The findings of the re-licensure survey, conducted 04/22/24 through 04/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 04/26/24, conducted on 10/30/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents due to staffing levels on the overnight shift. Findings include, but are not limited to:

At survey entrance on 04/22/24, the facility had 14 residents who resided in the secured memory care unit on floor one of the building, and 125 residents who resided on floors two through eight, for a total of 149 residents on eight floors.  

During an interview on 04/23/24, Staff 1 (ED) stated the facility currently staffed the overnight shift as follows:

* One CG for the locked memory care unit on floor one;

* One CG for floors two through eight; and

* One MT who floated between the locked memory care unit and floors two through eight.

When the CG in the memory care unit took breaks, including a 30-minute lunch break, the float MT stayed in the memory care unit. This left only one staff member to assist 125 residents on floors two through eight.

The facility had one resident who required two-person assistance for transfers and incontinence care, and did require assistance at night, as identified in his/her service plan. The resident resided on the second floor. The current staffing plan did not allow for his/her care needs to be met at all times. Additionally, when that resident did get care assistance, that meant no other staff was available to assist with any medication needs, provide additional memory care unit support, or address the needs of the other 124 residents on floors two through eight.

When asked whether the current staffing plan allowed for safe evacuation of residents in the case of an emergency, Staff 1 stated they did not have any documentation of evacuation drills or documentation of how staff would ensure the health and safety of residents in the case of an emergency which required evacuation.

On 04/25/24, the survey team requested two additional caregivers be added to the overnight shift for floors two through eight. The facility agreed, and provided documentation as to how they would meet this staffing plan.

The need for the facility to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, especially as related to sufficient staffing on the overnight shift, was reviewed with Staff 1, Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/25/24. They acknowledged the findings.

1. Facility has trained the NOC receptionist as a caregiver. Facility has also added 1 additional direct care staff to the NOC shift. There will be 5 total staff onsite overnight, able to aid in an evacuation if needed. Floors 1 and 2 will have designated one staff person each.

2. Facility has implemented additional staff support overnight by way of 1 additional direct care staff and training the NOC receptionist on caregiving duties. These additions are reflected in facility staffing plan.

3. Staffing plan will be evaluated following ABST updates no less than quarterly for for move ins, changes of condition and acuity changes.

4. The Executive Director or Designee.

2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's dementia.

The resident's 03/01/24 through 04/22/24 MARs and physician's orders were reviewed and identified the following:

Resident 6 had physician's orders:

*03/06/24: Tylenol 325 mg, take 2 tabs (650 mg) four times a day, not to exceed 3,500 mg daily, and the order was changed as follows:

*04/16/24: Tylenol 500 mg, take 2 tabs (1000mg) four times a day.

A review of the MARs showed from 03/01/24 through 04/22/24 the resident was receiving Tylenol 500 mg, 2 tabs (1000 mg) four times a day for a total of 4,000 mg per day.  

Interviews with Staff 3 (Director of Nursing) and Staff 18 (RN) showed the MAR was inaccurate. The resident had been receiving Tylenol 325 mg - 2 tabs (650 mg) four times a day on 03/01/24 through 04/16/24 when the physician changed the order to Tylenol 500 mg (1000 mg) four times a day. Staff 3 and Staff 18 determined the order change had been entered into the electronic MAR system incorrectly on 04/16/24. The MAR did not reflect accurately the correct dosage had been administered 03/01/24 through 04/16/24.

The need to ensure resident MARs were accurate was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate related to order transcription and order changes for 2 of 5 sampled residents (#s 2 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2012 with diagnoses including bladder cancer and major depressive disorder.

A review of Resident 2's 04/01/24 through 04/21/24 MAR, physician's orders, and Progress Notes dated 01/01/24 through 04/21/24 identified the following:

A physician's order dated 04/03/24 stated, "Dermaseptin to buttocks area. After peri care at each brief change, apply dermaseptin [sic] cream to buttocks area. You do not need to completely remove previous layer of barrier cream as it is meant to build up a barrier to moisture over several applications."

The order was incorrectly transcribed on the MAR as, " ...After peri care at each brief change, apply dermaseptin cream to buttocks area; remove the previous layer of barrier cream ..."

