The findings of the re-licensure survey, conducted 01/11/23 through 01/13/23, 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, 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

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 revisit to the re-licensure survey of 01/13/23, conducted 06/14/23, 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 1 was admitted to the facility in 10/2022 with diagnoses including dementia and macular degeneration. The resident's progress notes, dated 10/31/22 through 01/09/23, were reviewed. The following incidents were identified:

* 11/10/22 - CG noted a skin tear on resident's right arm; and

* 11/11/22 - MT noted a bruise on the resident's left hand.

Some components of an investigation were documented for each incident. However, the facility's investigations failed to document all required components, reasonably conclude the injuries of unknown cause were not a result of abuse, or report the incidents to the local SPD office if warranted after an immediate investigation.  

The facility was requested to report the above two incidents to the local SPD office during survey.

The need to ensure the facility immediately investigated a physical injury of unknown cause, and if the investigation could not reasonably conclude the injury was not a result of abuse, report it to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/12/23. They acknowledged the findings.   

The facility provided documented evidence they reported the two incidents on 01/13/23 at 10:24 am.

Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule-out abuse, document all required areas of an investigation, and report incidents to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 2 of 2 sampled residents (#s 1 and 2) with injuries of unknown cause. Findings include, but are not limited to:

1. Resident 2 was admitted to the MCC in 09/2021 with diagnoses including Parkinson's disease.   

Resident 2's progress notes, dated 10/04/22 through 01/03/23, were reviewed and the following injuries of unknown cause were identified:

* 10/18/22 - Avulsion (skin tear) to left elbow;

* 11/06/22 - Skin tear to right arm;

* 11/20/22 - Bruising to left forearm; and

* 11/23/22 - Skin tear to left arm.

Some components of an investigation were documented for each incident. However, the facility's investigations failed to document all required components, reasonably conclude the injuries of unknown cause were not a result of abuse and/or report the incidents to the local SPD office.

The facility was asked to report all four injuries of unknown cause to the local SPD office prior to survey exit. Confirmation was received on 01/13/23.

The need to investigate injuries of unknown cause immediately, document all required components of the investigation, and report the incident to the local SPD office if abuse and/or neglect could not be ruled out was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings.

1. Resident #2, community self-reported to the State of Oregon at the time of survey unknown origin to include 10/18/22 avulsion/skin tear to left elbow, 11/6/22 skin tear to right arm, 11/20/22 bruising to left forearm, 11/23/22 skin tear to left arm.  Resident #1, community self-reported to State of Oregon at the time of survey unknown origin to include 11/10/22 skin tear to right arm, 11/11/22 bruise to left hand.

2. Immediately/during the survey process a review of internal policies took place to confirm policy meets required standards. Staff have been in-serviced on documentation to requirements related to mandatory abuse reporting reflective of the abuse decision tree and mandatory requirements. All injuries will be investigated immediately with documentation to include required components. Staff have have been in-serviced specific to mandatory reporting requirments, injury investigations and proper documentation.

3. Daily.

4. Enliven Director, Executive Director, Assistant Executive Director.   

2. Resident 2 was admitted to the MCC in 09/2021 with diagnoses including Parkinson's disease.

The resident's most recent evaluation, dated 09/15/22 was reviewed during the survey.

An updated quarterly evaluation was requested from Staff 8 (Enliven Director) on 01/11/23.

There was no documented evidence a quarterly evaluation was completed timely.

The need to ensure residents were evaluated quarterly was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 on 01/13/23. They acknowledged the findings.

3. Resident 3 was admitted to the MCC in 08/2021 with diagnoses including dementia and mild cognitive disorder.

The resident's most recent quarterly evaluation, dated 11/11/22, was not made available to staff.

During an interview on 01/11/23, Staff 8 (Enliven Director) confirmed she had completed the evaluation and forgot to print it out for staff. Staff 8 also confirmed direct care staff do not have access to view the evaluation electronically.

