The findings of the re-licensure survey conducted 04/08/24 through 04/12/24 are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 04/12/24, conducted 10/28/24 through 10/29/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the relicensure survey of 04/12/24, conducted 01/22/25, 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 resident physical altercations were reported and injuries of unknown cause, when the facility investigation could not reasonably rule out abuse, were reported to the local SPD office for 2 of 2 sampled residents (#3 and 4) who had reportable incidents. Findings include, but are not limited to:

1. Resident 3 moved into the memory care facility in 09/2023 with diagnoses including Alzheimer's disease.  

The resident's care plan dated 09/21/23, observations and interviews with care staff between 04/08/24 and 04/11/24, indicated the resident ambulated independently throughout the facility, would take others' plates and blankets, and could be intrusive into other residents' spaces. A review of incident reports showed the following resident to resident incidents and injuries of unknown cause involving Resident 3:

* 01/27/24: Resident 3 was struck in the face by another resident during an altercation;

* 02/20/24: Progress note "alert for bruising to L [left] ankle"; and

* 03/21/24: Resident 3 was struck in the chest by another resident during an altercation.

In an interview on 04/10/24, Staff 1 (ED) stated the incidents had not been reported to the local SPD and the reports would be completed.

The need to ensure injuries of unknown cause that could not be reasonably ruled out for abuse and physical altercations were reported to the local SPD office was reviewed with Staff 1 and Staff 2 (Operations Specialist) and Staff 7 (Wellness Director) on 04/11/24. They acknowledged the findings.

Confirmation of the reporting was provided prior to survey exit.

2. Resident 4 moved into the memory care facility in 02/2024 with diagnoses including dementia.  

The resident's care plan dated 02/28/24, progress notes and incident reports dated from 02/28/24 through 04/08/24 showed the following:

* 03/20/24: "bruise on right forearm", resident unable to explain how the bruise was obtained.

In an interview on 04/10/24, Staff 1 (ED) stated the incident had not been reported to the local SPD office and the report would be completed.

The need to ensure injuries of unknown cause that could not be reasonably ruled out for abuse were reported to the local SPD office was reviewed with Staff 1 and Staff 2 (Operations Specialist) and Staff 7 (Wellness Director) on 04/11/24. They acknowledged the findings.

Confirmation of the reporting was provided prior to survey exit.

1. The Executive Director completed self reports of the incidents for resident #3 and #4.

2. The Executive Director will complete a self-training review of the Oregon Abuse Reporting Guide.

3. The Wellness Director and Executive Director will review and investigate Incident Reports daily per the Quality Assurance - Health Services Review Schedule.

4. The Executive Director will be responsible for ensuring corrections are completed and monitored.

2. Resident 2 was admitted to facility in 04/2023 with diagnoses including fracture of superior rim of left pubis, atherosclerotic heart disease, major depressive disorder, and graft-versus-host disease.

The resident's service plan dated 03/04/24, an Interim Service Plan dated 03/11/24, and progress notes dated 12/17/23 through 03/27/24, were reviewed. Resident 2 and staff were interviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Resident's choice of pureed diet;

* Pacemaker and checks;

* Limitations relating to self-propelling his/her wheelchair;

* Activity preference and assistance needed;

* Full assist with dressing;

* Full assist with grooming;

* Staff assistance with nail care;

* Conflicting information related to which days the resident received a shower;

* Conflicting information relating to incontinence;

* The resident's preferences of how s/he liked his/her beverages;

* Personal beverages in his/her apartment and assistance needed;

* Assistance needed by staff with scheduling appointments and transportation;

* Which medications the resident self-administered;

* Interventions for depression;

* Conflicting information relating to frequency of wellness checks; and

* Ambulation status with a front wheeled walker.  

The need to ensure the service plan was reflective of the resident's current status and included clear directions to staff was discussed with Staff 1 (ED), Staff 2 (Operations Specialist) and Staff 8 (Wellness Director) on 04/12/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were readily available to staff, reflective of residents' current care needs, the facility administrator was responsible for ensuring the implementation of services, and service plans provided clear directions to staff regarding the delivery of services for 4 of 6 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2019 with diagnoses including vascular dementia and type 2 diabetes mellitus.