The need to ensure MARs were accurate related to transcribed physician's orders was discussed with Staff 1 (ED), Staff 3 (Director of Nursing/RN) and Staff 21 (Quality Coordinator) on 04/26/24. They acknowledged the findings.

1. MAR for Resident 2 has been corrected to indicate the order as prescribed. MAR of Resident 6 has been corrected to indicate accurate start and end dates as precribed for different dosages.

2. Facility has implemented a multiple-step process for new medication order approvals. This process will now require a med tech, RCC and nurse to review the order both as prescribed and as it's transcribed to assure MAR accuracy. Additionally, the staff responsible for the order approval process have been trained on this process.

3. MARs will be reviewed quarterly.

4. Resident Care Coordinator and Director of Nursing.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to:

On 04/23/24, the facility identified their current staffing level during the overnight shift to be:

* One CG for the locked memory care unit on floor one;

* One CG for floors two through eight; and

* One MT who floated between the locked memory care unit and floors two through eight.

This was not sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident and to ensure a minimum of two direct care staff were available at all times for a resident who required two person care assistance.

The need to have a sufficient number of staff in each building to meet all scheduled and unscheduled needs of residents on the overnight shift, including a minimum of two direct care staff available at all times for a resident who required two direct care staff, was discussed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing) on 04/24/24 and 04/25/25. They acknowledged the findings.

Refer to C 160.

1. Facility has trained the NOC receptionist as a caregiver. Facility has also added 1 additional direct care staff to the NOC shift. There will be 5 total staff onsite overnight, able to aid in an evacuation if needed. Floors 1 and 2 will have designated one staff person each.

2. Facility has implemented additional staff support overnight by way of 1 additional direct care staff and training the NOC receptionist on caregiving duties. These additions are reflected in facility staffing plan.

3. Staffing plan will be evaluated following ABST updates no less than quarterly for for move ins, changes of condition and acuity changes.

4. The Executive Director or Designee.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) to specify the total number of minutes required to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:

The ABST was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/23/24 and 04/24/24.

The facility had a census of 149 residents when the survey team entered on 04/22/24. The facility consisted of two segregated areas:

* Floor one, a secured memory care unit with 14 residents; and

* Floors two through eight with 125 residents.

During the acuity interview on 04/22/24, staff identified one resident on floors two through eight who required two direct care staff to assist him/her.  

Residents on floors four through eight would need to descend stairs to evacuate the facility in the case of an emergency event in which the elevators would be inoperable.

During an interview on 04/25/24, Staff 1 and Staff 2 stated they were not currently accounting for evacuation needs, an unscheduled need, on the ABST.

The current ABST did not account for staffing two segregated areas and having two direct care staff available at all times for residents who required two direct care to assist them.

The need to ensure the ABST specified the total number of minutes required to the meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 and Staff 3 on 04/25/24. They acknowledged the findings.

1. Facility has trained the NOC receptionist as a caregiver. Facility has also added 1 additional direct care staff to the NOC shift. There will be 5 total staff onsite overnight, able to aid in an evacuation if needed. Floors 1 and 2 will have designated one staff person each.

2. Facility has implemented additional staff support overnight by way of 1 additional direct care staff and training the NOC receptionist on caregiving duties. These additions are reflected in facility staffing plan.

3. Staffing plan will be evaluated following ABST updates no less than quarterly for for move ins, changes of condition and acuity changes.

4. The Executive Director or Designee.

Based on interview and record review, it was determined the facility failed to ensure written fire drill records were kept that included all required information per the Oregon Fire Code (OFC) and have documented evidence fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

On 04/25/24, fire and life safety records dated 12/12/23 through 03/13/24 were reviewed. Fire drill documentation did not include one or more of the following required elements:

* Escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drill;

* Evacuation time-period needed; and

* Number of occupants evacuated.

Documentation of fire and life safety training for staff was provided, however the documentation did not include information on the date of the training and staff members who attended or participated in the training.

The need to ensure fire drill documentation included required components and documented evidence staff training was completed on alternating months was discussed with Staff 1 (ED), Staff 2 (Regional Director Health Services/RN), Staff 6 (Maintenance Director), and Staff 23 (Maintenance Assistant) on 04/25/24. They acknowledged the findings.

