investigation, the facility did not rule out abuse.

* An Incident Report & Investigation dated 02/23/22 stated the resident had a skin tear on his/her "right front lower leg," and staff documented s/he "had no idea" of the cause of the injury. The facility's investigation reported the resident "has fragile skin," but did not rule out abuse.

In an interview 03/29/22, Staff 3 (LPN) stated the injuries of unknown cause were not reported to the local SPD office.

The need to either reasonably rule out abuse and/or neglect for injuries of unknown cause or to report the injuries to the local SPD office was discussed with Staff  3 on 03/29/22 and with Staff 1 (Director) and Staff 2 (RCC) on 03/30/22. The facility reported the incidents to the local SPD office, per the survey team's request. Confirmation of the report was provided prior to survey exit.

1. Immediate actions taken to correct the rule violation include self reporting 2 incidents of unknown cause to APS prior to Survey exiting the community on 3/30/22. During the survey, Resident #2 had been found to have sustained skin tears to bilateral lower legs on separate dates. Skin tear identified on 2/16/22 to left lower shin, and skin tear identified on 2/23/22 to right lower shin.  Confirmation of the report was provided to the Survey team prior to survey exit.

2. The system will be corrected so this violation will not happen again by ensuring staff follow the 24 hour process where Staff fill out an incident report to initiate investigation of any incident identified in a timely manner. The community's Director and LN have reviewed the company policy and procedure to verify compliance with state regulations regarding incident investigations and required notification to APS persuant to the rule. All incidents with unknown cause will be reviewed/investigated by the Director and LN immediately to rule out abuse and neglect and to determine if APS should be notified if abuse and neglect cannot be ruled out.

3. This process will be evaluated with clinical meetings that take place on business days where IR's are reviewed/ investigated. The system will be reviewed within 30 days of implementation and thereafter during periodic quality assurance reviews to verify knowledge, understanding and compliance of the system as a whole.

4. The Director or designee will be responsible to ensure that injuries of an unknown cause will be investigated, documented and reported if necessary as required per Oregon Administrative Regulation.

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

a. On 03/29/22, the facility kitchen was observed to need cleaning in the following areas:

* Floors throughout the kitchen and dry food storage areas had black matter built up, food debris, and grease in corners, under equipment, and around perimeter edges;

* Doors and walls throughout the kitchen had a build-up of greasy smudges, spills, and splatters; and

* Interior and exterior surfaces of the freestanding oven had a heavy build-up of grease and burnt food debris.

b. The following areas needed repair:

* A trash can near the handwashing station was broken and the lid did not lift appropriately;

* The temperature control knobs on the steam table and oven (attached to the stove) were not in working order;

* The ice machine was missing the lower front cover; and

* The wall underneath the dishwashing area was missing portions of wall material.

The  kitchen was toured and areas needing cleaning and repair were discussed with Staff 1 (Director) and Staff 4 (Cook) on 03/29/22. They acknowledged the findings.

1. Immediate actions taken to correct the violations identified on 3/29/22 include creating a plan to resolve the following: Replacing the trash can located near the handwashing station, fixing the temperature control knobs on the steam table and oven, replacing the lower front cover to the ice machine, and repairing the missing portions of wall material to the wall under the dishwashing area. The Director is working with the Dietary Supervisor and kitchen staff to ensure these repairs are completed and the kitchen is kept clean and in good repair.

2. The system will be corrected so this violation will not happen again, as the Director and Dietary Supervisor have reviewed the areas identified as out of compliance during the Survey, as well as company policy and regulation standards. The cleaning schedule and self audit tool will include all components of both company policy and regulatory requirements. Completion and follow up on the cleaning and audit schedule will be enforced and staff educated on responsibilities.

3. The corrections will be evaluated/reviewed witin 30 days of implementation and every 30-90 days thereafter during periodic quality assurance reviews.  Environmental audits will be completed monthly by Dietary Supervisor and submitted to Director for review. Staff have been educated on process for reporting any sanitary or environmental concerns for follow up and repair in the interim.

4. The Director, Food Service Director and Maintenance will be responsible for ongoing compliance.  

Based on interview and record review, it was determined the facility failed to identify, evaluate, and refer changes of condition to the RN; consistently determine actions or interventions and monitor these for effectiveness; and/or to monitor through resolution for 2 of 3 sampled residents (#s 2 and 4) who experienced changes of condition. Resident 2 had repeated falls, culminating in a fall with a broken ankle. Findings include, but are not limited to:

1. Resident 2 was re-admitted to the facility in 02/2022, following a hospitalization and stay at a skilled nursing facility related to a broken ankle.