The need to ensure resident evaluations were made available to staff was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 on 01/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a new move-in evaluation documented all required elements of the evaluation for 1 of 1 new resident (#1) and quarterly evaluations were completed and/or available to staff for 2 of 2 residents (#s 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including dementia, macular degeneration, and hypertension. The 10/27/22 evaluation lacked the following elements:

* Routine preferences, including eating;

* Effective non-drug interventions for mental health issues;

* Personality, including how the person copes with change;

* Pain, including pharmaceutical and non-pharmaceutical interventions and how the person expresses pain or discomfort; and

* Environmental factors that impact behavior, including, noise, lighting, and room temperature.

The need to ensure new move-in evaluations documented all required elements was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings.

1. For Resident #1, #2, #3, we reviewed and updated evaluation documents with all required elements and resident #1, #2, #3 evaluations available to staff.  

2. A review of evaluation of required elements are included and personalized to each resident. We have updated the Oregon Health and Service Evaluation Tool to capture required elements. Quarterly evaluations are updated and current to reflect current resident needs.

3. Weekly for reevaluation or change in condition to maintain compliance with updates for resident need.

4. Enliven Director, Executive Director, Assistant Executive Director

2. Resident 2 was admitted to the MCC in 09/2021 with diagnoses including Parkinson's disease and dementia.

Observations were made, interviews with the resident's family and the facility staff were conducted, and the resident's most current service plan, dated 09/19/22, was reviewed.

a. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Use of geri-sleeves (for protecting fragile skin);

* Gluteal wounds and interventions;

* Shower transfer status;

* Toilet transfer status;

* Sit to stand lift;

* Assistance with evacuation;

* Use of compression sock and non-skid sock; and

* Splinting instructions.

b. The service plan was not adhered to in the following areas:

* Cueing for aspiration precautions; and

* Glasses.

c. An updated service plan was requested from Staff 8 (Enliven Director) on 01/11/23. No additional documentation was provided.

The need to ensure service plans were updated quarterly, were reflective of the current needs of the resident, provided clear caregiving instruction to staff and were followed was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 on 01/13/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of residents' needs, provided clear direction regarding the delivery of services, were accessible to staff and were followed for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2021 with diagnoses including dementia.

The most recent service plan available to staff was completed 06/14/22.

During an interview on 01/11/23, Staff 8 (Enliven Director) confirmed she had completed the quarterly service plan on 11/11/22; however, she forgot to print it for direct care staff to review.

The need to ensure service plans were accessible to staff was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 on 01/13/23. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 10/2022 with diagnoses including, dementia, macular degeneration and hypertension.

Observations were made, interviews with Witness 1 (Family Member) and facility staff were conducted, and the resident's most current service plan, dated 12/30/22, was reviewed during the survey.

a. The service plan was not reflective, lacked information, and/or did not provide clear direction to staff in the following areas:

* Use of hoyer lift for transfers;

* Evacuation assistance instructions;

* Frequency of incontinence checks;

* Activity preferences and assistance;

* Shower frequency and persons responsible;

* PT/OT evaluation for fall risk;

* Level and type of assistance for communication and cognitive impairments;

* Level and type of assistance for behaviors (for example, when calling out "help me");

* Instructions for oxygen delivery; and

* Assistive/adaptive devices including fall mattress.

b. The service plan was not adhered to in the following areas:

* Placement of hearing aids;

* Providing extensive assistance with meals; and

* Offering favorite foods at mealtimes.

The need to ensure service plans were reflective of the current needs of the resident, provided clear caregiving instruction to staff, and were followed was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings, and no additional documentation was provided.

1. Resident #1, #2, #3, service plans updated and personalized with clear direction and reflective of current needs and personal preferences for each resident.

2. Service plans are updated and current to reflect the individualized need of each resident and accessable in the the service plan binder for staff. Updated Oregon Health and Service Evaluation Tool to include required elements is completed for Residents.