Interviews with staff and review of the current service plan, dated 02/16/24, revealed Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Incorrect reference to resident not requiring assistance with injectable medications;

* Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped breakfast;

* Personality, including how the resident coped with change or challenging situations;

* Number of staff needed to assist with activities of daily living;

* Frequency for the nurse to provide diabetic nail care;

* Instructions on what types of skin impairments to report and to whom; and

* Specific instructions for setting room temperature.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), and Staff 6 (Wellness Director) on 04/12/24. They acknowledged the findings. No further information was provided.

3. Resident 3 moved into the facility in 09/2023 with diagnoses including Alzheimer's disease.

a. The service plan readily available to staff in the service plan binder kept on the unit was dated 09/21/23. An attached "service plan staff signature page" included signatures of direct care staff dated from 09/24/23 through 04/03/24. On 04/11/24, Staff 1 (ED) provided a current service plan dated 01/18/24. The 01/18/24 service plan was not readily available to staff.

b. Observations, staff interviews, and a review of the service plan available to staff, dated 09/21/23, and interim service plans showed the service plan was not reflective of the resident's current care needs or was not implemented related to:

* Interim service plan dated 03/25/24: offer clothing protectors or blankets to fold to reduce agitation;

* Activities to provide: "offer a small simple task such as folding towels, offer a wash rag to wipe down tables etc."; and

* Toileting assistance: "independent with all tasks of toileting".

The need to ensure service plans were readily available to staff, reflective of current care needs and were being implemented was discussed with Staff 1, Staff 2 (Operations Specialist), Staff 5 (Wellness RN), and Staff 7 (Wellness Director) on 04/12/24. They acknowledged the findings.

4. Resident 4 moved into the facility in 02/2024 with diagnoses including dementia.

Observations, staff interviews, and a review of the service plan, dated 02/28/24, and interim service plans showed the service plan was not reflective of the resident's current care needs, did not provide clear direction regarding the delivery of services, or was not being implemented related to:

* Bathing: use of special equipment, shower gurney;

* Use of side rails: the service plan states "left and right side rails attached to bed", however there were no side rails;

* Outside providers: Home Health RN for catheter care, OT and PT;

* Use of call light: service plan stated "able to use call system" but did not include information that the call light must be within reach related the resident's limited mobility; and

* "Continuous Positive Airways Pressure (CPAP)" device: instruction on who would clean the device and how to clean it; and

* Keep feet floated when in bed.

The need to ensure service plans were reflective of current care needs, provided clear direction to staff and were being implemented was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN), and Staff 7 (Wellness Director) on 04/12/24. They acknowledged the findings.

1. All resident service plans will be reviewed to ensure the plans are reflective of resident needs and current Service (Care) Plan is readily available to staff.

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service (Care) Plan Plan Policy.

3. The Wellness Director(s) and Executive Director will review the service plan schedule weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs for 2 of 3 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 08/2022 with diagnoses including dementia.

Interviews with caregiving staff and review of the current service plan, dated 10/16/24, revealed Resident 9's service plan was not reflective of the resident's current status in the following areas:

* Use of geri-chair;

* Puree diet texture and thickened liquids; and

* Eating meals in the dining room.  

The need to ensure service plans were reflective of residents' needs was discussed with Staff 1 (Executive Director), Staff 2 (Operations Specialist), Staff 26 (Wellness RN), and Staff 7 (Wellness Director). They acknowledged the findings.

2. Resident 8 was admitted to the facility in 10/2023 with diagnoses including Alzheimer's disease. The resident's 08/23/24 service plan and temporary service plans were reviewed, observations of the resident were made, and interviews with staff were conducted. The resident's service plan was not reflective of his/her needs in the following area:

* Communication, including ability to independently express wants and needs and ability to understand.

