The findings of the re-licensure survey, conducted 10/30/23 through 11/02/23, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities 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 re-visit to the re-licensure survey of 11/02/23, conducted 02/14/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities 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 second revisit to the re-licensure survey of 11/02/23, conducted 05/08/24 through 05/09/24, 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 observation and interview, it was determined the facility failed to ensure a homelike environment for the residents. Findings include, but are not limited to:
The facility was a memory care community consisting of 16 residents who were all diagnosed with some type of dementia. Approximately half the residents ate meals in the MCC dining room while the others ate meals in their rooms.
During lunch service on 10/30/23 and 10/31/23, residents in the dining room were given plastic utensils for their meals. Residents who ate in their rooms were also given plastic utensils and staff transferred each of their meals from a plate to a styrofoam container.
In an interview on 10/30/23, Staff 10 (CG) stated, "Sometimes we don't have enough silverware given to us from the assisted living, so we use plastic utensils." However, in an interview on 10/31/23, Staff 6 (Director of Culinary Services) stated, "There is plenty of silverware for the memory care community's meals."
In an interview on 11/1/23, Staff 1 (ED) stated, "Residents in the memory care community should have regular silverware for all their meals and residents who eat in their rooms should not receive their meals in styrofoam containers." During lunch service on 11/01/23, residents were provided metal utensils and all meals were served on regular dinnerware.
During lunch service on 11/02/23, residents were again provided plastic utensils with their meals.
The need to ensure a homelike environment for residents was discussed with Staff 1, Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/02/23. They acknowledged the findings.
1. New dishes were ordered specifically for the Arbor in order to have enough for the residents and guests.
2. All employees will be trained during orientation and as needed on using appropriate dishware in the Arbor to ensure they have the dishware available at all meals.
3. Meals will be observed by Arbor administrator and/or Executive Director weekly to ensure appropriate dishes are being utelized.
4.The Arbor Administrator, Executive Director, and Dietary Director will be responsible for maintaining the system.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to immediately investigate and document how the facility reasonably concluded a resident injury of unknown cause was not the result of abuse or failed to report the injury of unknown cause to the local SPD office or the local AAA as suspected abuse, for 1 of 1 sampled resident (#2) with a documented injury of unknown cause. Findings include, but are not limited to:
Resident 2 was admitted to the MCC in 09/2019 with diagnoses including vascular dementia, Alzheimer's disease and bilateral knee pain.
The record indicated the facility was informed by the hospice bath aide on 09/12/23 that Resident 2 had a "red open area on [right] side middle of [resident's] back." Staff 4 (LPN) documented she evaluated and provided wound care to the injury on 09/13/23.
There was no documented evidence the facility either reported the injury to the local SPD office or the local AAA as suspected abuse or immediately investigated and documented how the facility reasonably concluded the injury was not the result of abuse.
The need to ensure the facility responded appropriately to an injury of unknown cause was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 on 11/02/23. They acknowledged the findings.
The facility was instructed to report this injury to the local SPD office - confirmation of the report was received 11/03/23.
1. Injury of unknown cause for resident #2 was reported to APS on 11/3/23.
2. Arbor Administrator, LN, and Executive Director reviewed the abuse and neglect reporting guidelines and the need for thorough and timely investigations, including a review of the service plan and investigation as to whether previous interventions are being followed and proper documentation of such investigations is completed. Staff will be inserviced on the IR and reporting and investigation process.
3. Incidents reports will be reviewed to ensure proper response and investigation as a part of daily standup meeting. As part of the monthly CQI process, residents with skin monitoring or injuries. Incident report review during daily clinical meeting will include a thorough review of the investigation, including a review of the service plan and any previous interventions. If unable to rule out abuse and neglect, incidents will be reported to APS.
4. The Arbor Administrator, Executive Director and LN will be responsible for maintaining this system.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental and psychosocial needs. Findings include, but are not limited to:
During the re-licensure survey 10/30/23 through 11/02/23, there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community.
An activity calendar was provided which noted scheduled activities for each day of the week.
* Each weekday morning, a "Current Events" activity was scheduled at 9:00 am. This activity was not observed to occur on any days during the survey.
* Throughout each day of the survey, unit staff turned on various animal and nature television programs/videos in the common area of the unit - only one or two residents appeared to watch or pay attention to what was on the TV.
* On 10/30/23, "Walk and Talk" was scheduled at 10:00 am. This activity did not occur. At 1:00 pm, a "Root Beer Float Social" was scheduled. Only residents who were up and in the common area of the unit were offered a root beer float. Residents who were awake in their rooms, including Resident 1, were not invited to the activity or offered a beverage in their rooms.