3. Reviewed weekly and updated unless significant change in condition.

4. Enliven Director, Executive Director, Assistant Executive Director  

Based on observation, interview and record review, it was determined the facility failed to ensure resident changes of condition were evaluated, resident specific interventions were determined, documented and communicated to staff on each shift, the determined interventions or actions were monitored consistent with the residents evaluated needs and service plan, and conditions were monitored per the residents' evaluated needs with weekly progress noted until the condition resolved for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Resident 1 experienced severe and ongoing weight loss. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including dementia, pulmonary embolism, macular degeneration and other fatigue.

a. Resident 1's clinical records including weight records dated 10/31/22 through 01/05/23, evaluations and service plans dated 10/28/22 through 12/30/22, MARs dated 12/01/22 through 01/11/23 and progress notes identified Resident 1 experienced a significant change of condition pertaining to weight loss.

Weight records showed Resident 1 experienced severe and ongoing weight loss between 10/31/22 and 01/11/23.  

The following weights were documented in Resident 1's weight record:

* 10/31/22 - 173 pounds;

* 12/05/22 - 177.4 pounds;

* 12/27/22 - 162.2 pounds; and

* 01/05/23 - 161.2 pounds.  

On 01/11/23 at 1:03 pm, Staff 10 (MT/CG) reported the resident's weight as of that day was 160 pounds.

From 12/05/22 through 01/05/23, the resident lost 16.2 pounds which consisted of a severe weight loss of 9.13 % total body mass in 30 days. Between 01/05/23 and 01/11/23 the resident continued to lose weight.

The service plan, dated 12/30/22 reflected that the resident required full assistance with all ADL care including, "Extensive" assistance for meal consumption. The service plan directed caregiving staff to provide regular encouragement to select menu items and that the resident liked "Mexican food, steak. Favorite dessert is ice cream, [s/he] especially likes vanilla. [S/he] likes apple, cranberry juice. Current diet orders are [mechanical] soft with thin liquids."  

Resident 1's MAR reflected the intervention of a nutritional drink began on 12/09/22 and directed staff to, "Give nutritional drink of choice twice daily if skipping meals," and to "offer milk shake if resident skips meal or lack of intake."

Progress notes on the following dates identified the resident missing meals and having a lack of intake for multiple meals:

* 11/16/22 - 50% of dinner and eight ounces of fluids;

* 11/17/22 - "Ate couple bites of breakfast/lunch, offered milk shake made by kitchen;"

* 11/19/22 - Refused breakfast;  

* 11/20/22 - Missed breakfast and lunch;

* 11/21/22 - Ate "about 50% of dinner" with the resident's daughter assisting;

* 12/16/22 - Refused dinner;

* 12/18/22 - Refused breakfast and ate half of the soup for lunch;

* 12/20/22 - Refused breakfast, ate 20% of dinner and drank two ounces of juice with no mention about the afternoon meal;

* 12/22/22 - Refused breakfast and ate 20% of dinner;

* 12/23/22 - Slept through breakfast, ate 50% of lunch and 40% of dinner;

* 12/24/22 - Refused breakfast, ate 50% of lunch and 20% of dinner with daughter assisting resident; and

* 12/25/22 - Refused breakfast.  

There was no documented evidence the intervention for a nutritional drink was offered or if it was, how much of the drink the resident consumed in the resident's clinical record.

The following was observed on 01/11/23 and 01/12/23:

On 01/11/23 at 11:27 am lunch was served. The resident picked up an empty spoon and put it in his/her mouth. S/he repeated this four times. At 11:37 am staff asked the resident, "Do you want a bite?" Staff was observed to give Resident 1 another bite, then walked away.

Resident 1 picked up an empty spoon and attempted to take a bite of food 18 times. Staff approached the table as the resident was asking for help to get closer to the table. Staff assisted with getting him/her closer and walked away. Resident 1 tried to eat from the empty spoon three more times.