The need to ensure service plans were reflective of residents' needs was discussed with Staff 1 (Executive Director), Staff 2 (Operations Specialist), Staff 26 (Wellness RN), and Staff 7 (Wellness Director). They acknowledged the findings.

1. The service plan for Resident #8 and #9 have been updated to ensure the plans are reflective of resident needs.

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service (Care) Plan Plan Policy.

3. The Wellness Director(s) and Executive Director will review the service plan schedule weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

4. Resident 5 was admitted to the facility in 04/2023 with diagnoses including Alzheimer's disease, abnormal weight loss, and scoliosis. Resident 5 received hospice services.  

The resident's service plan, dated 02/11/24, significant change of condition assessment dated 02/14/24, and progress notes dated 01/22/24 through 04/07/24, were reviewed. Observations were made and care staff were interviewed during the survey.

During the survey Resident 5 was observed to require staff assistance to eat, and ate 100% of meals and fluids offered.

In interview with Staff 7 (Wellness Director) on 04/12/24, she stated Resident 5 had the weight loss intervention of weekly weight monitoring starting 12/07/23 due to risk for weight loss, and the weekly monitoring was confirmed in the 02/14/24 weight loss assessment.

At the time of the weight loss assessment on 02/14/24 Resident 5 weighed 90.5 pounds. During the survey, Resident 5 was weighed and found to weigh 99.0 pounds.

Review of the weight record between 01/01/24 and 04/01/24 showed nine of twelve weeks there was no weight taken.  

The intervention for weekly weights remained on the 04/2024 MAR, but was not consistently implemented.

In interview with Staff 5 (Wellness RN) on 04/11/24 she acknowledged the missing weekly weights, and that some of the weights taken may not have been accurate due to Resident 5 requiring an individualized two person procedure for weights due to physical status.

The requirement to monitor each resident consistent with his or her evaluated needs and service plan was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), and Staff 7 (Wellness Director) on 04/12/24. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition were evaluated, actions or interventions communicated to staff on each shift, resident specific interventions were determined and documented, and the condition was monitored with weekly progress noted until resolution, and residents were monitored consistent with his or her evaluated needs and service plan for 5 of 6 sampled residents (#s 1, 2, 3, 4, and 5) who were reviewed for changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to facility in 04/2023 with diagnoses including major depressive disorder and graft-versus-host disease.  

The resident's service plan, dated 03/04/24, an Interim Service (Care) Plan dated 03/11/24, and progress notes, dated 12/17/23 through 03/27/24, were reviewed. Resident 2 and staff were interviewed.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

* 02/29/24: Staff documented the resident was having suicidal thoughts; and

* 03/14/24: Staff noted obtaining urine analysis for a suspected urinary tract infection.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), and Staff 8 (Wellness Director) on 04/12/24. They acknowledged the findings.

5. Resident 1 was admitted to the facility in 12/2019 with diagnoses including vascular dementia and type 2 diabetes mellitus.

Clinical records, including the resident's current service plan and observation notes from 12/01/23 through 04/01/24, were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:

* 02/28/24: "RN instructed this MT to hold insulin"; and

* 03/27/24: Recorded in MAR blood glucose level of 62 mg/dl which constituted a low blood glucose level.

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), and Staff 6 (Wellness Director) on 04/12/24. They acknowledged the findings. No further information was provided.

2. Resident 3 moved into the memory care facility in 09/2023 with diagnoses including Alzheimer's disease.  

The resident's service plan, dated 09/21/23, Interim Service Plans, dated 02/25/24 through 03/25/24, and progress notes, dated 12/07/23 through 03/21/24, were reviewed. Observations were made, and care staff were interviewed during the survey.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

* 01/06/24: A quarterly review documented the resident had experienced weight loss; and

* 03/21/24: The resident was involved in an incident when s/he was struck in the chest.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift, and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN), and Staff 7 (Wellness Director) on 04/12/24. They acknowledged the findings.