* On 10/31/23, Staff 14 (Activity Assistant) was on the unit leading a "Sit and Stretch" activity at 10:30 am. Six of sixteen residents on the unit attended the activity. The "Pet Play Day" activity, scheduled at 2:00 pm, lasted 10 minutes when a staff person walked through the unit with her dog.
* On 11/01/23, Staff 14 spent minimal time on the unit and no scheduled activities occurred. Caregivers and the MT were observed spending time talking one-to-one with a few of the residents in the common area.
* On 11/02/23, Staff 14 led the scheduled "Sit and Stretch" activity. Only a few residents attended.
* In an interview on 10/30/23, Resident 1, a newer resident to the unit, expressed the desire to attend activities out in the common areas so s/he could socialize and meet the other residents. Resident 1 required two staff to assist with transfers into his/her wheelchair. The resident expressed frustration that staff were not offering to get him/her into the wheelchair and help him/her join activities.
The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, physical, mental and psychosocial needs was discussed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/02/23. They acknowledged the findings.
1. Hire and train Life Enrichment director for Arbor, train the Life Enrichment Assistant and employees to follow the activity calendar and include residents not in the common area. If the LED is unavailable Arbor Admin will review the calendar and ensure that activities being performed as schedule or an alternative activity is available.
2. Activity calendar will be reviewed during daily stand up meeting, 5 days a week. If the LED is unavailable, the Arbor Administrator will designate another staff member to perform the activities. Staff will be trained on 1:1 activities and they will be scheduled for times when there is no activity staff in the building.
3. The Activity calendar will be reviewed at stand up meeting weekly and monthly at CQI. Life Loop technology will be used to document attendance.
4. The Life Enrichement Director, Executive Director and Arbor Administrator are responsible for maintaining this system.
Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. This is a repeat citation. Findings include, but are not limited to:
Observations during the survey on 02/14/24, showed there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community. An activity calendar was provided which noted scheduled activities for each day of the week. The activities noted for 02/14/24 included the following:
* All Clean Hands on Deck at 11:00 am and 4:00 pm. Staff were observed to wash residents' hands with warm wash clothes before lunch and dinner beginning approximately 10:45 am and 3:45 pm.
* Mindful Conversations at 12 pm. Near this time Staff were observed completing last pieces of meal clean up, talking amongst themselves and some short visits with a few individual residents.
* Walking Wednesday at 12 pm and Music at 1:00 pm. Music was playing in one half of the dining room throughout the afternoon and two residents were taken on individual walks around the unit.
The television was on throughout the day with either a movie or nature show playing.
* Arts and crafts at 2:00 pm. At approximately 2:15 pm five residents were invited to color. There were 2-3 residents actively drawing/coloring with the activity staff.
Six additional residents in the common area were in front of the TV. Four residents were awake, one of whom was yelling, laughing, and crying intermittently. The other two residents in the common area were asleep. One to two residents appeared to be actively watching the nature program.
Residents were observed wandering the hallway or seated in one of the two dining areas. Residents who were in their apartments were not approached for activity invitations during observations.
A game was started with one resident at approximately 3:00 pm. The other residents in the surrounding area were not participating with the game.
The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1 (ED), Staff 3 (MC Administrator), and Staff 19 (Regional Director) on 02/14/24.
1. Life enrichment director was enrolled in Oregon Care Partners "Life Enrichment" training on 2/29/24. Train LED on creating an activity program that encompasses group activities and one on one activities. Train LED on ways to approach residents to encourage their participation. LED to train with another LED mentor from another building to gain knowledge of expectations and programming ideas. LED will review each residents preferences to create a program that provides social and recreational activities based on individual and group interest and physical, mental, and psychosocial needs. Provide training to all direct care staff regarding expectations of their involvment in resident activities both in large groups and one on one settings.
2. ED and Arbor admin to review and approve monthly calendar. Review all new residents to ensure Life enrichment needs are being met through Activity programming. Ongoing direct care staff trainings related to life enrichement
3. This will be observed 5 days a week, discussed 5 days a week in stand up meeting, and reviewed monthly in our CQI meeting. ED will monitor activity calendar to ensure activities are happening as scheduled at least weekly.
4. Life Enrichment Director, Arbor Administrator, and Executive Director.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an initial move-in evaluation included all required elements, for 1 of 1 sampled resident (# 1) who recently moved in. Findings include, but are not limited to:
Resident 1 moved into the memory care community in 10/2023 with diagnoses including Parkinson's disease and dementia.
Resident 1's move-in evaluation, dated 10/12/23, lacked information regarding the following required elements:
* Physical health status including: Visits to health practitioner(s), ER, hospital or NF in the past year;
* Vital signs if indicated by diagnosis, health problems, or medications;
* Cognition, including: memory and confusion;
* Pain: pharmaceutical and non-pharmaceutical interventions.
