The findings of the re-licensure survey, conducted 04/17/23 through 04/20/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 04/20/23, conducted 08/02/23, 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 and Community Based Services Regulations OARs 411 Division 004.

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 04/20/23, conducted 10/26/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse and neglect and reported to the local SPD office as required for 1 of 1 sampled resident (#2) whose incidents were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2017 with diagnoses including risk of falls and mild cognitive impairment.

Resident 2's clinical record revealed the following:

An incident report for an unwitnessed fall, dated 04/10/23, documented: "Resident claimed [s/he] fell during the night right next to bed and had a visible bruise on [his/her] right and left arm."

During an interview on 04/19/23, Staff 2 (Health & Wellness Manager) stated the resident reported s/he fell on his/her back and endorsed back pain after the fall. There was no documentation or a report of a resident statement regarding the bruises on his/her arms.

There was no documented evidence the facility reasonably concluded and documented that the bruising to the resident's arms was a result of the fall on his/her back and was not the result of abuse or neglect. The facility did not report the injury to the local SPD office as suspected abuse or neglect.

The need to ensure injuries of unknown cause were investigated promptly and reported if necessary was discussed with Staff 1 (General Manager) and Staff 2 on 04/19/23. The surveyor requested the incident be reported to the local SPD office, and confirmation of reporting was received prior to survey exit.

The community reported bruise of unknown origin on 4/19/2023 for Resident #2 to SPD as abuse or neglect could not be resonsably ruled out at time of report.

Staff have been educated on how to report bruises/injury of unknown origin using Incident report. All staff have been retrained on the community's reportable incident policy. Health and Wellness Manager and coordinator also educated on reportable incident and abuse reporting policy.

GM will ensure that all new hire employees participate in New Employee Orientaion which includes abuse and neglect reporting.

Incident reports will be reviewed daily by the General Manger (GM) and Health and Wellness Manager (HWM). General Manager is responsible to see that the corrections are completed/monitored.    

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and/or were implemented for 2 of 6 sampled residents (#s 2 and 6). Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 05/2021 with diagnoses including chronic obstructive pulmonary disease (COPD), Alzheimer's disease, and anxiety disorder.

The resident's current service plan and most recent evaluation, updated 04/04/23, were reviewed and staff were interviewed. The following areas were identified as not being reflective of the resident's current status and care needs and/or were not implemented:

* Orientation to person, place, and time;

* Confusion;

* Frequency of re-orientation needed;

* Ability to use call system;

* Escorts needed; and

* Frequency of safety checks.

The need to ensure service plans reflected the current status and needs of residents and were implemented was discussed with Staff 1 (General Manager) and Staff 2 (Health & Wellness Manager) on 04/20/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 07/2017 with diagnoses including osteoarthritis of the hip and mild cognitive impairment.

The resident's current service plan, dated 03/05/23, and temporary service plans were reviewed, observations were made, and interviews with the resident and caregivers were conducted on 04/18/23 and 04/19/23. Resident 2's service plan was not reflective of identified needs in the following areas:

* Medication administration status;

* Non-pharmaceutical pain interventions; and

* Resident's use of a private companion.

The need to ensure service plans were reflective of the identified needs of the resident was discussed with Staff 1 (General Manager) and Staff 2 (Health & Wellness Manager) on 04/20/23. They acknowledged the findings.

Residents 2 and 6 have been re-evaluated and service plans have been updated and are now reflective of the resident's current status. The service plans provide clear direction to staff on how to appropriately manage the concerns listed in the C260 section of the Statement of Deficiencies.

Service Plan development, training was conducted by H&W Manager with the team. Service plans will be audited monthly and reviewed quarterly by Health and Wellness Manager.

The General Manager is responsible to see that the corrections are completed and monitored.        

Based on interview and record review, it was determined the facility failed to ensure they had an effective system for tracking controlled substances for 1 of 1 sampled resident (#1) who was prescribed a PRN narcotic medication. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 01/2019 with diagnoses including osteoarthritis and myalgia.