3. Resident 4 moved into the memory care facility in 02/2024 with diagnoses including dementia and stroke.  

The resident's service plan, dated 02/28/24, interim service plans, dated 03/04/24 through 03/29/24, and progress notes, dated 02/28/24 through 04/07/24, were reviewed. Observations were made and care staff were interviewed during the survey.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution.

Progress notes documented the following:

* 03/10/24: An open wound was found near the resident's left elbow. There was no documentation the wound had been monitored between 03/21/24 and 04/11/24;

* 03/25/24: The resident displayed behaviors of yelling and making "derogatory" statements towards staff; and

* 03/25/24: The resident "states [s/he] is in pain all the time."

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN), and Staff 7 (Wellness Director) on 04/12/24. They acknowledged the findings.

1. All resident records will be reviewed to ensure all change of condition is identified with appropriate action per policy.

2.  The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Change of Condition policy and Skin Integrity Program. All direct care staff will receive additional training on the Stop and Watch Form.

3.  The Executive Director, Wellness Director(s), and Wellness Nurse will review this area each working day per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition with documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#'s 3 and 4) who were reviewed for significant changes. Findings include, but are not limited to:

1. Resident 3 moved into the memory care facility in 09/2023 with diagnoses including Alzheimer's disease.

The resident's clinical record was reviewed and revealed Resident 3 experienced weight loss from 10/01/23 through 01/11/24. Weight records showed the following:

* 10/01/23: 129 pounds;

* 11/01/23: 122 pounds;

* 12/01/23: 121 pounds; and

* 01/01/24: 116.8 pounds.

Resident 3 lost 12.2 pounds in three months, or 9.6% of body weight. This constituted a significant change of condition requiring an RN assessment. On 01/06/24, the facility RN completed a "quarterly" assessment and identified weight loss, but the assessment did not document findings, resident status, and interventions made as a result of the assessment related to the weight loss.

The need to ensure an RN conducted an assessment that included findings, status and interventions when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN), and Staff 7 (Wellness Director). They acknowledged the findings.

2. Resident 4 moved into the memory care facility in 02/2024 with diagnoses including dementia and stroke with affected left side extremities.

Review of the resident's progress notes, dated 02/28/24 through 04/07/24, and outside provider notes revealed the resident had an "unstageable" wound on his/her left elbow, discovered on 03/10/24. The wound was observed and treated by the resident's home health provider on 03/12/24. The provider communication form was reviewed by the facility's RN on 03/14/24. On 03/15/24 an assessment was completed by the facility RN. The assessment identified a "skin concern: A. pressure area."

The pressure wound constituted a significant change in condition for which an assessment by the facility RN was required.

The 03/15/24 assessment completed by the facility RN did not include documentation of findings, resident status, and interventions made as a result of the assessment related to the wound.

During an interview on 04/10/24, Staff 5 (Wellness RN) acknowledged an assessment with all required components had not been completed for the wound.

The need to ensure an RN conducted an assessment that included findings, status and interventions when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5, and Staff 7 (Wellness Director). They acknowledged the findings.

1. All resident records will be reviewed to ensure a change of condition assessment has been completed by the Wellness Nurse.

2.  The Executive Director and Wellness Nurse will  receive additional training on the Change of Condition policy and Skin Integrity Program.  

3.  The Wellness Nurse will review this area each working day per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

2. Resident 9 was admitted to the facility in 08/2022 with diagnoses including dementia.

The 07/11/24 to 10/28/24 progress notes, incident reports, and ISPs were reviewed.

On 9/27/24 a change of condition assessment related to hospice was completed and documented "9/26/24 LN assessed anterior peri area to have no open skin breakdown".

An incident note on 10/04/24 recorded "RN was on site assessing Res. during brief change when she saw 2 pressure sores on resident coccyx".  

The new pressure sores were noted as open (Stage II) which required a timely RN assessment that documented findings, resident status, and interventions made as a result of the assessment.

In interview on 10/28/24, Staff 26 (Wellness RN) acknowledged that after the discovery on 10/04/24 there was no service plan update until 10/08/24, and she did not complete an assessment of the wounds until 10/09/24.