At 12:07 pm, staff asked the resident if s/he was, "still doing ok" and Resident 1 replied, "I'm finished." Staff removed the plate. At 12:08 pm, Resident 1 stated to the staff, "Can I get something to eat? Something like breakfast? I want a good meal." Staff replied, "Do you want dessert for lunch?" Another staff member approached the resident and offered ice cream, and the resident agreed and said, "That would be good." Staff brought mint chocolate chip ice cream to Resident 1. The resident's service plan reflected vanilla was his/her favorite flavor.

On 01/12/23 at 10:25 am, Resident 1 was observed with a nutritional shake and applesauce. Staff was assisting the resident with eating and drinking. At 10:32 am, the staff member walked into another room. At 10:33 am, a different staff member approached the resident and sat next to him/her. The staff member wiped the resident's mouth occasionally but was not observed to assist the resident with eating or drinking. Resident 1 ate 5 to 10% of the applesauce and 20% of nutritional supplement.

On 01/12/23 at 12:17 pm, lunch was brought into the dining room. Resident 1 was still at the dining room table from the earlier observation. Staff brought the resident orange juice, although his/her service plan reflected that apple and cranberry juice were his/her preferred beverages. The resident also was given cottage cheese and a cup of water. Resident 1 was observed to begin feeding him/herself, with spilling noted. By 12:22 pm, the resident no longer attempted to eat on his/her own. There were no staff observed assisting the resident to eat.

At 12:27 pm, kitchen staff delivered a plate of a chopped up hamburger. The resident attempted to scoop pieces of hamburger from the left corner of the plate then brought an empty spoon to his/her mouth five times. At 12:37 pm, Resident 1 picked up a piece of bun with his/her fingers, placed it in his/her mouth, attempted to chew it, then spit it out and coughed. Staff observed that then stated, "I'll get you a peanut butter and jelly sandwich." At 12:40 pm, the resident took a small piece of hamburger with his/her fingers and put it in his/her mouth, attempted to chew it, then spit that out as well.

At 1:04 pm, the resident told activity staff that s/he was done. There was no observation a peanut butter sandwich was offered.

There was no documented evidence the facility evaluated Resident 1's severe weight loss and monitored the resident's continued weight loss consistent with his or her evaluated needs and service plan.

The need to ensure resident significant changes of condition were evaluated, resident specific interventions were determined and documented, communicated to staff on each shift and made part of the resident's record was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/12/23. They acknowledged the findings.

b. The following short-term changes of condition were identified:

* 11/11/22 - Right upper body bruising;

* 11/15/22 - Return from the emergency room;

* 11/30/22 - Yeast rash;

* 12/15/22 - Return from a hospital admission; and

* 12/24/22 - Fall out of bed.

There was no documented evidence that resident specific interventions were determined and documented, communicated to staff on each shift, interventions were made part of the resident's record, and weekly progress noted until the condition resolved.  

The need to ensure resident changes of condition were evaluated, resident specific interventions were determined and documented, communicated to staff on each shift and made part of the resident's record with weekly progress noted until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/12/23. They acknowledged the findings.  

2. Resident 2 was admitted to the MCC in 09/2021 with diagnoses including Parkinson's disease and dementia.

Resident 2's progress notes, dated 10/04/22 through 01/10/23 were reviewed and revealed multiple changes of condition.

a. The following changes of condition lacked documented evidence monitoring instructions and/or interventions were communicated to staff:

* 10/07/22 - Flu vaccination;

* 12/30/22 - Gluteal wound; and

* 01/07/23 - Right forearm skin tear.

b. The following changes of condition lacked documented evidence monitoring instructions and/or interventions were communicated to staff with progress noted, at least weekly, through resolution:

* 10/17/22 - Right arm skin tear;

* 10/18/22 - Left elbow avulsion;

* 11/06/22 - Right arm skin tear;

* 11/14/22 - Covid vaccination;

* 11/20/22 - Left forearm bruising;

* 11/23/22 - Left arm skin tear;

* 12/13/22 - Cough, fatigue and change in ADL needs;

* 12/20/22 - Return from a hospital admission; and

* 12/30/22 - Diet change and increased pocketing.