The resident's facility record, including Resident Service Notes dated 12/09/21 through 03/28/22, Incident Report & Investigations dated 12/07/21 through 03/02/22, Temporary Service Plans dated 12/08/22, Change in Service Plans dated 02/10/22 and 03/28/22, and interviews with staff identified the following:

* The resident experienced the following unwitnessed falls:

- 12/07/21 at 1:30 am, staff documented they found resident on the floor in the bathroom. No injury was noted. The intervention noted on the incident investigation report was "Resident to use call pendant for transferring and toileting." There was no documented evidence this intervention was implemented. The resident experienced a second fall at 3:50 am. Staff documented they found the resident on the floor; the resident complained of foot pain. The resident was sent to the "ER about 2 AM on 12-8-21," where the ankle was x-rayed; a sprain was diagnosed.

Interventions included "encourage/remind to call for transfer assistance (for all transfers) - on 2 hour checks"; "assist with dressing and toileting needs"; and "Sarah Lift can be used for transfers for weakness and fall prevention." There was no documented evidence the facility monitored the effectiveness of the interventions.

- 12/12/21 at 7:30 am: Resident on the floor in the bathroom. No injuries were documented. There was no documented evidence the facility developed new or relevant interventions related to fall prevention.

- 12/14/21 at "11:35ish" pm: Staff documented the resident was found on the floor next to her recliner and had no visible injury. In her investigation, the facility RN's intervention was to remind the resident to call for assistance. There was no documented evidence the facility developed new or relevant interventions related to fall prevention.

- 12/15/21 at 10:00 a.m.: Resident was found on the bathroom floor and did not have any visible injuries. The RN documented the brakes on the resident's wheelchair were "hard to apply," and handles would be added to the brakes "to see if that will be easier for [him/her]."

Resident Service Notes indicated the resident had two falls on 12/15/21, both without injury. Only one Incident Report & Investigation was provided to the surveyor. There was no documented evidence the facility developed new or relevant interventions related to fall prevention following the second fall on 12/15/21.

- 12/16/21, 11:30 a.m.: Resident was found on the floor in the bathroom. No injuries were documented on the Incident Report & Investigation. The RN did not include any interventions in her investigation.

- 12/16/21, 3:00 p.m.: Staff documented the resident fell "between wheelchair/recliner." The resident sustained skin tears to the right forearm and left elbow. The listed intervention was to "get new handles for w/c, remind resident to ask for help -  BP low will review meds."

- 12/16/21, 11:23 p.m.: Resident was found on the bathroom floor. S/he complained of pain in his/her back and hip, for which Tylenol was administered. No interventions were documented in the investigation.

An RN note on 12/16/21 indicated the resident had experienced multiple falls and his/her "BP low" after "2, high after another, VS [vital signs] were monitored recently, sent to MD." There was no documented evidence the interventions were monitored for effectiveness.

A staff note dated 12/17/21 indicated the resident  had a non-injury fall, after which "Staff/Med Aide expressed absolute importance of using pendant to leave chair." There was no documented evidence new fall prevention interventions were developed.

- 12/17/21, 4:27 a.m.: Staff documented the resident was found on the bathroom floor bleeding, with the "bone poking out of ankle." Staff called 9-1-1, and the resident was transported to the ED. The incident was reported by the facility to the local APD office 12/17/21.

After breaking his/her ankle, the resident underwent surgery to repair the ankle. An Initial Nursing Assessment dated 02/10/22 indicated the resident returned from a rehabilitation facility on 02/09/22.

The facility's previous RN resigned in early 02/2022, so she could not be interviewed.

There was no documented evidence new and relevant fall interventions were consistently developed or monitored for effectiveness when Resident 2 experienced multiple unwitnessed falls. The resident continued to experience falls in 12/2021, the last of which resulted in an ankle fracture.

The facility's failure to consistently determine actions or interventions for falls and monitor them for effectiveness was discussed with Staff 1 (Director) and Staff 2 (RCC) on 03/30/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 06/2020, with diagnoses including diabetes and osteoarthritis.

a. The resident's 02/18/22 service plan, 09/12/21 through 03/28/22 Resident Service Notes, 06/2021 through 03/12/2022 weight records, and 03/01/22 through 03/28/22 MAR were reviewed, staff were interviewed, and observations were made. The following was identified:

* Resident's documented weights were:

- 06/2021: 225 pounds;

- 07/2021: 229.4 pounds;

- 09/2021: 223.5 pounds;

- 10/12/21: 251.4 pounds;

- 11/12/21: 251.0 pounds;

- 12/12/21: 255.4 pounds;

- 01/12/22: 240.2 pounds;

- 02/12/22: 249.6 pounds; and

- 03/12/22: 259.6 pounds.