The need to ensure a timely RN assessment was completed for significant changes of condition was discussed with Staff 1 (Executive Director), Staff 2 (Operations Specialist), and Staff 3 (Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed that documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 8 and 9) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 10/2023 with diagnoses including Alzheimer's disease.

The resident's 07/11/24 to 10/28/24 progress notes and 06/03/24 weight records were reviewed. The following was identified:

From 06/03/24 to 10/03/24 the resident gained 14 pounds, or 10% of his/her body weight. The weight gain constituted a significant change of condition, which required a timely RN assessment that documented findings, resident status, and interventions made as a result of the assessment.

At 2:20 pm on 10/28/24, Staff 26 (Wellness RN) stated no assessment had been completed.

The need to ensure an RN assessment was completed for significant changes of condition was discussed with Staff 1 (Executive Director), Staff 2 (Operations Specialist), and Staff 3 (Wellness Director). They acknowledged the findings.

1. The change of condition for Resident #8 and #9 has been updated with ongoing monitoring until resolved or part of baseline.

2.  The Executive Director and Wellness Nurse will  receive additional training on the Change of Condition policy including timely assessment and documentation.  

3.  The Wellness Nurse will review this area each working day per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included medication specific instructions and resident specific parameters and instructions for PRN medications for 2 of 6 sampled residents (#s 2 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to facility in 04/2023 with diagnoses including pain in unspecified lower leg and graft-versus-host disease (GVHD).

The resident's MARs dated 03/08/24 through 04/08/24 and physician's orders were reviewed. The following inaccuracies were identified:

a. The instruction to staff relating to tacrolimus ointment (an immunosuppressive agent for skin GVHD), "apply to affected areas topically [two] times daily" with no direction of where the affected areas were.

b. Resident 2 had an order for acetaminophen (for pain) with directions for staff to administer "1 - 2 [tablets]" with no parameters on when to administer one versus two tablets.

c. The signed physician's order for tramadol (for pain) had parameters on how much of the medication to administer per a pain scale, but it was not transcribed onto the MAR.  

d. There was no direction to staff on the sequential order of PRNs used to treat the same diagnosis for the following medications:

* Acetaminophen for pain;

* Tramadol for pain;

* CP Lido/Ant+Sim/Diph for oral GVHD;

* Mouthwash "BLM" for oral GVHD;

* Hydrocortisone ointment for skin GVHD "flare"; and

* Triamcinolone ointment for skin GVHD "flare".

The requirement for MARs to be accurate and include medication specific instructions and resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), and Staff 8 (Wellness Director) on 04/12/24. They acknowledged the findings.

2. Resident 4 moved into the memory care facility in 02/2024 with diagnoses including dementia and stroke.

The resident's MARs dated 03/01/24 through 04/08/24 and physician's orders were reviewed.  

The medication record did not include specific parameters and instructions for PRN medications, including the sequential order to administer PRN medications with the same reasons for use for the following:

* Bisacodyl for constipation;

* Magnesium citrate for constipation;

* Milk of magnesia for constipation;

* Senna for constipation;

* Ben-gay cream for pain; and

* Voltaren cream for pain.

The need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), and Staff 7 (Wellness Director) on 04/11/24. They acknowledged the findings.

1. All Medication Administration Records will be reviewed to ensure accurate medication records.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Orders policy.

3.  The Wellness Director(s) and Wellness Nurse will review daily per the Quality Assurance - Health Services and Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 2 of 3 sampled residents (#s 3 and 4) whose treatments were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 09/2023 with diagnoses including Alzheimer's disease.

The resident's 12/07/23 through 03/21/24 progress notes, interim service plans, physician orders signed 01/13/24, and the 01/01/24 through 01/31/24 MARs/TARs were reviewed.

On 01/13/24, progress notes documented "caregiver noticed [s/he] was bleeding from right arm... 1 cm open scratch on forearm". An incident report completed the same day documented "med tech [MT] cleaned it up and used steri tape and covered it."

