The findings of the change of ownership survey, conducted 06/26/23 through 06/29/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the 06/26/23 change of ownership survey, conducted 11/27/23 through 11/28/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411-054-0030 for Residential Care and Assisted Living Facilities.  

Based on interview and record review, it was determined the facility failed to immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#3) who experienced a fall. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2017 with diagnoses including weakness, anxiety and tremors and was identified in the acuity interview as having a history of falls.

A review of the resident's record, including the most recent service plan, interim service plans, 05/2023 and 06/2023 MARs, incident investigations, hospital discharge paperwork and progress notes dated between 03/28/23 and 06/26/23, as well as interviews with staff and the resident revealed the following information:

The 05/2023 MAR included the following order: "Offer resident walks daily. Use gait belt and [four-wheeled walker]. Additional staff member to follow with a wheelchair. Walk 25-50 feet as resident tolerates. Document refusals." An interim service plan dated 05/25/23 stated, "Walk resident with [four-wheeled walker] and gait belt on, following with wheelchair. Use 2 people."

On 06/02/23, the resident experienced a fall and sustained a nose fracture. The facility investigation completed 06/02/23 indicated the resident was walking with one staff member who was pushing the wheelchair behind him/her. A 06/14/23 facility incident report stated "[a]buse and neglect were ruled out no [sic] harm was done."

The facility failed to use two staff escorts when walking the resident as specified in the service plan. The resident fell and sustained a nose fracture, which constituted neglect.

The incident was reported by the facility per the survey team's request. Confirmation of the report was provided prior to survey exit.

The need to ensure all incidents of abuse or suspected abuse were reported to the local SPD was discussed with Staff 1 (MCC Director) and Staff 5 (RCC) on 06/28/23. They acknowledged the findings.

Facility reported the incident per survey team's request.

Facility will correct this violation by immediately

reporting abuse or suspected abuse to SPD. All

possible reportings will be promply investigated to

prevent reoccurrence.

All incident reports will be reviewed daily with a

completed investigation to determine if abuse and

neglect are ruled out.

RCC, MCD, ED and HSD will review all incident reports

daily, MCD and ED will report all suspected abuse to

SPD.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

1. Review of the facility's move-in evaluation template revealed it lacked the following elements:

* History of mental health treatment; and

* Effective non-drug interventions for mental health.

2. Resident 4 was admitted to the facility in 12/2022 with diagnoses including stroke. His/her evaluation failed to address the following elements:

* Dental status;

* History of dehydration or unexplained weight loss or gain;

* Recent losses; and

* Unsuccessful prior placements.

The need to ensure new move-in evaluations included all required elements was discussed with Staff 1 (MCC Director) and Staff 6 (RCC) on 06/28/23. They acknowledged the findings.

Facility will obtain all missing elements from the initial

evaluation.

Prior to potential resident moving in, the initial

screening will be completed at assessment. All State

required ADL's will be addressed to see if facility is

able to meet residents needs prior to move in.

Prior to potential resident moving in, all State Required

elements will be reviewed to see if resident meets

facility UDS and Consumer Summary Statement and

all required information is in the residents initial Care

Plan. Labels have been purchased for all original

documents for New Residents. RCC/MCD/ED will label

all appropriate paperwork with "Do not Purge Orignial

Document".

24 hours before admission ED will review hardchart to

verify compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services and services were implemented for 1 of 3 sampled residents (#3) whose service plans were reviewed. Resident 3 sustained a nose fracture. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 05/2017 with diagnoses including weakness, anxiety and tremors and was identified in the acuity interview as having a history of falls.

A review of the resident's record, including the most recent service plan, interim service plans, 05/2023 and 06/2023 MARs, incident investigations, hospital discharge paperwork and progress notes dated between 03/28/23 and 06/26/23, interviews with staff and the resident and observations of the resident revealed the following information:

1. The 05/2023 MAR had the following order: "Offer resident walks daily. Use gait belt and FWW. Additional staff member to follow with a wheelchair. Walk 25-50 feet as resident tolerates. Document refusals."