1) Fire drills and Staff Fire & Life safety trainings will be completed on alternating months and documented in accordance with OFC required drill components, including the date of the training and staff members who attended or participated in the training.

2) Scheduled monthly drills will be completed following new fire drill form that contains required elements, adding: Escape route used; Problems encountered, comments relating to residents who resisted or

failed to participate in the drill; Evacuation time-period needed; and Number of occupants evacuated.

3) Fire drills and Fire & Life safety training will be reviewed monthly for completion.

4) Maintenance Director, Executive Director or designee.

Based on observation and interview, it was determined the facility failed to ensure the design of an RCF emphasized a residential appearance while retaining the features required to support special resident needs relating to handrails installed on one or both sides of resident-use corridors. Findings include, but are not limited to:

During a tour of the RCF on 04/23/24 at 09:20 am the following was identified:

Approximately 40 feet of corridor on the third floor separating the swimming pool on one side, and the beauty salon on the other side, did not include handrails on either side of the corridor.

The need to ensure handrails were installed on one or both sides of resident-use corridors was discussed with Staff 1 (Executive Director) on 04/25/24. He acknowledged the findings. No further information was provided.

1. Facility will install a handrail on one side of the relevant corridor and in compliance with OAR.

2. Facility will ensure the handrail is installed as required by OAR.

3. This will be evaluated upon installation, after which will not require ongoing evaluation.

4. Maintenance Director, Executive Director or designee.

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

During a tour of the facility on 04/23/24 at 9:20 am, the following was identified:

a. Common areas in the RCF portion of the facility:

* Handrails throughout the facility were worn and had exposed wood, especially on the fourth floor;

* Dust was accumulated on the wall behind the dryers in the laundry rooms on the fourth, fifth, and six floors;

* Numerous fluorescent light fixtures in the facility stairwells were lacking fixture covers;

* Gap in drywall under the air duct in the commercial laundry room; and

* Numerous ceiling vent grates were covered with dust.

b. Dining area in MCC part of the building:

* Various light fixtures with dead bugs inside;

* Finish on wood around dishwasher worn off; and

* Worn and damaged cabinet frames and doors and missing drawers in the kitchen island cabinets.

c. Building Exterior:

* The area outside the trash dumpster contained old furniture, appliances, and other discarded items;

* The exterior building wall near the trash dumpster had a large, L-shaped hole;

* The meditation garden area dirty with rusty firepit and old, soiled furniture;

* Third-floor patio grill and grill grates dirty, rusted, and covered with baked-on grease; and

* Pan with collected grease on ground next to grill on patio.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) and Staff 6 (Maintenance Director) on 04/23/24, 04/24/24, and 04/25/24. They acknowledged the findings. No further information was provided.

1. Findings have been addressed, cleaned or repaired. Old appliances, refuse items and existing patio grills have been discarded.

2. The maintenance walkthrough checklist has been updated to include monitoring of finding areas. These areas will be monitored for compliance on a routine basis to ensure the environment is maintained, clean and in good repair.

3. Maintanence will conduct quarterly walkthrough inspections.  

4. Maintenance Director, Executive Director or designee.

Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility. Findings include, but are not limited to:

The building was toured on 04/23/24 at 09:20 am. Observations and interviews with staff confirmed RCF residents were able to exit the facility from a door on the second floor adjacent to the elevator and which led to an employee entrance. The route did not have a functioning alarm or other system to alert staff when residents exited the building.

In the MCC portion of the facility, two doors leading from the dining area to the secured courtyard were observed without a functioning alarm system to alert staff when a resident exited the building into the courtyard.

On 04/25/24, Staff 1 (Executive Director) demonstrated a temporary system installed on 04/24/24 in the MCC dining area that included audible door chimes, although the chimes were not loud enough to be widely audible. During the survey, staff ordered a pager-based door alarm system to be installed as a replacement.

The need to ensure the facility had an alarm or other acceptable system to alert staff when residents exited the RCF and MCC was discussed with Staff 1 and Staff 2 (Regional Director of Health Services/RN) on 04/25/24. They acknowledged the findings. No further information was provided.

1. Doors without proper notification systems installed have been identified.

2. Door notification transmitters have been added to the loading dock and memory care courtyard doors to notify staff when opened.