The move-in evaluation was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN). They acknowledged the findings.
1. Evaluation and service plan for resident #1 has been updated to include all required components.
2. To prevent reccurence, facility will complete preadmission and admission evaluations per regualtion and company policy on all new residents. Facility to utilize admisision checklist to ensure preadmission and admission evaluations are completed. Evaluations will then be completed within 30 days, quarterly and with significant change of condition.
3. This system to be audited utilizing the clinical admission checklist which includes components to be audited prior to admission, upon admission, 72 hours from admission and at 30 days. This system will be evaluated monthly as part of our CQI program.
4. The Arbor Administrator and Executive Director are responsible for maintaining this system.
There are no detail notes for this visit.
2. Resident 3 was admitted to the MCC in 08/2018 with diagnoses including Alzheimer's disease.
The record indicated that between 07/01/23 and 10/30/23 Resident 2 experienced the following changes of condition:
* 07/01/23: Weight record documented a 9% weight loss. Resident 3 was assessed by the facility RN however no interventions were developed and no further weight monitoring recorded;
* 09/14/23: Resident 3 was sent to the emergency room due to "face looked droopy on the left side and was unable to form any kind of sentence"; and
* 09/18/23: Return from four day hospitalization with new diagnoses of pulmonary embolism.
Resident 3 experienced changes of condition that were deviations in their health. There was no documented evidence the facility developed interventions, or monitored the resident's status following these changes of condition.
The need to ensure the facility had a process for determining what actions or interventions were needed for a resident and monitoring the resident following a change of condition was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/02/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident in response to a change of condition and failed to monitor and document on the progress of the resident at least weekly until the condition resolved, for 2 of 2 sampled residents (#s 2 and 3) who had changes of condition requiring monitoring. Findings include, but are not limited to:
1. Resident 2 was admitted to the MCC in 09/2019 with diagnoses including vascular dementia, Alzheimer's disease and bilateral knee pain.
The record indicated that between 08/01/23 and 10/30/23 Resident 2 experienced the following changes of condition:
* 08/06/23: increase in furosemide (used to treat edema and fluid build-up);
* 10/06/23: medication error - was administered another resident's blood pressure medication by accident;
* 10/08/23: injectable insulin was decreased and on 10/19/23: injectable insulin was discontinued;
* Falls during the night on 08/14/23, 08/25/23, 08/28/23, 09/03/23, 09/08/23, 09/20/23 and 10/03/23 (twice within 15 minutes).
Though the facility developed an Interim Service Plan (ISP) for several of these events, the ISPs lacked instructions for staff as to how to respond and what, if any, monitoring should be completed and documented. There was no documented monitoring of the resident's status following these changes of condition.
The need to ensure the facility had a process for determining what actions or interventions were needed for a resident and monitoring the resident following a change of condition was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/02/23. They acknowledged the findings.
1. Evaluation and service plan for resident #1 has been updated to include all required components.
2. To prevent reccurence, facility will complete preadmission and admission evaluations per regualtion and company policy on all new residents. Facility to utilize admisision checklist to ensure preadmission and admission evaluations are completed. Evaluations will then be completed within 30 days, quarterly and with significant change of condition.
3. This system to be audited utilizing the clinical admission checklist which includes components to be audited prior to admission, upon admission, 72 hours from admission and at 30 days. This system will be evaluated monthly as part of our CQI program.
4. The Arbor Administrator and Executive Director are responsible for maintaining this system.
Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, instructions or interventions were communicated to staff on all shifts, and progress was documented weekly until resolution for 1 of 2 sampled residents (#5). This is a repeat citation. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 04/2018 with diagnoses including Alzheimer's disease.
The resident's clinical record, including MAR, weight records, and progress notes dated 01/01/24 through 02/13/24, were reviewed, the resident was observed, and interviews with staff were conducted.
The resident's weight was documented as:
* 70.4 pounds on 12/08/23; and
* 62.2 pounds on 01/09/24.
This constituted a severe weight loss of 11.6% in 30 days.
At the time of survey, there was no working scale to evaluate the resident's weight.
There was no documentation the resident was evaluated, resident-specific instructions or interventions were developed, reviewed for effectiveness, and communicated to staff on all shifts, and the change of condition monitored at least weekly until resolution.
The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and monitored through resolution was discussed with Staff 1 (ED) and Staff 3 (MC Administrator) on 02/14/24. They acknowledged the findings.
1. RN to review all resident #5 to ensure Significant change of condition has been updated and clear guidelines given to direct care staff on plan of care and any changes in service plan have been updated. Discussed with RN the requirements for RN assessment with clear interventions and direction for direct care staff.