The residents 04/01/23 through 04/17/23 MARS, signed physician orders, the Controlled Substance Disposition log, and the medication card were reviewed. The following was identified:

* The resident had a signed physician order for Morphine Sulf IR 15 mg tab give ½ - 1 tab (7.5-15 mg) every six hours as needed for breakthrough pain.

* An entry in the Controlled Substance Disposition log dated 04/06/23 was not signed by the staff member who removed the tablet from the medication card.

* The number of tablets remaining on the card was blacked out on the Controlled Substance Distribution log and another number written beside it.

* There was no entry on the MAR reflecting the resident was administered PRN morphine on 04/06/23.

In an interview on 04/19/23, Staff 2 (Health & Wellness Manager) stated she was aware there had been a "medication error" for the resident on 04/06/23, and the incident had been reported to the local SPD office. On 04/20/23, Staff 2 indicated she discovered the facility had not previously reported the medication error of 04/06/23, but she had reported it on 04/18/23. A copy of the report was received.

The need for the Controlled Substance Distribution log and the MAR to match, and for any discrepancies to be investigated and documented, was discussed with Staff 1 (General Manager) and Staff 2 (Health & Wellness Manager) on 04/20/23. They acknowledged the findings.

The community has made numerous attempts to have the staff member who gave the medication come in to sign the Controlled Substance Disposition Log, however this employee resigned their position and has failed to return communication attempts. The community has reviewed video surveillance to verify this employee did infact remove the medication on the date and shift stated that it was given to the resident.  A report to SPD was completed on 4/18/2023.  

Staff training has been conducted to review company medication services policy.

Health and Wellness Manager will review the controlled substance logs weekly with the GM during established weekly 1:1 meetings.

The GM is responsible to see corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to medication orders for 1 of 2 sampled residents (#2) who had documented medication refusals. Findings include, but are not limited to:

Resident 2's MAR, dated 04/01/23 through 04/16/23, was reviewed during survey. Staff documented refusal of the following medications:

* Acetaminophen (for pain) on nine occasions; and

* Muscle rub cream (for pain) on 20 occasions.

The physician had requested to be updated for all medication refusals. There was no documented evidence the facility notified the physician when the resident refused medications between 04/01/23 and 04/16/23.  

The need to ensure the facility notified the physician or other practitioner of medication refusals was discussed with Staff 1 (General Manager) on 04/20/23. She acknowledged the findings.

Resident 2's PCP has been notified of all refused and missed medications.

Med techs have been re-trainined on proper protocol for resident refusal of medication and how to properly document details in the MAR, notifying the Health and Wellness Manager and the residents physician.

All Medication refusals will be audited and reviewed daily by Health and Wellness Manager.

General Manager will be reponsible for monitoring compliance.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed on 04/18/23 and discussed with Staff 1 (General Manager). She reported the ABST was populated by the service plan for each resident.

There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using.

The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 (General Manager) and Staff 2 (Health & Wellness Manager) on 04/20/23. They acknowledged the findings. Staff 1 was referred to the Department's ABST Policy Analyst.

The General Manager and HWM have been retrained to better explain the communities current use of staffing tool (ABST), within the Eldermark platform.

The evaluation tool includes all 22 required ADLs. The evaluation tool is used to drive an acuity score which equates to number of hours of direct care the community will schedule.

The General Manager and HWM will review communities current tool weekly and as needed to ensure that the community is staffing the appropriate staff based on acuity of residents.  

Operations Leader and General Manager reviewed company policy related to State staffing requirements as it prertains to Oregon. Community Evaluation tool consists of all 22 required ADLs to determine Acuity Based Staffing. IDR has been submitted to CBC on 5/8/2023.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation and failed to ensure ABST was updated quarterly for 1 of 2 sampled residents (#10) whose ABST were reviewed.  Findings include, but are not limited to:

a. The facility's ABST was reviewed on 08/02/23 and discussed with Staff 1 (General Manager). She reported the ABST was populated by the service plan for each resident.