An interim service plan dated 05/25/23 stated, "Walk resident with 4WW and gait belt on, following with wheelchair. Use 2 people." On 06/02/23, the resident experienced a fall and sustained a nose fracture. The facility investigation completed 06/02/23 indicated the resident was walking with one staff member who was pushing the wheelchair behind him/her.

The facility failed to ensure services were implemented per the service plan.  Resident 3 had a fall and sustained a nose fracture.

2. The service plan lacked clear direction to staff regarding catheter care for Resident 3, including who was responsible for daily emptying of the bag.

The need to ensure service plans provided clear direction to staff and services were implemented was discussed with Staff 1 (MCC Director) and Staff 5 (RCC) on 06/28/23 at 2:45 pm. They acknowledged the findings.

Facility will review all residents service plans and

identify any that don't have a clear direction for staff.

Service plan team will make changes with interim

service plans to ensure workers have a clear direction

on all residents ADLs. These will be reviewed daily

until resident evaluation period then implemented into

Resident Service Plan.

Clear direction for all ADLs will be detailed in service

plans; these will be updated during initial assessment,

30 days, quarterly or if a significant change of condition

occurs.

Resident Care Coordinator and ED will monitior the

service plan binders making sure all staff are

reviewing, understanding, and following them.

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

Resident 2 was admitted to the facility in 10/2022 with diagnoses including congestive heart failure, chronic respiratory failure and osteoporosis.

Review of Resident 2's weight record indicated the resident lost 10.4 pounds or 6.53% body weight between 05/2023 and 06/2023 (weights were obtained during the first week of each month). This represented a significant change of condition for which an RN assessment was required.

The facility RN did not complete an assessment of Resident 2's weight loss until 06/21/23, approximately two weeks after the change of condition was identified.

Interventions to address the weight loss were initiated on 06/13/23 which included a health shake with each meal, daily meal intake monitoring and weekly weight monitoring.

Review of the meal intake record indicated the resident was generally consuming approximately 75% of meals offered and was accepting health shakes at each meal. In an interview on 06/28/23, Resident 2 stated his/her appetite was "good" and that s/he ate every meal. A current weight was requested; the resident's weight on 06/28/23 was 152.4 pounds, an increase of 3.5 pounds since the first week of the month.

The need to ensure an RN assessment of any significant change of condition was completed timely was discussed with Staff 2 (Health Services Director) on 06/28/23 and Staff 1 (MCC Director) on 06/29/23. They acknowledged the assessment was not completed timely.

Facility will review all resident's service plans; identify

any areas lacking or not in compliance with the state

requirements.  Community RN will review and do initial assessment prior to residents moving into community.

The initial service plan will be completed by Community RN prior to admission with all state required elements.

Service plans will be updated and will incorporate all

missing elements in the person-centered service plan.

Including past and current life events, hobbies and

interests. After care plan is completed a meeting will be

held with resident and appropriate parties, signatures

and copies will be provided. In-service's will be held

monthly to ensure all service plans are being reviewed

by all facility workers. When a resident experiances a significant change in baseline, the community RN will do a detailed change of condition within 48 hours of change from baseline.Community RN works 40 hours in-house, and is available on-call 24 hours a day.

A Service plan is evaluated during initial assessment,

30 days, and every quarter or when a significant

chanage of condition occurs.

ED, HSD, MCD and RCC will meet and discuss

residents during high risk meeting weekly.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 1 sampled resident (#7) who had specific orders for the administration of PRN psychotropic medications. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 10/2022 with diagnoses including generalized anxiety disorder, Parkinson's disease and Lewy body dementia. The record indicated the resident frequently experienced severe episodes of anxiety.

The resident was prescribed two PRN psychotropic medications:

* Lorazepam for anxiety; and

* Quetiapine for agitation.

Instructions directed staff to administer lorazepam first and, if the medication was not effective after two hours, to contact the facility RN prior to administering the quetiapine.

On 06/13/23 and 06/21/23 the MAR indicated staff administered the quetiapine without first administering the lorazepam as ordered. There was also no documented evidence staff contacted the RN prior to administering the quetiapine.

The need to ensure unlicensed facility staff followed medication orders as prescribed was reviewed with Staff 1 (MCC Director) and Staff 2 (Health Services Director) on 06/29/23. They acknowledged the findings.