The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff and documented progress, at least weekly, until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 08/2021 with diagnoses including dementia.

The resident's progress notes, dated 10/02/22 through 01/04/23 were reviewed and identified multiple changes of condition.

a. The following changes of condition lacked documented evidence monitoring instructions and/or interventions were communicated to staff and lacked monitoring with progress noted, at least weekly, until resolved:

* 10/07/22 - Flu vaccination;

* 11/11/22 - Behavior which included a new intervention to give as needed pain medication;

* 11/14/22 - Covid-19 vaccination;

* 11/24/22 - Emesis and sent to emergency room;

* 11/27/22 - Return from hospital stay; and

* 11/27/22 - New medication and treatment orders.

The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff and documented progress, at least weekly, until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings.

1. Resident #1, #2, #3 Change in condition was evaluated and monitored. Interventions determined and documented at least weekly until resolution. Temporary Service Plan completed, communicated and available for staff.

2. Utilization of temporary service plan initiated until resolution of short term changes in condition. Ongoing communication from direct care staff to Enliven Director, community RN, ED, Asst. ED. For long term change in condition, a new evaluation is intiated with input from resident, responsible party, direct care staff, Enliven Director, Health Care Provider(s). Interventions will be implemented by care staff. Ongoing documentation of resident's care plan will be included. Effectiveness of interventions will be documented on the care plan. Staff have been in-serviced on described procedures above in numbers 1. and 2.

3. Anytime there is a change in condition.

4. Enliven Director, Executive Director, Assistant Executive Director.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status, interventions made as a result of the assessment as well as the assessment was completed timely for 1 of 2 sampled residents (#1) reviewed for significant changes of condition. Resident 1 experienced severe and ongoing weight loss. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including dementia, pulmonary embolism, macular degeneration and other fatigue.

a. Resident 1's clinical records including weight records dated 10/31/22 through 01/05/23, evaluations and service plans dated 10/28/22 through 12/30/22, MARs dated 12/01/22 through 01/11/23 and progress notes identified Resident 1 experienced a significant change of condition pertaining to weight loss.

Weight records showed Resident 1 experienced severe and ongoing weight loss between 10/31/22 and 01/11/23.  

The following weights were documented in Resident 1's record:

* 10/31/22 - 173 pounds;

* 12/05/22 - 177.4 pounds;

* 12/27/22 - 162.2 pounds; and

* 01/05/23 - 161.2 pounds.  

On 01/11/23 at 1:03 pm, Staff 10 (MT/CG) reported the resident's weight as of that day was 160 pounds.

From 12/05/22 through 01/05/23, the resident lost 16.2 pounds which constituted a severe weight loss of 9.13 % in 30 days. Between 01/05/23 and 01/11/23 the resident continued to lose weight.

In a 12/12/22 progress note, the facility RN noted poor intake, bilateral lower leg edema and that the family was aware of the resident not at baseline relating to eating and drinking.

There was no documented evidence the RN completed an assessment which included documentation of findings, the resident's status and interventions made as a result of the assessment for Resident 1's severe weight loss.

The need to ensure significant changes of condition that were assessed by an RN included documentation of finding, the resident's status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/12/23. They acknowledged the findings.

Refer to C 270, example 1a.  

b. Resident 1 was admitted to hospice services on 12/21/22 which constituted a significant change in the resident's condition.

On 01/04/23, the facility RN documented a "Change of Condition - Admit to Hospice - 12/21/22" assessment in the progress notes.

There was no documented evidence that the RN completed an earlier, thus timely assessment for the resident's admission to hospice services.

The need to ensure significant changes of condition had a timely assessment completed by an RN was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/12/23. They acknowledged the findings.

1. Resident #1 assessed by RN and documented findings on resident status and interventions made as a result of RN assessment

2. Enliven Director and Health Service Team, including community RN, will meet weekly to discuss each resident and address any concerns. Community RN to complete timely assessment and document findings.Community RN to participate in service plans related to significant changes in condition.