2. To prevent recurrence, staff will be reeducated on our alert charting guidelines and when to notify the LN. 24 hour summary will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will include a LN assessement, which will include any changes to the plan of care. When a change of condition is determined to be a significant change, a comprehensive nursing assessment will be completed by the RN, and the condition will be monitored until resident is stable.
3. This system will be evaluated five days a week as part of daily clinical meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring.
4. The Arbor Administrator, Executive Director, DHS, and RN are responsible for maintaining this system.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#s 2 and 3) who experienced a significant change of condition. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 08/2018 with diagnoses including Alzheimer's disease.
Review of Resident 3's weight record indicated the resident lost 14.4 pounds or 9% of their body weight between 04/01/23 and 07/01/23. This represented a significant change of condition for which a timely RN assessment was required.
There was no documented RN assessment of Resident 3's weight loss until 07/27/23, approximately three weeks after the change of condition was identified.
The "Nutritional Update Assessment MCC" document completed by Staff 5 (RN) noted the weight loss of 9%, however it failed to document findings, resident status, and interventions developed as a result of the assessment.
The 07/27/23 RN assessment recommended no changes to the service plan: "Current Plan/Conclusion: continue plan of care." The service plan was not updated, and no revised interventions were developed and the resident's weight was not monitored.
The need to ensure an RN assessment of any significant change of condition was completed timely and included determined by the RN that included findings, resident status, and interventions made as a result of the assessment was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/02/23. They acknowledged the findings
2. Resident 2 was admitted to the MCC in 09/2019 with diagnoses including vascular dementia, Alzheimer's disease and bilateral knee pain. The resident was receiving hospice services at the time of the survey.
On 10/05/23, a hospice RN documented the discovery of a "stage 4" wound on Resident 2's coccyx.
On 10/06/23, Staff 5 (RN) transcribed the information from the hospice provider note in a weekly "Significant Change of Condition update" form (which Staff 5 was utilizing to monitor Resident 2's status post-hospice admit).
Documentation of a stage 2 or greater wound on a bony prominence (the coccyx) represented a significant change of condition for which an assessment was required by the facility RN. There was no documented evidence the facility RN completed an assessment of the resident which documented findings, resident status and interventions made as a result of this assessment.
Subsequent documentation indicated the hospice provider was providing ongoing wound care twice weekly and the facility was providing additional wound care as needed.
The need to ensure all significant changes of condition were assessed and documented by the facility RN was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/01/23. They acknowledged the findings.
1. Thorough RN assessments have been completed per regulation. These assessments were used to update the resident's service plans and give the care staff clear guidelines on resident's current needs.
2. To prevent recurrence, change of condition policy and procedure has been reviewed with RN. To further prevent recurrance, 24 hour summary will be reviewed five days a week as part of daily standup meeting. at the beginning of the week, the 72 hour summary will be reviewed to include review of all documentation from the weekend. When a significant change of condition is identified, a comprehensive nursing assessment will be completed timely by the RN and the condition will be monitored with weekly updates until resident is stable. The RN will also take the Role of the Nurse in community based care class.
3. This system will be evaluated five days a week as part of daily clinical meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring as well as other audits to identify any changes that may have been missed by other systems.
4. The Arbor Administrator, Executive Director and RN are responsible for maintaining this system.
Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment of a significant change of condition and documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#5) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 04/2018 with diagnoses including Alzheimer's disease.
The resident's clinical record, including current service plan, MAR, weight records, and progress notes dated 01/01/24 through 02/13/24, were reviewed, the resident was observed, and interviews with staff were conducted.
The resident's weight was documented as:
* 70.4 pounds on 12/08/23; and
* 62.2 pounds on 01/09/24.
This constituted a severe weight loss of 11.6% in 30 days.
At the time of survey, there was no working scale to evaluate the resident's weight.
A "Monthly Coordination of Care Assessment" was completed by an RN on 01/16/24, noting that the resident's average meal intake was trending down.
The facility RN was unavailable for interview. Staff 20 (Regional Nurse Consultant) was interviewed, and no additional information was provided.
The need to ensure an RN assessed all significant changes of condition including findings, resident status, and interventions made as a result of the assessment in a timely manner was discussed with Staff 1 (ED) and Staff 3 (MC Administrator) on 02/14/24. They acknowledged the findings.
1. Thorough RN assessments have been completed for resident #5 and service plan was updated with any changes per regulation. These assessments were used to update the resident's service plans and give the care staff clear guidelines on resident's current needs.