3. Door notification system will be evaluated quarterly as part of maintenance inspections.

4. Maintenance Director, Executive Director or designee.

Concerns were identified and the facility was provided with technical assistance in the following area:

H 1515: OAR 411-004-0020 (2) Physical Setting: Individual Accessible

(b) The setting is physically accessible to an individual.

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

Refer to C 160, C 360, C 361, C 420, C 511, C 513, C 555.

Refer to C 160, C 360, C 361, C 420, C

511, C 513, C 555.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 9, 11, 12 and 22) completed all required pre-service orientation and dementia training topics; 3 of 3 newly-hired direct care staff (#s 9, 11 and 12) completed all additional pre-service dementia training topics; and 2 of 2 long term non-care staff (#s 5 and 24) completed annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 04/23/24 through 04/25/24.

1. There was no documented evidence Staff 11 (MT), hired 12/24/23, Staff 12 (CG), hired 03/04/24, Staff 9 (CG), hired 03/11/24 and Staff 22 (Housekeeping Assistant), hired 03/04/24, completed one or more of the following pre-service orientation and dementia training topics:

* Infectious Disease Prevention;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach.

2. There was no documented evidence Staff 9, Staff 11 and Staff 12 completed one or more of the following pre-service dementia training topics required of direct care staff:

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and

* Use of supportive devices with restraining qualities in memory care communities.

3. There was no documented evidence Staff 5 (Activities Director), hired 07/12/21, and Staff 24 (Assistant Chef), hired 06/04/14, completed the required annual infectious disease training.

The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules was discussed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN), Staff 3 (Director of Nursing/RN), Staff 19 (RCC) and Staff 21 (Quality Coordinator) on 04/25/24. They acknowledged the findings.

1. Training plans have been audited and missing elements identified. Existing employees have been assigned the missing courses.

2. Training plans have been adjusted to include courses that provide required training elements in accordance with regulation.

3. Staff training will be reviewed on a monthly basis to assure completion.

4. Human Resources Generalist, Executive Director or designee.

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

Refer to C 310.

Refer to C310

Based on observation and interview, it was determined the facility failed to ensure access to secured outdoor space and walkways allowed residents to enter and return without staff assistance. Findings include, but are not limited to:

During a tour of the RCF on 04/23/24 at 09:20 am the following was identified:

In the MCC portion of the facility, two doors leading from the dining area to the secured courtyard were observed to be difficult for residents to open from the courtyard side, requiring the assistance of staff to allow residents to return to the dining area.

The need to ensure access to secured outdoor space and walkways allowed residents to enter and return without staff assistance was discussed with Staff 6 (Maintenance Director) on 04/23/24 and Staff 1 (Executive Director) on 04/25/24. They acknowledged the findings. No further information was provided.

1. The door has been inspected and was found easy to use at time of inspection.

2. The door handle has been lubricated as preventative maintenance and to promote ease of use.

3. The ease of use will be evaluated quarterly as part of maintenance walk through inspections.

4. Maintenance Director, Executive Director or designee.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, and outdoor furniture was of sufficient weight, stability, and design not to aid in elopement. Findings include, but are not limited to:

During a tour of the RCF on 04/23/24 at 09:20 am the following was identified:

The fence surrounding the secured courtyard was missing one board and had numerous other smaller gaps, the gate separating the secured courtyard from the exterior area was only five feet, eight inches high, and the secured courtyard contained various chairs that could aid in resident elopement.

The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, and outdoor furniture was of sufficient weight, stability, and design not to aid in elopement was discussed with Staff 6 (Maintenance Director) on 04/23/24, and Staff 1 (Executive Director) and Staff 2 (Regional Director of Health Services, RN) on 04/24/24 and 04/25/24. They acknowledged the findings. No further information was provided.

1. The Memory Care Courtyard fence boards were secured and gate replaced on 4/24/24. The outdoor furniture in question was removed from the area to be further assessed for sufficient weight on 4/23/2024.

2. Maintenance has been trained on the importance of security as it pertains to the Memory Care fence and outdoor furnings.

3. The Memory Care Fence and furnishings will be evaluated quarterly.

4. Maintenance Director, Executive Director or Designee.