The findings of the initial licensure survey conducted 08/12/24 through 08/15/24 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 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 revisit to the initial survey of 08/15/24, conducted 12/23/24 through 12/24/24, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored with weekly progress noted until resolution for 1 of 5 sampled residents (#4) who experienced short term changes of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility on 06/10/24 with diagnoses including Alzheimer's disease.

Review of 06/10/24 through 08/14/24 progress notes, 08/03/24 service plan, and Temporary Service Plans (TSP's) revealed Resident 4 experienced the following short-term changes of condition:

* 06/14/24 - Redness to bilateral upper extremities;

* 06/28/24 - Medication order, start tramadol 50 mg (for severe pain) give one tablet every six hours PRN; and

* 07/17/24 - Medication order, start docusate 100 mg (for constipation) give one capsule once a day.

The facility lacked documented evidence the skin concerns and medication changes were monitored with progress noted at least weekly through resolution .  

The need to ensure each of Resident 4's short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Manager) and Witness 1 (Consultant) on 08/15/24. They acknowledged the findings.

1.  On 08/24/2024, Registered Nurse conducted an assessment for weekly skin monitoring and return from the hospital for Resident #4.  Weekly monitoring also completed on 08/26/24, 09/03/24, 09/05/24 and 09/09/24.  

2.  Program Director(s) or Designee will monitor each short term change of condition at least weekly until resolved.  The Program Director(s) or Designee will train the clinical team on the requirement of documenting observed changes in condition until a condition is resolved.  

3.  Program Director(s) and/or Designee(s) will conduct daily clinical meetings to occur at a minimum of five times weekly to review, discuss changes of condition(s) to monitor for compliance.

4.  Quarterly audits will conducted by the Program Director(s) or Designee for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (#4) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 4 was admitted to the memory care on 06/10/24 with diagnoses including Alzheimer's disease. The resident's clinical record indicated the resident had a history of pressure injuries to the skin. On 06/11/24 the facility RN requested  an order for a wound consult from the resident's primary care physician.

On 06/13/24 the facility RN documented the resident had a stage two wound to the coccyx area. A stage two or greater pressure wound represented a significant change of condition, for which an assessment was required by the facility RN.

There was no documented evidence the facility RN conducted an assessment which included resident status and interventions made as a result of the assessment.

On 06/27/24 the facility RN noted the wound had progressed to a stage three wound. The change constituted as a significant change of condition, for which an assessment was required by the facility RN.

There was no documented evidence the facility RN assessed the resident including the resident's status and interventions specific to the change to the wound.

In a 08/14/24 interview, Witness 6 (Home Health LPN) stated Resident 4's wound to the coccyx area had improved significantly.

The need for the facility RN to conduct an assessment when a resident experienced a significant change of condition was reviewed with Staff 1 (Administrator), Staff 2 (Memory Care Manager) and Witness 1 (Consultant) on 08/15/24. They acknowledged the findings.

1.  On 08/24/2024, Registered Nurse conducted an assessment for weekly skin monitoring and return from the hospital for Resident #4.  Weekly monitoring also completed on 08/26/24, 09/03/24, 09/05/24 and 09/09/24.  

2.  The Registered Nurse will make timely assessments with each significant change of condition, to include ongoing weekly progress notes until resolution.  

3.  The Clinical Team and Program Director(s) conduct daily clinical meetings to occur at least five times weekly to review, discuss changes of condition(s) and monitoring for compliance.  

4.  Quarterly audits will conducted by the Program Director(s) or Designee for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight of the medication system, for 2 of 5 sampled residents (#s 1 and 3) whose physician orders and MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2024 with diagnoses including unspecified dementia and mood disturbance.

Review of the physician orders indicated on 07/23/24 the physician changed Resident 1's prescription for memantine (to treat symptoms of dementia) from 10 mg twice daily to 5 mg in the morning and 10 mg in the evening.

Review of Resident 1's MAR from 07/01/24 through 08/11/24 indicated the morning administration instructions were changed to indicate the resident was self-administering the medication.

In an interview on 08/13/24, Witness 2 (Consultant) confirmed the MAR had been updated incorrectly and that the resident was not self-administering the medication. She further reported the facility had not administered the morning dose of the medication as ordered between 07/23/24 and 08/13/24.

The lack of oversight of Resident 1's MAR when medication changes occurred was discussed with Staff 1 (Administrator) on 08/15/24. She acknowledged the error and said that even though the facility nurse had indicated she had reviewed the order and MAR, the MAR was still updated incorrectly.