2. To prevent recurrence, change of condition policy and procedure has been reviewed with RN. To further prevent recurrance, 24 hour summary will be reviewed five days a week as part of daily standup meeting. at the beginning of the week, the 72 hour summary will be reviewed to include review of all documentation from the weekend. When a significant change of condition is identified, a comprehensive nursing assessment will be completed timely by the RN and the condition will be monitored with weekly updates until resident is stable.
3. This system will be evaluated five days a week as part of daily clinical meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring as well as other audits to identify any changes that may have been missed by other systems.
4. The Arbor Administrator, Executive Director, DHS, and RN are responsible for maintaining this system
There are no detail notes for this visit.
2. Resident 2 was admitted to the MCC in 09/2019 with diagnoses including vascular dementia, Alzheimer's disease and bilateral knee pain.
The resident was prescribed and, between 10/01/23 and 10/30/23, was administered two PRN medications:
* Lorazepam 0.5 mg - 1 tablet as needed for anxiety; and
* Morphine sulfate oral solution 0.25 ml by mouth as needed for pain or dyspnea.
Review of the MAR and the Controlled Substance Disposition log revealed the following discrepancies:
a. There were six times a facility staff signed the Controlled Substance Disposition log indicating the lorazepam was removed from locked storage but did not document on the MAR that the medication was administered.
b. There were two times a facility staff signed the Controlled Substance Disposition log indicating the morphine was removed from locked storage but did not document on the MAR that the medication was administered.
The need to ensure the tracking of controlled substances was accurate was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/01/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 1 and 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:
1. Resident 1 moved into the facility in 10/2023 and had diagnoses including Parkinson's disease and dementia.
The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 10/12/23 through 10/30/23, were reviewed.
Resident 1 had physician orders for the following controlled medications:
* Morphine sulfate 20 mg/ml - give by mouth every one hour as needed for pain; and
* Lorazepam 0.5 mg - take one tablet by mouth every four hours as needed for anxiety.
The following discrepancies were identified between the resident's MAR and the Controlled Substance Disposition log:
* On 10/15/23 and 10/21/23 - Resident 1's PRN morphine sulfate was documented as removed from locked storage in the Controlled Substance Disposition log, but it was not documented as administered on the MAR;
* On 10/12/23 and 10/13/23 - Resident 1's PRN lorazepam was documented as removed from locked storage in the Controlled Substance Disposition log, but it was not documented as administered on the MAR.
Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed on 11/1/23 with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN). They reviewed the documentation and acknowledged the discrepancies.
1. All Narcotic counts have been audited and corrected by LN and RCC including MAR to Cart audit.
2. Med room and Narcotic audits will be completed weekly by RCC. Any errors or concerns will be reported promptly to LN for investigation and correction.
3. Audits will be completed weekly. These audits will be reviewed in our monthly CQI meeting and will include a a review of any identified trends or concerns.
4. RCC, LN, Executive Director, and Arbor Administrator will be responsible to ensure audits are happening as well as appropriate follow-up of any concerns.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to carry out orders as prescribed, for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the MCC in 09/2019 with diagnoses including vascular dementia, Alzheimer's disease and bilateral knee pain.
Review of the record indicated:
a. Resident 2's hospice provider wrote an order dated 09/11/23 to "Please weigh [resident] twice a month."
There was no documented evidence the facility obtained Resident 2's weight as ordered. The last recorded weight was documented on 06/05/23.
b. Between 10/01/23 and 10/30/23, the resident was not administered the following medications as ordered:
* Furosemide (to treat edema) on 10/03/23, 10/06/23, 10/07/23, 10/13/23 and 10/20/23 due to the medication not being available or on order from the pharmacy;
* Risperdone (to treat behavior problems in persons with dementia) on 10/01/23 through 10/05/23, 10/07/23 through 10/11/23 and on 10/28/23 due to the medication being on order; and
* The MT working the 2 pm - 10 pm shift on 10/28/23 documented she could not find the resident's furosemide, chlorecalciferol (for Vitamin D deficiency), memantine (for dementia), glipizide (to treat diabetes) and metformin (to treat diabetes).
The MAR and the need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/01/23. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease and dementia.
Review of the resident's physician orders dated 10/11/23 included an order for the facility to obtain weekly weights for four weeks to establish a baseline weight for the resident.
A 10/21/2023 progress note stated: "Was told by other staff that wheelchair scale is broken again."
There was no documented evidence the facility obtained Resident 1's weight each week as ordered.
The need to ensure physician's orders were followed as prescribed was discussed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/01/23. They acknowledged the findings.
1. Physician orders have been reviewed for all residents. Care staff have received additional training on timely ordering to ensure medications are available. All residents have been weighed according to physician orders. Direct care staff have been trained on how to take weights per orders. Direct care staff have been provided equipment to obtain weights.