3. As needed, reviewed weekly.

4. Enliven Director, Executive Director, Assistant Executive Director, Community RN.  

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 2 sampled residents (# 2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 09/2021 with diagnoses including Parkinson's disease and dementia.

During the acuity interview on 01/11/23, the resident was identified to receive home health services.

Resident 2's outside provider notes, dated 10/18/22 through 01/10/23, were reviewed during the survey and revealed the following recommendations:

* 10/25/22 - "Please put plastic bag etc. over LLE [lower left extremity] for showers;"

* 12/06/22 - "Please be mindful of the axillary region and provide frequent skin checks;"

* 12/22/22 - "Continue with position changes and monitor bottom for pressure related injuries;"

* 12/29/22 - "Staff can urge patient to swish liquids or finger sweep prior to laying down to reduce risk of aspiration;" and

* 01/10/23 - "Frequent (every 1-2 hours) position changes should be encouraged."

There was no documented evidence staff were informed of new interventions and the service plan adjusted to ensure continuity of care.

The need to ensure the facility coordinated care with outside service providers and communicated recommendations for staff to follow was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings.  

1. Resident #2, reviewed Outside Provider Forms and communicated to staff - as needed, interventions and service plan updated to ensure continuity of care.

2. Outside provider visits will be reviewed to confirm recommendations and/or orders are implemented or initiating a temorary service plan or service plan update as appropriate. In-service staff on proper flow of information from outside providers.

3. Daily.

4. Enliven Director, Executive Director, Assistance Executive Director.  

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 1 of 3 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the MCC in 10/2022. The resident's 12/01/22 through 01/11/23 MARs and physician orders were reviewed.

a. The following medications did not have current physician's orders but were transcribed on the MAR:

* Acetaminophen tablets, both scheduled and PRN for pain;

* Artificial tears PRN for dry eyes;

* Melatonin PRN for insomnia;

* Nutritional drink PRN for nutrition; and

* Nystatin PRN for yeast infection.

b. The facility failed to administer Eliquis, for pulmonary embolism, per physician's orders four times in 12/2022.

The need to ensure physician orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/12/23. They acknowledged the findings.  

1. Resident #1, corrected resident records, Physician Order's reviewed, resident records updated.

2. We completed an audit of all Physician Orders vs. EMAR orders to ensure all Physician Orders are carried out as written and signed by the Health Care Provider. In-service staff on components of medication administration.

3. As orders change or new ones implemented.

4. Enliven Director, Med-Aides, Executive Director, Assistant Executive Director.

Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner and administered by the facility for 1 of 3 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the MCC in 10/2022. The resident's 12/01/22 through 01/11/23 MARs and physician orders were reviewed.

The following medications had physician's orders but were not transcribed on the MAR:

* Acetaminophen suppository PRN for pain;

* Bisacodyl suppository PRN for bowel care;

* Haloperidol PRN for nausea, agitation or anxiety; and

* Hyoscyamine sulfate PRN for terminal secretions.

The need to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner that were administered by the facility was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/12/23. They acknowledged the findings.  

1. Resident #1, MAR reviewed and updated reflective of all medications prescribed by heath care provider(s) and transcribed to MAR accurately.

2. Completed an audit of all Physician Orders vs. EMAR orders to verify all Physician Orders are carried out as written and signed by the Health Care Provider. In-service staff on components of medication administration.

3. As orders change or new ones received/ implemented.

4. Enliven Director, Med-Aides, Executive Director, Assistant Executive Director.

Based on interview and record review, it was determined the facility failed to ensure direct care staff were trained in the use of abdominal thrust and First Aid within 30 days of hire for 3 of 3 sampled direct care staff (#s 11, 13 and 14) whose training records were reviewed.  Findings include, but are not limited to:

On 01/13/23, staff training records were reviewed with Staff 3 (HR). The following deficiencies were identified:

There was no documented evidence Staff 11 (CG), hired on 11/10/22, Staff 13 (MT), hired on 08/31/22, and Staff 14 (CG), hired on 11/18/22, had demonstrated competency in First Aid and abdominal thrust training within 30 days of hire.