* From 09/2021 to 10/12/21, Resident 4 gained 27.9 pounds, an increase of 12.48% in his/her total body weight. This constituted a severe weight gain.

An RN assessment completed 11/22/21 indicated the resident's weight would be monitored.

* Additional severe weight gains, based on the 09/2021 weight, were noted at three months (12/12/21) and six months (03/12/22).

* Between 12/12/2021 and 01/12/22, the resident lost 15.2 pounds, or 15.95% of his/her total body weight, which constitutes a severe weight loss.

There was no documented evidence staff referred the weight fluctuations to the RN for follow-up or monitored the resident's weight.

The resident's 03/01/22 through 03/28/22 MAR indicates s/he was prescribed Torsemide (a water pill) for edema in 12/2021.

Resident 4 was observed eating breakfast and lunch on 03/28/22 and breakfast on 03/29/22. On 03/28/22, s/he ate 50% of his/her breakfast and 100% of his/her lunch. On 03/29/22, s/he ate 100% of his/her breakfast.

b. Resident 4 experienced medication changes on 01/12/22 (scheduled Tylenol added) and 02/16/22 (multivitamin, cinnamon, and garlic discontinued). There was no documented evidence these medications were monitored for adverse side effects.

The need to identify, evaluate and refer changes of condition to the RN, and monitor changes of condition through resolution was discussed with Staff 1 (Director) and Staff 2 (RCC) on 03/30/22. They acknowledged the findings.

1. Immediate actions taken to correct the rule violation for Residents #2 and 4 include: The Director, LN and RCC have evaluated and are monitoring the noted residents above, following their changes of condition which will continue until resolved. Staff training scheduled for 4/20/22 to include when and what to report to the nurse. This training will also include review of the community's current 24 hour process, which is our system to identify and monitor those residents who have had a change of condition.

2. The system will be corrected for ongoing compliance under C270 by following the community's current policy and procedure for change of condition. The Director and LN have reviewed the policies and procedures regarding change of condition and monitoring to ensure compliance under current OAR's in this area . The Communication Log (24 hour report) will be reviewed daily at stand-up (M-F) to identify changes that would require monitoring, additional interventions, incident reporting and investigation, TSP's and updates to service plans. Staff will be educated about the differences between short term change and significant changes in condition during the meeting scheduled for  4/20/22.

3. The process needing correction will be reviewed with daily clinical standup, and within 30 days of implementation and thereafter during periodic quality assurance reviews to verify compliance, knowledge and ongoing understanding.

4. The Director, LN and RCC have overall responsibility to ensure residents' conditions are assessed by RN, evaluated, monitored and documented as required per regulation.

Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed in a timely manner following severe weight fluctuations for 1 of 1 sampled resident (# 4) who experienced weight changes. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2020, with diagnoses including diabetes and osteoarthritis.

a. A review of the resident's 09/12/21 through 03/28/22 Resident Service Notes, 06/2021 through 03/12/2022 weight records, and 03/01/22 through 03/28/22 MAR, identified the following:

* From 09/2021 to 10/12/21, Resident 4 gained 27.9 pounds, from 223.5 pounds to 251.4 pounds, an increase of 12.48% in his/her total body weight. This constituted a severe weight gain.

On a quarterly Nursing Assessment dated 11/22/21, the RN documented the resident's weight gain, with enough information to be considered a significant change of condition assessment. The assessment was completed over a month after the significant weight gain was documented.

There was no documented evidence staff who entered the weight information into the computer system had referred the weight gain to the RN for follow-up.

* Additional severe weight gains, based on the 09/2021 weight, were noted at three months and six months.

* Between 12/12/2021 and 01/12/22, the resident lost 15.2 pounds, or 15.95% of his/her total body weight, which constituted a severe weight loss.

There was no documented evidence an RN had completed a significant change of condition assessment for the resident's weight loss in 01/2022.

The facility's RN resigned in early 02/2022 and had not been replaced, so it was not possible to interview her.

The need for a significant change of condition assessment, which included findings, resident status, and interventions made as a result of the assessment, to be completed by an RN in a timely manner was discussed with Staff 1 (Director) and Staff 2 (RCC) on 03/30/22. They acknowledged the findings.