2. EMAR administration progress notes will be reviewed as part of the 24 hour daily audit (72 hour audit on Mondays) to ensure medications are delivered in a timely manner. Weekly MAR audits will be done to ensure accuracy. Ongoing education will be provided to medication aides as needed based on findings of audits. Weekly TAR audit done to ensure all ordered weights are being done.
3. Weights and orders will be monitored and discussed at daily clinical meeting, during weekly RCC audit review, and monthly as part of our CQI audits.
4. RCC, Arbor Administrator, Executive Director and LN will be responsible for maintaining this system.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, non-pharmacological interventions have been tried with ineffective results, for 1 of 1 sampled resident (#2) who was prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to:
Resident 2 was admitted to the MCC in 09/2019 with diagnoses including vascular dementia, Alzheimer's disease and bilateral knee pain.
The record indicated Resident 2 was prescribed lorazepam 0.5 mg - 1 tablet as needed for anxiety. Between 10/01/23 and 10/30/23, the MAR indicated the resident was administered the medication 11 times.
For nine of the 11 times the medication was administered, there was no documented evidence in the resident's record that non-pharmacological interventions have been tried first with ineffective results.
The need to ensure staff attempted and documented non-pharmacological interventions hade been tried first with ineffective results was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/01/23. They acknowledged the findings.
1. LN audited psychoactive PRN medications to ensure each one had non-drug interventions entered unless otherwise ordered by physician. LN added reqired field to be completed showing non drug interventions have been attempted and were not successful prior to giving medication.
2. LN will use the triple check system to ensure all psychoactive medications have proper interventions including the supplemental documentation for non drug interventions. HCC and Caregivers will be educated on the interventions and how to incorporate them.
3. 24 hour report (72 hour report on Mondays) will be monitored 5 days a week at stand up meeting to ensure proper documentation on eMAR. Psychoactive medications will be reviewed monthly at CQI meetings.
4. LN, Executive Director, and Arbor Administrator will be responsible for that these corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed use the results of an acuity-based staffing tool to develop and routinely update the facility's staffing plan and convert evaluated care needs of residents into staff hours to generate a facility staffing plan. Findings include, but are not limited to:
The facility used the Oregon Department of Human Services ABST.
Review of the data on 10/30/23 showed the ABST generated staffing hours were not used to generate a staffing plan.
The need to ensure ABST was used to develop and update the facility's staffing plan was reviewed with Staff 1 (Executive Director), Staff 2 (Administrator of Record) and Staff 5 (LPN) on 10/30/23 and 10/31/23. They acknowledged the findings and stated they would work with the ABST Policy Analyst to improve their system.
1. ABST has been updated and corrected to show accurate need for hours/ staffing.
2. ABST will be updated for every move- in/ out, transfer to hospital or return from hospital/higher level of care. Additionally, the ABST will be reviewed for accuracy and updated if needed evey time a resident's evaluation and service plan are reviewed/updated (i.e. within 30 days of admission, quarterly or with significant change of condition). staffing schedule will be developed and updated based on ABST.
3. Staffing will be discussed 5 days a week in stand up meeting. ABST will be reviewed for accuracy and compared to schedule monthly at CQI meeting.
4. Executive Director and Arbor Administrator will be responsible for monitoring that ABST is update and being used for staffing.
Based on interview and record review, it was determined the facility failed to ensure accuracy of entries related to resident care needs into an acuity-based staffing tool to develop the facility's staffing plan and failed to staff to the levels indicated by the ABST. This is a repeat citation. Findings include, but are not limited to:
The facility used the Oregon Department of Human Services ABST.
Review of the data on 02/14/24 showed the staffing hours generated by the ABST were not used to staff the minimum number of direct care staff directed by the ABST and noted in the posted staffing plan.
In an interview on 02/14/24, Staff 1 (ED) indicated all residents were entered into the facility ABST, but the data was not all accurate. Staff 1 stated they continued to work on updating entries for an accurate reflection of resident care needs and the number of hours needed for direct care staff to provide resident care.
The need to ensure the ABST was used to develop and update the facility's staffing plan and resident care needs were accurately entered was discussed with Staff 1 (ED) on 02/14/24. She acknowledged the findings.
1. Audit ABST and ensure time is entered accurately to ensure we are allowing the appropriate time on the tool. Hiring more direct care staff to meet or exceed ABST.
2. Change staffing to meet or exceed time showing on ABST.
3. This will be updated and audited with every move in, move out, service plan change, and hospital returns.
4. LPN, Arbor Admin, and ED
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). Findings include, but are not limited to:
Fire drill records reviewed from May 2023 through September 2023 lacked documentation of the following:
* Escape route used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed;
* Evidence alternate escape routes were used; and
* Evidence of immediate changes that were made for the residents who were identified as unwilling to participate in the fire drills, to ensure the evacuation standard could be met.