The need to ensure direct care staff demonstrated competency in first aid and abdominal thrust within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 on 01/13/23. They acknowledged the findings.

1. Staff #13 has completed First Aid/Abdominal thrust training (#11 & #14 no longer are employed with the company).

2. Memory care staff to complete required training specific to First Aid and abdominal thrust. New hire care-staff will complete required training prior to providing direct care.

3. Upon hire and prior to expiration.

4. Enliven Director, HR, Executive Director, Assistant Executive Director

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components and staff were trained in fire and life safety on alternating months of the fire drills. Findings include, but are not limited to:

Fire and life safety records from 06/2022 through 12/2022 were reviewed and the following deficiencies were identified:

a. Fire drill records lacked the following required Oregon Fire Code (OFC) fire drill components:

* Date and time of the drill;

* Problems encountered, comments related to residents who resisted or failed to participate in the drills, and what changes were made to ensure the evacuation standard was met; and

* Number of occupants evacuated.

During an interview on 01/12/23, Staff 2 (Assistant ED) confirmed the facility staff had not evacuated or relocated residents to a point of safety and was unable to provide documentation the facility met the evacuation standard. Staff 2 requested and was provided a copy of the current Community Based Care Fire and Life Safety Review form.

b. Fire drill records lacked documented evidence fire and life safety instruction was provided to staff on alternate months of the fire drills.

The need to ensure the facility documented all required fire drill components required by the OFC, was evacuating or relocating residents to the point of safety and provided fire and life safety instruction to staff on alternating months of the fire drills was discussed with Staff 1 (ED) and Staff 2 on 01/13/23. They acknowledged the findings.

1. Fire and Life Safety drills will be completed every month with documentation in accordance to Oregon Fire Code and all drill components.

2. Scheduled monthly drills.

3. Review monthly for completion.

4.Executive Director, Executive Director, Assistant Executive Director, Maintenance Director.

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

On 01/12/23, fire and life safety records were 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.

During an interview with Staff 2 (Assistant ED) on 01/12/23, the requirement to conduct fire and life safety training for residents, at least annually, was discussed. Staff 2 confirmed the facility didn't have a process to ensure annual fire safety training for residents was completed.

1. Process has been created and completed to verify each resident is evaluated upon admission and current residents have been evaluated to their ability to participate in evacuation process.

2. Residents will be informed and trained on fire drill and evacuation scheduled alternating months and documented.

3. Residents will be reevaluated as needs change. At move-in and annual reinstruction.

4. Enliven Director, Executive Director, Assistant Executive Director, ZEST (activities).

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 231, C 372, C 420 and C422.

Refer to Plan of Correction:

-C372

-C231

-C420

-C422

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 8, 11, 13 and 14) completed all required orientation, pre-service and competency training within required timelines, and 3 of 3 sampled long term direct care staff (#s 9, 10 and 12) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

Training records were reviewed with Staff 3 (HR) on 01/13/23. The following deficiencies were identified:

a. Staff 8 (Enliven Director), hired 09/16/22, failed to complete orientation training for fire safety and emergency procedures.

b. Staff 11 (CG), hired 11/10/22, Staff 13 (MT), hired 08/31/22, and Staff 14 (CG), hired 11/18/22, failed to complete orientation training for fire safety and emergency procedures and infectious disease prevention.

c. Staff 13 and Staff 14 failed to complete pre-service dementia training prior to providing care and services independently.

d. Staff 11, 13 and 14 failed to demonstrate competency in the following training topics within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

e. Staff 9 (MT), hired 02/04/19, Staff 10 (MT), hired 12/16/19, and Staff 12 (CG), hired 06/17/19, failed to complete 16 hours of annual in-service training that included six hours of dementia care training topics.