The resident's 01/2024 MAR/TAR showed staff failed to document the treatments administered to the skin tear on the resident's treatment administration record.

The need to ensure all treatments administered by the facility were documented on the treatment administration record was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN), and Staff 7 (Wellness Director). They acknowledged the findings.

2. Resident 4 moved into the memory care facility in 02/2024 with diagnoses including dementia and stroke.

The resident's 02/28/24 through 04/07/24 progress notes, interim service plans, outside provider communication forms, 02/28/24 and 03/11/24 signed physician orders, and the 03/01/24 through 03/31/24 MAR/TAR were reviewed.

a. On 03/10/24, progress notes documented "caregiver found open wound under elbow ...[MT] performed first aid." The 03/2024 MAR/TAR lacked documentation the treatment was administered.

b. An outside provider communication form completed by the home health RN, dated 03/12/24, included directions for staff to "change the foam dressing to the left elbow wound with a foam dressing and replace netting if it falls off." The treatment instructions were not included on the treatment record.

c. An interim service plan, dated 03/14/24 instructed staff to "apply barrier cream after every brief change..." The 03/01/24 through 04/07/24 MARs/TARs were reviewed and lacked documentation the treatments were administered.

The need to ensure an accurate treatment record and all treatments administered by the facility were documented on the treatment administration record was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN), and Staff 7 (Wellness Director). They acknowledged the findings.

1. All Treatment Administration Records will be reviewed to ensure accurate medication records.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Orders policy.

3.  The Wellness Director(s) and Wellness Nurse will review daily per the Quality Assurance - Health Services and Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

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

The facility consisted of three detached buildings. Building A housed 14 memory care residents, Building B housed 20 RCF residents, and Building C/D housed 28 memory care residents.

The current facility staffing plan and Acuity Based Staffing Tool (ABST) were reviewed, and interviews with facility staff were conducted. The following was revealed:

* Building A had no residents who required two-person assist or the use of a mechanical lift for transfers;

* Building B had five residents who required two-person assist for transfers, three of whom required the use of a mechanical lift;

* Building C/D had 11 residents who required two-person assist for transfers, six of whom required the use of a mechanical lift;

* Based on the ABST-generated staffing model, the facility was required to schedule one direct care staff for Building A, two direct care staff for Building B, and two direct care staff for Building C/D to cover the night shift; and

* According to the facility's actual staffing plan, only one dedicated direct care staff was scheduled and available for Building B at all times. The night MT was shared as a floating direct care staff among the three buildings and therefore was not scheduled and available for Building B at all times.

The need to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was reviewed with Staff 1 (ED) and Staff 2 (Operations Specialist) on 04/12/24. They acknowledged the findings. No further information was provided.

1. The community has adjusted the staffing plan to have two designated staff in cottages at night when there is a two-person transfer in residence. The floating staff member will work in cottages without two-person transfers or when there are at least two staff members scheduled.  

2. The Executive Director, Wellness Director(s), and other department managers will cover open shifts as needed.

3. The Executive Director will review weekly and as needed.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to address all evaluated care needs of residents, including the amount of staff time needed to provide care, in the facility's acuity-based staffing tool (ABST) for 3 of 6 sampled residents (#s 2, 3, and 4) whose ABST input was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (ED) and Staff 2 (Operations Specialist) on 04/10/24.

Review of Residents 2, 3 and 4's ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 and Staff 2 on 04/12/24. They acknowledged the findings. No further information was provided.

1. The ABST will be updated with each service plan review (see C260) to ensure document is reflective of evaluated care needs.

2. The Executive Director will complete a self-training review of the Acuity Based Staffting Tool (ABST) Provider Guide and begin using the ABST Portal for completing the ABST.

3. The Executive Director will review weekly and as needed.

4. The Executive Director will ensure the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 17, 18, and 19) completed and documented training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 04/10/24.