Facility will review current systems and procedures for

obtaining, documenting, implementing, and monitoring

treatment orders. Identify any areas where the facility is

not in compliance with state requirements.

Facility will correct all unclear peramiters of

medications scheduled and non-scheduled. When

obtaining new orders HSD will be responsible to make

sure that the peramiters have a clear understanding on

steps to take. Retrain all unlicensed medication aids on

contacting HSD prior to administering.

Quarterly when facility sends Physican Orders for

providers to sign.

HSD, RCC and ED will monitor and maintain clear

understanding for all medication orders.

Based on interview and record review, it was determined the facility failed to maintain an accurate MAR for 1 of 2 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2022 with diagnoses including congestive heart failure, chronic respiratory failure and osteoporosis.

Resident 2 was prescribed two PRN medications for pain:

* Acetaminophen - two 500 mg caplets every 6 hours; and

* Morphine sulfate solution - 0.5 ml every 15 minutes.

In an interview on 06/28/23, Staff 9 (MT) reported the resident was not consistently able to self-direct which medication s/he preferred.

The 06/2023 MAR lacked resident-specific parameters and instructions for when to administer each medication.

The need to ensure the MAR included clear parameters and instructions for staff when a resident was prescribed multiple PRN medications to treat the same condition was reviewed with Staff 2 (Health Services Director) on 06/28/23 and Staff 1 (MCC Director) on 06/29/23. They acknowledged the lack of parameters.

PCP was faxed to review medication and RN explained

concerns of orders.

Facility RN,RCC,memorycare dirctor and ED will

review medications when new orders come and weekly

during high risk meeting. Will contact PCP of any

medication concerns. PCP quarterly review

Weekly during high risk, quarterly by pcp and with new

orders

Facility RN, RCC, Memory care director, and ED

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior included written, resident-specific parameters for 1 of 2 sampled residents (#7) whose MARs were reviewed. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 10/2022 with diagnoses including generalized anxiety disorder, Parkinson's disease and Lewy body dementia. The record indicated the resident frequently experienced severe episodes of anxiety.

The resident was prescribed two PRN psychotropic medications:

* Lorazepam for anxiety; and

* Quetiapine for agitation.

The 06/2023 MAR lacked resident-specific parameters which described how Resident 7 exhibited anxiety and agitation.

The need to ensure the MAR included written, resident-specific parameters for PRN psychotropic medications was reviewed with Staff 1 (MCC Director) and Staff 2 (Health Services Director) on 06/29/23. They acknowledged the lack of parameters.

Parameters will be written clear step by step and all

unlicensed trained medication aids will notify HSD prior

to administerring.

Care team will perform high risk weekly, care team will

create clear understanding of what medication to give

giving direct parameters. Retraining staff on

documentation and calling the appropriate parties

when passing medications.

When a new order changes the parameters in place for

the medication HSD, RCC or ED will go in and make

sure the order is correct and clear resident specific

parameters.

HSD, RCC and ED will monitor

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 13 and 15) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were reviewed on 06/28/23 and revealed the following:

* Staff 12 (Cook), hired 02/13/23, lacked documented evidence training was received in resident rights and values of CBC care, infectious disease prevention, and fire safety and emergency procedures prior to beginning job duties.  

* Staff 13 (CG), hired 04/10/23, lacked documented evidence training was received in infectious disease prevention and fire safety and emergency procedures prior to beginning job duties.

* Staff 15 (CG), hired 05/23/23, lacked documented evidence training was received in abuse reporting requirements and fire safety and emergency procedures prior to beginning job duties.

The need to ensure all required pre-service orientation was completed prior to staff beginning job responsibilities was reviewed with Staff 1 (MCC Director) and Staff 3 (Business Office Manager) on 06/28/23. They acknowledged the findings.

Office Manager and ED will do a complete audit of

employee files, idenifying the files that have

discrepencies.

Facility will hold a manditory staff meeting providing all

missing documents having appropriate staff members

sign and date stating they understand the missing

documents, attached will be a word document stating

the employee's hire date and the correct date it was

addressed. ED will do an audit on onboarding

paperwork to determine if we have all state required

documents.

ED will ensure that the New Hire Paperwork and

onboarding requirements are up to date each quarter

to make sure that arent lacking in this area.