2. Resident 3 was admitted to the facility in 02/2024 with diagnoses including Parkinson's disease and syncope.

The resident was prescribed carbidopa-levodopa (to treat Parkinson's disease) 25-100 tablet to be administered at 8 am, 11 am, 2 pm, 5 pm, and 8 pm. The medication requires an individualized, timed administration regimen to prevent an increase in Parkinson's symptoms, and the physician should be contacted for a missed dose to prevent under or overdosing.

Resident 3's MAR for the 11 am medication administration on 07/12/24 was blank. The MAR did not include any documentation as to whether the medication was administered or not. A progress note, dated 07/12/24, written by a MT read:

"Med supposed to be given by day shift. Day shift did not inform swing shift. Swing shift called day shift after day shift left building to find out status, ask why med not given, etc. Med given at 3:10 pm."

The resident was administered the medication at 2:00 pm as scheduled, and administered the additional dose that was missed earlier at 3:10 pm. The MAR lacked instructions for unlicensed staff regarding what to do for a missed medication administration. There was no documented evidence the MT contacted a medical professional for instructions on whether to administer the missed medication or not.

The need to ensure medications included parameters for medication administration, including instructions for a missed medication, and that unlicensed staff were properly trained on the scope and limits of their job duties, was discussed with Witness 2 (Consultant) on 08/14/24 and Staff 1 (Administrator) and Witness 1 (Consultant) on 08/15/24. They acknowledged the lack of parameters and that the MT should not have administered the medication without specific instructions from a medical professional.

1. On 8/14/24, AL Program Director updated the order for Resident #1, removing the self-med designation for the morning dose. On 8/31/24, AL Program Director initiated a request to the Neurologist of Resident #3 for parameters surrounding Carbidopa-Levodopa administration.

2.  Program Director(s) or Designee to conduct training for all current Med Techs that includes education regarding self-med orders, medication administration, non-pharmaceutical interventions and parameters by 10/14/24. Program Director(s)  or Designee will request parameters for all current and new residents admitting with an order for Carbidopa-Levodopa.

3.  The Clinical Team and Program Director(s) conduct daily clinical meetings to occur at least five times weekly to review and discuss medication variances and parameters and monitoring for compliance.

4.  Program Director(s) or Designee and Pharmacist Consultant will audit all current residents' medication orders quarterly for ongoing compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled residents (#2) who was reviewed for self-administration. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2024 with diagnoses including insomnia, anxiety, and major depressive disorder.

During the acuity interview on 08/12/24, Resident 2 was not identified as self-administering any of his/her medications. Review of Resident 2's Progress Notes from 05/13/24 through 08/12/24 noted s/he was self-administering all of his/her medications from the initial admission to the facility until hospitalization on 06/02/24 related to a fall. This was confirmed by Resident 2 in an interview on 08/13/24, and Staff 7 (MT) in an interview on 08/14/24. The facility assumed the medication management when Resident 2 was discharged from the hospital back to the facility on 06/04/24.

Review of Resident 2's medical records revealed no physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was given to the facility at the time of admission. In interviews with Witness 2 (Consultant) on 08/14/24 and Staff 1 (Administrator) on 08/15/24, they both acknowledged no order for Resident 2 to self-administer medications was available.

The need to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1 (Administrator) and Witness 1 (Consultant) on 08/15/24 at 11:25 am. They acknowledged the findings. No further information was provided.

1. The Assisted Living Program Director obtained a copy of the physician order for resident #2 to self-adminster medications dated 5/13/24, from the Primary Care on 8/20/24 and placed a copy in the resident's chart.  On 09/06/24, The Assisted Living Program Director verified all current residents that self-administer medications have copies of physician orders, authorizing self-administration of medications in their chart.

2.  Program Director(s) or Designee will obtain self-medication orders prior to, upon admission or with changes in medication management for all current and future residents.

3. Program Director(s) or Designee will obtain self-medication orders prior to, upon admission or with changes in medication management for all current and future residents.

4. The Program Director(s) or Designee are responsible to verify all current residents have orders and audit all current residents' charts quarterly for three quarters.  