There was no documented evidence Staff 17 (CG), Staff 18 (MT), or Staff 19 (CG), hired 02/09/24, 02/09/24, and 03/06/24, respectively, completed training in First Aid and abdominal thrust within 30 days of hire.

The need for staff to complete all required training within the specified time frames was discussed with Staff 2 (Operations Specialist) and Staff 3 (Business Office Director) on 04/10/24. They acknowledged the findings.

1. All employee records will be reviewed to ensure documented evidence of completion of First Aid and abdominal thrust are present.

2. The Executive Director and Business Office Director will receive additional training on Training required within 30 days for Direct Care Staff.  

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4.The Executive Director will ensure the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 04/08/24, fire drill and fire and life safety records for the previous six months were requested.

Review of the documentation provided revealed:

a. There was no documented evidence the facility provided fire and life safety training on alternate months for staff;

b. Written fire drill records did not include information on:

* Location of simulated fire origin;

* The escape route used;

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

* Staff members on duty and participating;

* Evacuation time period needed; and

* Number of occupants evacuated.

The need to provide fire and life safety instruction to staff on alternate months and the requirements regarding fire drills were discussed with Staff 1 (ED) and Staff 2 (Operations Specialist) on 04/12/24. They acknowledged the findings. No further information was provided.

1. The community will complete fire drills life safety instruction at least every other month.

2. The Executive Director and Mainteance Director will receive additional training on the Fire Life Safety Training & Drill Flow Chart and the Fire Drill Checklist.

3. The Maintenance Director will review monthly per the Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, on fire and life safety procedures according to the Oregon Fire Code (OFC), and keep a written record of fire safety training, including content of the training sessions and the residents attending. Findings include, but are not limited to:

On 04/11/24, Staff 1 (ED) and Staff 2 (Operations Specialist) were asked to explain the facility's process for providing residents with annual instruction on fire and life safety procedures. Staff 2 reported the facility picked one month a year when fire and life safety training was provided to all residents. However, the facility was unable to produce any documented evidence confirming the annual training had been provided.

The need to ensure residents were re-instructed, at least annually, on fire and life safety procedures according to the OFC and to keep a written record of fire safety training, including content of the training sessions and the residents attending, was discussed with Staff 1 and Staff 2 on 04/12/24. They acknowledged the findings. No further information was provided.

1. All resident records will be reviewed to ensure completion of the new resident safety orientation checklist has been completed.

2. The Executive Director and Mainteance Director will receive additional training on the New Resident Safety Orientation Checklist and the Fire Life Safety Training & Drill Flowchart.

3. The Maintenance Director will review with each new move-in and annually per the New Resident Checklist and Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

Based on observation and interview, 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 260, C 280, Z 162.

Refer to C 260, C 280, Z 162.

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

A tour of the facility on 04/08/24 through 04/10/24 revealed the following areas were in need of repair:

Building A:

* The door leading into the kitchen had peeling paint;

* The air conditioning unit in the wall, located in the dining area was not sealed and a gap was observed from the interior of the wall to the exterior;

* Laundry room walls had gaps around pipes that were not sealed; and

* Multiple apartment doors had scuffs and scrapes with peeling paint.

Building C:

* Multiple resident unit doors had scuffs and peeling paint;

* The drywall in the small dining area located next to the kitchen had damage and peeling paint; and

* The drywall in the common area living room located behind the recliners had damage and peeling paint.

The environment was toured with Staff 1 (ED) on 04/09/24. The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed. She acknowledged the findings.

1. The building areas identified will be repaired (paint touch up, sealong gaps, etc.)

2. The Executive Director and Maintenance Director will receive additional training on the Quarterly Building Inspection.

3. The Maintenance Director and Executive Director will review quarterly per the Quality Assurance - Maintenance Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

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 231, C 360, C 361, C 372, C 420, C 422, and C 513.