Business Office Manager and Resident Care

Coordinator will monitor that all pre-service trainings

are completed and a skills check off is turned in before

repleased to the floor.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 13, 14 and 15) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 06/27/23 and revealed the following:

There was no documented evidence Staff 13 (CG), hired 04/10/23, Staff 14 (MT), hired 02/16/23 and Staff 15 (CG), hired 05/23/23 had demonstrated competency in all required areas within 30 days of hire including:

* 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 and observation and reporting;

* General food safety, serving, and sanitation;

* Other duties as applicable (including medication administration); and

* First Aid/Abdominal Thrust.

The need to ensure staff demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 (MCC Director) and Staff 5 (Business Office Manager). They acknowledged the findings.  

Facility will audit on all direct care staff and identify if

they obtained a skills competency checkoff list, and

First aid Food handling.

Facility will hold a manditory meeting allowing

individuals to obtain missing documents or

certifications. Facility will monitor Relias Trainings

closely.

Business Office Manager will be doing a check off list

with all new team members making sure all state

requirements are obtained in 30 days.

Business office manager will monitor and ED will

enforce that this is being followed and completed.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 2 long-term direct care staff (#s 16 and 17) whose training records were reviewed. Findings include, but are not limited to:

Facility training records were reviewed on 06/28/23 and revealed the following:

Training records for Staff 16 (CG), hired 09/07/16, and Staff 17 (MT), hired 05/19/15, lacked documented evidence of completing 12 hours of required annual training, including six hours relating to the care residents with dementia.

The need to ensure staff completed required annual in-service training based on anniversary dates of hire was reviewed with Staff 1 (MCC Director) and Staff 5 (Business Office Manager) on 06/28/23. They acknowledged the findings.

Facilitity will do an audit on all staff members annual

required trainings.

Facility will provide computers, work space and time to

allow staff to complete courses that are required. Staff

members that don't have required trainings completed

will be removed off floor and will complete training

hours.

Facility will provide documentations from in-services

that credit towards these trainings as we do

informational trainings monthly centering dementia,

ADLs and the state requirements.

Business Office Manager will better monitor this before

releasing any staff to direct supervisor he/she will make

sure all appropriate trainings and certifications are

completed prior to 30 days.

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

Fire and life safety records from 12/2022 through 06/2023 were requested and reviewed:

* There was no documented evidence fire drills were conducted every other month;

* There was no documented evidence of fire and life safety instruction for staff on alternating months; and

* The facility's fire drill documentation form did not include evidence alternate routes were used during the fire drills.

In an interview on 06/27/23 at 1:00 pm, Staff 4 (Environmental Service Director) acknowledged the fire drill form lacked the required components and that fire drills had not been conducted every other month as required.

The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, to document all required elements for fire drills, and to document the use of alternate exit routes as required by the Oregon Fire Code was discussed with Staff 1 (Memory Care Director) and Staff 6 (RCC) on 06/29/23. They acknowledged the findings.

Fire drills have been getting done on different shifts.

Staff meeting on fire life and safety alternate month.

Binder has been put in place to document time,

location and who attends drill with divider for

Alf,memory care and resident training.

On going fire drills every other month different shifts

and in person staff meeting fire life and safety training

opposite months.Binder with dividers for training

documentation.

Every month one month with fire drill other month staff

meeting training.

Maintenance director will be doing drills and training

and document and place in binder.

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

Fire and life safety records from 12/2022 through 06/2023 were requested and reviewed.

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

During an interview on 06/27/23 at 1:00 pm, Staff 4 (Environmental Service Director) confirmed the facility did not have a process to ensure fire safety training for residents was completed.

On 06/29/23, the need to ensure residents were instructed on fire and life safety procedures at least annually, was discussed with Staff 1 (Memory Care Director) and Staff 6 (RCC). They acknowledged the findings.

Holding a meeting with residents go over fire life and

safety and fire drills. Placing emergency exit sheets in

each residents apartment.

Upon move in will go over information get signed

documentation resident has been informed of fire life

and safety and continue yearly for all residents.

Emergency exit sheet in all apartments.

Upon move in and yearly.

Maintenance director will correct and monitor