1. Immediate action taken to correct the rule violation include a comprehensive review of Resident #4 who was found to have significant weight gain over the past several months. Nursing will verify current weight, and implement interventions appropriate to support weight depending on identified causative factors for weight gain. Resident will be monitored weekly to ensure the interventions in place are effective to either maintain weight or decrease weight if fluid overload is the underlying factor idenfied. Nursing will coordinate care with Resident #4's Provider to ensure timely updates and initiate any new orders as advised by the Provider.  

2. The system will be corrected so this violation will not happen again, as Staff will be educated on when to notify Nursing for significant changes such as return from higher level care, or transition to Hospice, for example. Staff will continue to follow the 24 hour process to place any Resident on alert who has sustained a change of condition for Nursing to identifiy if a significant change assessment should be completed based off OAR's. Nursing will review Monthly weights to identify any significant weight loss or gain over a period of 30, 90 or 180 days. Nursing will ensure assessments for significant change of condition be completed in a timely manner and the plan of care/ interventions in place will be monitored for effectiveness by RN. The Director and LN have reviewed the policy, procedures and state regulations regarding RN assessment for significant change of condition and monitoring. TSP's and Alert Charting will be reviewed daily at stand-up meetings to identify acute change of condition vs significant, which would require further  action/ assessment and resident specific intervention should be completed by the RN.

3. The process will be reviewed daily with clinical standup, within 30 days of implementation and thereafter during periodic quality assurance reviews to verify compliance, knowledge and understanding.

4. The Director, LN and RCC will be responsible for ensuring the corrections are completed, and RN assessments and monitoring are completed timely as needed on an ongoing basis per OAR's.

Based on observation and interview, it was determined the facility failed to ensure  all exterior pathways were made of hard, smooth material and were maintained in good repair. Findings include, but are not limited to:

Observations of the exterior areas on 03/28/22, showed drop-offs, in excess of three inches, along pathway edges in multiple areas.

Additionally, the pathways had areas of damaged, uneven, and/or cracked cement.

The need to ensure all exterior pathways were maintained in good repair and did not have potential tripping hazards was discussed with Staff 1 (Director) on 03/29/22. She acknowledged the findings.

1. Immediate actions taken to correct the rule violation include: The Director along with Director of Maintenance have evaluated findings on the report to create plan for all exterior pathway drop-offs to be filled in, and the uneven, cracked and damaged pathways noted during the survey to be repaired and  maintained.

2. The system will be corrected so this violation will not happen again through conducting periodic and scheduled checks of grounds. The "Quarterly Self-Inspection Worksheet" will include the exterior component in conjuction with Safety Committee review to ensure all exterior pathways are maintained in good repair and there are no potential areas for tripping hazards.

3. This process will be reveiwed within 30 days of implementation and thereafter during safety reviews which occur quarterly. Staff will be re-educated on the process for reporting environmental concerns as needed in the interim.

4. The Director and Director of Maintenance will be responsible to ensure that the corrections are completed and all exterior pathways are maintained and remain in good repair.  

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

Observations of the facility on 03/28/22 through 03/30/22 showed the following areas were in need of cleaning and/or repair:

a. Staff laundry room:

* Surfaces of the utility sink and surrounding walls had a build-up of brown stains and splatters;

* A section of laminate flooring was missing behind and to the sides of the washing and drying machines;

* The perimeter of the floor had a build-up of dirt and dust; and

* The laminate surface of the folding table was lifting and peeling.

b. Resident laundry room:

* Flooring under the sink was lifting and peeling and there was a build-up of black dirt and dust.

c. Visitor restroom:

* There was a large hole in the floor exposing the underlying plumbing; and

* The sink counter was missing the front section of the laminate surface material.

d. Multiple light fixtures in common areas and corridors were not working or were missing the fixture.

The areas in need of cleaning and repair were shown to Staff 1 (Director) on 03/29/22. She acknowledged the findings.

1. Immediate actions taken to correct the rule violation include review of all areas needing cleaned or repaired in the staff laundry room as well as the visitor restroom during 3/28-3/30/22 survey. The Director and Director of Maintenance have evaluated the finding and have created a "Survey Action Plan" for all tasks indicated to require cleaning and repair.

2. The system will be corrected, as the Director and Maintenance have implemented a cleaning schedule to be completed weekly by housekeeping staff in ensure environment is clean and maintained in good repair. Staff training on maintenance work orders and submission to be conducted at staff meeting on 4/20/22 for general environmental needs.

3. This process will be reviewed within 30 days of implementation and thereafter during periodic quality assurance checks and by Safety Committee quarterly using our "Safety Self-Inspection Worksheet".

4. The Director and Maintenance Director will be responsible to ensure that the corrections are made, and the environment remains clean, maintained in good repair and have adequate lighting per regulation.