Based on interview and record review, it was determined the facility failed to review the acuity-based staffing tool (ABST) for each resident no less than quarterly, preferably at the same time the resident's service plan was updated, for 2 of 5 sampled residents (#s 3 and 5) and multiple unsampled residents. Findings include, but are not limited to:

The facility used the ODHS ABST to assess the time required to meet each resident's care needs and to develop a staffing plan to ensure an adequate number of staff were scheduled.

Review of the date each resident's assessment was last reviewed indicated Residents 3 and 5, and seven non-sampled residents' assessments, had not been updated since 04/09/24. This was more than 90 days prior to the survey.

The need to ensure the facility reviewed the ABST for each resident no less than quarterly was discussed with Staff 1 (Administrator) on 08/15/24. She acknowledged the findings.

1. The Assisted Living Program Director reviewed all current assisted living residents' ABST profiles on 08/31/24.  The Memory Care Program Director reviewed all current memory care residents' ABST profiles on 08/29/24.

2. The AL Program Director updated the ABST policy to include language for the need to review at least one of the 22 areas in a resident's ABST profile, even with no changes, to reflect being reviewed.

3. The ABST will be reviewed before a new resident moves in, whenever there is a significant change of condition, but no less than quarterly at the same time a service plan is updated for ongoing compliance.

4. The Program Director(s) or Desginee will be responsible to monitor the ABST for compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire drill records included documentation of all required elements. Findings include, but are not limited to:

On 08/13/24, fire drill records dated 03/14/24 through 07/31/24 were reviewed and showed the facility failed to document the following required elements:

* Location of simulated fire origin;

* Escape route used;

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

* Evacuation time period needed.

On 08/13/24, the need to ensure all required components of fire drills were documented was discussed with Staff 1 (Administrator) and Staff 4 (Director of Plant Operations). They acknowledged the findings.

1. The Director of Plant Ops, Regional Director of Plant Ops and National Director of Risk Management updated the fire drill form to include the Oregon specific requirements.

2. The Program Director(s) or Designee will notify the Director of Plant Ops of any regulatory changes required to fire drill documentation, fire and life safety training so forms may be updated and training completed timely.

3. Director of Plant Ops or Designee will ensure unannounced fire drills and fire safety trainings are entered into TELS, the community platform for building operations, conduct fire drills monthlyand fire safety trainings every other month.

4. The Director of Plant Ops, Program Director(s) or Designee will audit drills, training records quarterly for ongoing compliance.

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

During a tour of the RCF on 08/12/24 at 10:40 am, the following was identified:

Approximately 10 feet of the corridor in the MCC between the emergency exit door and room 113 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 4 (Director of Plant Operations) on 08/13/24 at 1:05 pm and Staff 1 (Administrator) on 08/15/24 at 1:10 pm. They acknowledged the findings. No further information was provided.

1.  The Director of Plant Operations consulted with Walsh Construction and they took measurements the week of September 9th for fabrication of hand rails.

2. The Director of Plant Operations will ensure Walsh Construction installs the missing handrails in Memory Care no later than 10/14/24.

3. The Director of Plant Ops or Designee will conduct community rounds of the physical environment monthly for ongoing compliance

4.  The Director of Plant Ops or Designee will be responsible for ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure each resident room had an entrance door that was lockable by the individual, with the individual and only appropriate staff having a key to access the room.

Observations of the facility Memory Care unit indicated resident room entry doors used an electronic key fob system to unlock the door in place of a traditional door key.

In an interview on 08/15/24, Staff 1 (Administrator) and Staff 2 (Memory Care Manager) stated the facility was unable to provide electronic key fobs to each resident because the system was not set-up properly yet - each key fob opened all the other resident room doors and the exit doors to the secured unit.

The need to ensure each resident room entrance door was lockable by the individual and each resident was given a key was reviewed with Staff 1, Staff 2 and Witness 1 (Consultant) on 08/15/24. They acknowledged the findings.

1. The Memory Care Program Director completed key assessments and issued key fobs to all residents or their Power of Attorneys to their apartment doors on  09/03/24.  In addition, all updated service plans were printed and placed in the Hall Book on 09/30/24.

2. The Program Director or Designee will conduct key assessments and issue keys accordingly, upon admission, with changes as necessary at 30-day, 90-day and change of conditions.

3.  Quarterly audits for ongoing compliance.

4.  Program Director(s) or Designee will be responsible for ongoing compliance.

Based on observation, 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 361, C 420, and C 511.

Refer to C361, C420 and C511.

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 270, C 280, C 300, and C 325.

Refer to C270, C280, C300 and C325.