On 11/1/23 the need to ensure fire drill records included all required components was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN). They acknowledged the findings.
1. A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills. All staff will be re-educated at next staff meeting on the fire drill procedure.
2. To prevent recurrance company fire drill form will be utilized and will be filled out completely, including all required components. Computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.
3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.
4. The Arbor Administrator, Executive Director and Maintenance Director will be responsible for maintaining this system
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). This is a repeat citation. Findings include, but are not limited to:
Fire drill records reviewed from 11/2023 through 02/2024 lacked documentation that drills were conducted every other month on alternating shifts.
Fire Drill documentation lacked documentation of all required elements, including the following:
* Escape route used;
* Number of occupants evacuated;
* Evacuation time-period needed; and
* Evidence alternate escape routes were used.
On 02/14/24, the need to ensure fire drill records included all required components and were completed every other month was reviewed with Staff 1 (ED), Staff 3 (MC Administrator), and Staff 7 (Maintenance Director). They acknowledged the findings.
1. A training was done with Maintenance Director that included a review of all required components including documentation of memory care participation.
2. To prevent recurrance company fire drill form will be utilized and will be filled out completely, including all required components. Computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.
3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.
4. The Arbor Administrator, Executive Director and Maintenance Director will be responsible for maintaining this system
There are no detail notes for this visit.
Based on observation, 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 242, C 270, C 280, C 361, C 420, and C 513.
See other plan of corrections C242, C270, C280, C361, C420, and C513
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the residents were kept clean and in good repair. Findings include, but are not limited to:
The interior of the MCC was toured on 10/30/23. A remodel of the common areas was in process at the time of the survey, however, resident rooms were not included in the remodel. The following items needed cleaning or repair:
* Room 122 had areas of pushed in drywall and wall damage around the bed, a windowsill with exposed particleboard, and a broken side rail attached to a resident's bed;
* Room 121 had a persistent unpleasant odor on all days of the survey; and
* The wheelchair accessible scale (used to monitor the weight of residents who could not stand) was not functioning at the time of the survey.
The areas and equipment that required cleaning or repair were shown to and reviewed with Staff 1 (ED) and Staff 2 (Administrator of Record) on 10/31/23 and on 11/01/23, they acknowledged the findings.
1. A complete walkthrough of the community was completed and all areas needing cleaning and/or repair will be completed no later than 1/1/2024.
2. To prevent recurrance, Maintenance Director and Executive Director will conduct a weekly walkthrough of the community and will identify any areas needing cleaning and/or repair. Weekly walkthrough will be reviewed at standup meeting and a plan will be put in place for any identified items. Re-training will be done at all staff on how to enter work orders when staff note something that needs repaired.
3. Completion of weekly walkthrough tasks will be reviewed monthly as part of the community's CQI process. Weekly review of work orders.
4. The Arbor Administrator, Executive Director and Maintenance Director are responsible for maintaining this system.
Based on observation and interview, it was determined the facility failed to ensure all equipment necessary for the health, safety, and comfort of the residents were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:
The wheelchair accessible scale (used to monitor the weight of residents who could not stand) would not power on and was not functioning at the time of survey. The scale was stacked with storage items, including metal bed rails, and was not useable by staff.
The areas and equipment that required repair were shown to and reviewed with Staff 1 (ED) and Staff 7 (Maintenance Director) on 02/14/24. The staff indicated the scale was repaired after the last survey and they were unaware the scale was again broken. The staff acknowledged the findings.
1. A complete walkthrough of the community was completed and all areas needing repair will be completed no later than 3/30/24. New wheelchair scale purchased and in place. All direct care staff trained on how to appropriately and expectations to notify clinical team supervisor when changes occur and/ or equipment such as the scale is not working.
2. To prevent recurrance, Maintenance Director and Executive Director will conduct a weekly walk through of the community and will identify any areas needing cleaning and/or repair. Weekly walkthrough will be reviewed at standup meeting and a plan will be put in place for any identified items. Re-training will be done at all staff on how to enter work orders when staff note something that needs repaired.
3. Completion of weekly walkthrough tasks will be reviewed monthly as part of the community's CQI process. Weekly review of work orders.
4. The Arbor Administrator, Executive Director and Maintenance Director are responsible for maintaining this system.
There are no detail notes for this visit.
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 200, C 231, C 242, C 361, C 420 and C 513.
Refer to POC for C200, C231, C242, C361, C420 and C513.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 242, C 361, C 420, and C 513.