There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using.

b. Review of two sampled residents' records and interviews with staff noted the ABST entries were not updated quarterly for Resident 10 whose last update was 04/10/23.

The need to have all required ADLs on the ABST, and to ensure the ABST was updated quarterly was discussed with Staff 1 (General Manager) on 08/02/23 at approximately 2:30 pm.  Staff 1 was referred to continue working with ABST Policy Analyst.

Health and Wellness Manager has reviewed the sample residents that were taken for resurvey and has compared ADLs listed in ABST tool to ADLs listed in OAR 411-054-0037.  The missing ADL's will be applied to ABST tool to ensure accurate relfection of resident care needs and service minutes for each ADL that is missing.  

Health and Wellness Manager will review all residents in Assisted Living ADLs to ensure that all 22 ADLS that are listed in OAR 411-054-0037 and the time that is needed to provide those services.  

HWM and GM will review ABST tool weekly during prearranged meeting to ensure accurate staffing patterns are being observed based on ABST.

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months, conduct fire drills every other month, and document all required components on fire drill records. Findings include, but are not limited to:

Fire and life safety records from 10/2022 through 04/2023 were requested and reviewed:

* Although the facility provided fire and life safety instruction to staff on 01/27/23, there was no evidence of consistent instruction on alternating months of fire drills.

* Fire drill records lacked the following components:

- Location of simulated fire origin was not consistently documented;

- Escape route used;

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

- Evacuation time period needed was not consistently documented;

- Number of occupants evacuated; and

- Evidence alternate routes were used during the fire drills.

* Staff interviewed on 04/18/23 were not knowledgeable of the designated point of safety.

Fire and life safety training and fire drill documentation requirements were discussed with Staff 1 (General Manager) and Staff 4 (Plant Operations Manager) on 04/18/23. They acknowledged the findings.

OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and instruction

A copy of the SOD is placed in the fire drill binder as corrections cannot be made for missed fire drills. General Manager has provided fire drill process and documentation education to Plant Operation Supervisor. Plant Operation Supervisor will ensure resident participation in relocation or evacuation and that details including escape route, education, and residents that participated or refused are recorded and will maintain documentation compliance with monthly drills.  General Manager will audit all fire drills post-drill quarterly to ensure documentation and detailed compliance.

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

Fire and life safety records from 10/2022 through 04/2023 were requested and reviewed.

There was no documented evidence a written record of fire safety training for residents, including content of the training sessions and the residents who were in attendance, was completed at least annually.

On 04/18/23, the need to ensure residents were instructed on fire and life safety procedures, at least annually, was discussed with Staff 1 (General Manager) and Staff 4 (Plant Operations Manager). They acknowledged the findings.

OAR 411-054-0090 (5) Fire and LIfe Safety:Training for residents

SOD placed in fire drill binder as the violation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor and or HWM will ensure resident has been instructed on the procedures per OFC within 24 hours of admission into Assisted Living and will be re-insturcted annually. Documentation will be keep to reflect those trainings. Weekly meeting will be held between GM and Plant Operations Supervisor to monitor compliance.

General Manager will be reponsible for monitoring compliance.     

Based on 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 C 361.

Refer C361

Based on observation and interview, it was determined the facility failed to ensure the design of the ALF supported resident needs relating to the installation of handrails at one or both sides of resident-use corridors. Findings include, but are not limited to:

The interior of the building was toured on 04/17/23 at 10:11 am. The corridor on Floor One, located in between the two resident-use dining rooms, lacked handrails. In addition, there were no handrails in the corridor leading to Elevator 3, located on Floor Two.

The need to ensure handrails were accessible to residents along corridors was discussed with Staff 1 (General Manager) and Staff 4 (Plant Operations Manager) on 04/18/23. They acknowledged the findings.