The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties, pre-service training was completed prior to working independently, and long term direct care staff completed 16 hours of annual in-service training, which included six hours of dementia care training, was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 on 01/13/23. They acknowledged the findings.

1. Reviewed and implemented newly hired direct care staff completed all orientation training prior to beginning any job duties. Pre-service training completed prior to working independently and long-term direct care staff completed 16 hours of annual in-service training.

2. Staff to complete required ongoing training. Confirm all new hires complete required training with documentation.

3. Monthly.

4. Enliven Director, HR, Executive Director, Assistant Executive Director.

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 252, C 260, C 270, C 280, C 290, C 303 and C 310.

Refer to Plan of Correction:

-C252

-C260

-C270

-C280

-C290

-C303

-C310

2. Resident 2 was admitted to the MCC in 09/2021 with diagnoses including Parkinson's disease and dementia.

Residents 2's current service plan, dated 09/19/22, was reviewed during survey. Although the service plan provided some information regarding the resident's nutrition and hydration needs, it lacked information related to the resident's individualized nutrition and hydration preferences.  

The need to develop individualized plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings.  

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was provided based on resident's needs and preferences and was available during resident's waking hours and included in the service plan for 2 of 3 sampled memory care residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including dementia, macular degeneration, and hypertension.

Observations during the survey from 01/11/23 through 01/12/23 revealed the following:           

* Resident 1 had difficulty feeding him/herself due to cognitive and physical impairments and was observed with signs of difficulty swallowing and consistent delayed coughing with thin liquids;

* Staff were observed to provide minimal assistance to the resident during meals;

* Staff were not observed to offer favorite foods as listed on the service plan; and

* The resident was offered a nutritional shake for one of two missed meals.

During an interview on 01/11/13 at 12:17 pm, Staff 9 (MT/CG) confirmed that Resident 1 often slept in and missed breakfast.

Resident 1's 12/30/22 service plan directed staff to provide "Extensive" assistance for meal consumption. The service plan directed caregiving staff to provide regular encouragement to select menu items and listed the resident's food and liquid preferences. A 12/18/22 progress note stated, "Received Faxed [sic] by PCP about Healthcare Provider Plan of Action ...Nutritional supplement - twice daily as needed if skipped meals."

The daily meal program for nutrition and hydration was not provided by staff based on resident's needs and preferences and was not available throughout Resident 1's waking hours.

The need for individualized nutrition and hydration plans to be provided based on resident's preferences and needs and available throughout waking hours was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 8 (Enliven Director) on 01/13/23. They acknowledged the findings.

1. Resident #1, #2 service plan was reviewed for nutritional and hydration needs. Service plan individualized and reflective of resident preferences and assessable to care staff.

2. Updated Oregon Health and Service Evaluation to include nutritional and hydration likes and dislikes. To be included in individual service plan. In-service training for staff regarding resident preferances and level of assistance required for meals.

3. Daily, with observed changes implemented as necessary/required.

4. Enliven Director, Executive Director, Assistant Executive Director.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:

a. Resident 1, 2 and 3's "Tell us about you" form offered some historical information about the resident's previous interests, hobbies, and occupations; however, the facility failed to evaluate the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

b. Resident 1 and 2 lacked an individualized activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities.  

The need to ensure an individualized activity plan was developed for each resident based on their activity evaluation was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 4 (Zest Director/Activities) on 01/13/23. They acknowledged the findings.

1. Resident #1, #2, evaluation was reviewed and updated to include current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate and identification of activities for behavioral interventions. Activity plan detailed to what, when, how and how often staff should offer and assist the resident to participate in activities.

2. Enliven resident questionnaire specific to resident likes and interests to be reflective in resident service plan.To confirm an individualized activity plan is developed for each resident based on resident activity evaluation.

3.  Reviewed quarterly.

4. Enliven Director, Executive Director, Assistant Executive Director, ZEST Director (activities).