See other plan of corrections C242, C270, C280, C361, C420, and C513
Based on interview and record review, it was determined the facility failed to ensure newly-hired staff completed all required pre-service and competency training and long term direct-care staff completed required annual in-service training, for 5 of 5 sampled staff (#s 9, 12, 13, 14 and 15). Findings include, but are not limited to:
Staff training records were reviewed with Staff 16 (Business Office Manager) on 11/01/23. The following were identified:
a. Staff 14 (Activity Assistant), hired 10/05/23, had not completed the required pre-service dementia training prior to providing services to residents.
b. Staff 9 (CG), hired 07/11/23, was not documented as having demonstrated competency in caregiving duties until 10/04/23 - more than 30 days after she was hired.
c. Staff 12 (MT) lacked documentation of demonstrated competency in medication administration.
d. Staff 13 (MT), hired 06/08/23, lacked documentation of demonstrated competency in caregiving duties and medication administration.
e. Staff 15 (CG), hired 02/04/22, lacked documentation of having completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training, reviewed from 03/01/22 through 02/28/23.
Training deficiencies and requirements for training of new and long term employees was reviewed with Staff 1 (ED), Staff 2 (Administrator of Record), Staff 4 (LPN) and Staff 16 on 11/02/23. They acknowledged the findings.
1. An audit of the training grid and files was completed to ensure all correct trainings are being tracked. Business office manager has updated training grid to include state mandated trainings. Activity Assistant was given required dementia trainings.
2. RCC will develope a training plan for new employees to ensure all training is completed before the required time frame. Business office manager will update the training grid as trainings are completed by employees.
3. Training grid will be sent to department heads as well as discussed weekly in stand up meeting on Fridays. Monthly audits will be done at CQI meetings.
4. Business office manager, Executive Director and Arbor Administrator are responsible to monitor that the trainings are being completed.
There are no detail notes for this visit.
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 270, C 280, C 302, C 303, and C 330.
Refer to POC for C252, C270, C280, C302, C303, and C330.
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. This is a repeat citation. Findings include, but are not limited to:
Refer to C 270 and C 280.
See other plan of corrections C242, C270, C280, C361, C420, and C513
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident for activities and develop an individualized activity plan for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3 ) whose service plans were reviewed. Findings include, but are not limited to:
During the survey there were 16 residents residing in the memory care unit. Observations showed that between 8:30 AM - 3:30 PM daily, there were up to eight residents in the common areas and the remaining residents were in their rooms. Many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which some residents attended. All residents were diagnosed with some type of dementia.
Resident 1 was receiving hospice services, was non-ambulatory, and spent most of his/her time during the survey in his/her room in bed. On 10/30/23 at 1:00 PM a root beer float group activity was scheduled. Resident 1 was in her/his room and in bed. Resident 1 was not asked to participate in the activity and was not offered a root beer float.
During the survey, Resident 2 was observed up in the common area in the mornings in a manual wheelchair which the resident could self-propel. During these times, staff were not observed to engage the resident in any activities other than an exercise group that the resident attended on 10/31/23. During the group, the resident did not participate in the activity and spent the time rolling his/her wheelchair around in circles.
On 10/30/23 interviews with caregivers and observation showed Resident 3 was dependent of staff for all care needs, and did not get out of bed. On 10/30/23, Resident 3 was admitted to the hospital and remained there for the rest of the survey.
Resident 1, 2 and 3's service plan and "Life Enrichment Plan" documents were reviewed. Though the activities section of the service plan included some information about each resident's past and current interests, the facility had not fully evaluated the resident's:
* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for participation; and
* Activities that could be used as behavioral interventions.
There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities. There were no instructions for providing activities for residents who did not participate in group activities.
During an interview on 10/31/23 Staff 3 (Administer in Training) confirmed she did not evaluate Resident 1's individual activity status and was not part of the service planning team to develop individualized activity plans.
The need to develop an individualized activity plan, which was based on a thorough evaluation of the resident's interests, abilities and needs, was discussed with Staff 1 (ED), Staff 2 (Administrator of Record) and Staff 4 (LPN) on 11/01/23. They acknowledged the findings.
1. Individualized activity plans have been developed and service plans updated for all 4 sampled residents.
2. Community recently hired a new Life Enrichment Director for the Arbor, who will complete training on regulations related to activity programming for residents, including individualized activity plans. All resident activity profiles will be updated to include Individualized activity plans for all residents based on their activity preferences and needs. Inservicing will occur with all care staff on the individualized activity plans available to them.
3. Monthly, as part of our CQI program, changes in activity levels will be reviewed and individualized activity plans will be adjusted as needed. Individualized activity plans will be evaluated with each evaluation/service plan review quarterly, or with significant change of condition.
4. The Arbor Administrator and Arbor Life Enrichment Director will be responsible for maintaining this system
There are no detail notes for this visit.