To correct the citation the community has contacted vendors to install handrails on floor one as well as floor two near elevator 3 in resident use cooridors.  Community will be in compliance by facility alleged compliance date.  

The GM is responsible to see that the corrections are completed/monitored.

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

The facility was toured on 04/17/23 at 10:11 am. The following areas were observed to need cleaning and/or repair:

Floor One

* Both dining rooms had tables with built-up debris observed on cast iron bases;

* The buffet in the small dining room was in need of cleaning and had peeling laminate;

* The wall behind the buffet in the small dining room had peeling wallpaper;

* Wood cabinets in the small dining room were scratched;

* The shelf where staff and residents could pick up the "To Go" orders, located in the large dining room, was in need of cleaning; and

* Scuffed paint was observed in multiple resident use areas.

Floor Two

* Multiple resident apartment doors were scuffed;

* The laundry room and trash room doors were scuffed and in need of cleaning;

* Insects were observed in some of the ceiling lamps along the corridors; and

* Multiple walls had areas in need of painting or cleaning.   

The environment was toured with Staff 1 (General Manager) and Staff 4 (Plant Operations Manager) on 04/18/23 at 11:00 am. They acknowledged the findings.

All identified items in SOD have been corrected. General Manager has reviewed community appearance of general building, with Guest Services Manager and Plant Operations Supervisor. Weekly walk through will be condcuted by General Manager with Guest Service Manager and Plant Operations Supervisor to ensure all areas are clean, tidy and in good repair. The General Manager is responsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure soiled clothing was laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:

The facility soiled laundry process was reviewed with Staff 16 (CG/MT) on 04/17/23 at 10:54 am. He explained all towels and linens went "downstairs" to be washed, and residents' clothing was washed by staff on Floor Two, either in the laundry room or in the resident's rooms where stackable washers and dryers were located. When asked about the process of washing soiled clothing, Staff 16 stated he rinsed the clothing out in a utility sink located in the Floor Two laundry room and washed them in a residential machine with the laundry detergent provided by the resident.

On 04/18/23 at 11:00 am, the main laundry room located on the Lobby Floor was toured. The soiled linen area was observed to have a flushing rim clinical sink with a hand-held rinsing device, provided a one-way flow of soiled laundry, and a chemical disinfectant was used with every load of laundry.  

The need to ensure all staff laundered soiled clothing in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant was discussed with Staff 1 (General Manager) and Staff 4 (Plant Operations Manager) on 04/18/23. They acknowledged the findings.

Plant Operation Supervisor and housekeeping team have been retrained on the community exposure control plan. Each new housekeeping team member will be trained on proper handling of soiled laundry by the Plant Operations Supervisor during the General Orientation.  

The Plant Operation Supervisor will conduct biweekly audits with team members to ensure adherance to communtiy soiled linen protocol.

The General Manager is responsible to see that the corrections are completed/monitored.  

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations which were subject to incidental contact by individuals. Findings include, but are not limited to:

During a tour of the facility on 04/17/23 the following observation was made:

The surface of an outdoor gas fireplace was turned on and observed on the Floor One outdoor patio. The surveyor's thermometer reached a temperature of 284.4 degrees Fahrenheit on the glass front of the fireplace.

One resident was observed during the survey walking in the vicinity of the outdoor fireplace, but was not observed to be close enough to come into accidental contact with the hot surface.

The possibility of contact with the glass front of the fireplace due to insufficient barrier to prevent incidental contact was discussed with Staff 1 (General Manager) and Staff 4 (Plant Operations Manager) on 04/18/23. They acknowledged the findings.

In order to meet compliance to this rule the outdoor fireplace has been shut down until a barrier can be installed to ensure residents do not come in contact with glass on fireplace.   

The community has contacted vendors to have a barrier placed around the outdoor fireplace.  The barrier will be installed by date of alleged compliance.

Plant Operations Supervisor will be responsible for monitoring monthy temperature readings. The General Manager is responsible to see that the corrections are completed/monitored.