Refer to C231, C360, C361, C372, C420, C422, and C513.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 long term staff (#14) completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training on dementia care, and 1 of 2 long term non-direct care staff (#10) completed the annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 04/10/24. The following was identified:

a. There was no documented evidence Staff 14 (MT), hired 10/01/21, had completed the required number of annual in-service training hours, including annual infectious disease training, and at least six hours of training related to dementia care.

b. There was no documented evidence Staff 10 (Housekeeping), hired 03/30/20, completed the required annual infectious disease training.

The need to ensure the required annual training was completed by staff in the time frames specified in the rules was discussed with Staff 2 (Operations Specialist) and Staff 3 (Business Office Director) on 04/10/24. They acknowledged the findings.

1. . All employee records will be reviewed to ensure documented completion of pre-service orientation, pre-service dementia training, competency demonstration, annual infectious disease training, and annual continuing education are completed.

2. The Executive Director and Business Office Director will receive additional training on General & Memory Care Orientation, Training Checklists, and the Staff Records Checklist.

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.   

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 260, C 270, C 280, C 310, and C 315.

Refer to C260, C270, C280, C310, and C315.

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 260 and C 280.

Refer to C 260 and C 280.

Based on observation, interview and record review, it was determined the facility failed to develop an individualized nutrition and hydration plan for each resident and included in the resident's service plan for 3 of 5 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2019 with diagnoses including vascular dementia and type 2 diabetes mellitus.

Resident 1's service plan dated 02/16/24 was reviewed. The resident's service plan lacked information regarding a daily meal program of hydration based upon the resident's preferences and needs.

The need to develop an individualized nutrition and hydration plan for the resident and include the information in the resident's service plan was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), and Staff 6 (Wellness Director) on 04/12/24. They acknowledged the findings. No further information was provided.

2. Resident 3 moved into the memory care facility in 09/2023 with diagnoses including Alzheimer's disease.

Observations of the resident during lunch meals on 04/08/24, 04/09/24 and 04/10/24 showed Resident 3 frequently left the table during meals and required cuing to return to the table and eat. When a staff person or visitor was present and sat with the resident, s/he would sit for longer periods and accepted physical assistance to eat. The resident spent long hours walking around the common areas of the unit. Interviews with care staff revealed the resident was not able to express his/her needs verbally due to cognitive deficits and aphasia.

Resident 3's service plan, dated 09/21/23, was reviewed. The resident's service plan lacked information regarding a daily program for nutrition and hydration based upon the resident's preferences and needs. There was no information on snacks or hydration to be provided to the resident.

The resident's clinical record showed his/her weight had declined over the past six months and there was no information on service plan to address the weight loss.

The need to ensure an individualized nutritional plan for each resident was documented in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN) and Staff 7 (Wellness Director). They acknowledged the findings.

3. Resident 4 moved into the memory care facility in 02/2024 with diagnoses including dementia and stroke with affected left side extremities.

Observations of the resident during lunch meals on 04/09/24, 04/10/24 and 04/11/24 showed Resident 4 required positioning upright in a tilt-in-space wheelchair and attended lunch in the dining room as tolerated. At times, the resident preferred to eat meals in his/her room related to fatigue or pain. Resident 4 was able to use his/her right hand to hold a cup and drink fluids if it was placed in his/her right hand, often would not initiate eating, and accepted physical assistance from care staff to eat meals.

In an interview on 04/09/24, Staff 21 (CG) was observed removing a lunch plate from the resident's room. Resident 4 had refused the meal and Staff 21 explained the meat may have been too hard for the resident to chew.

Resident 4's service plan, dated 02/28/24, was reviewed. The resident's service plan stated the resident "is able to mostly eat independently, may need cueing to continue to consume meals". The service plan lacked information on what to do if meals were refused or snacks to be provided to the resident. The service plan included information related to fluids including "ensure a cup with handle is near [resident] so it can be easily accessed". Observations of the resident in his/her room and in common areas from 04/09/24 through 04/11/24 showed the resident did not have fluids available within reach.

The need to ensure an individualized nutritional plan for each resident was documented in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 5 (Wellness RN) and Staff 7 (Wellness Director). They acknowledged the findings.

1. All memory care resident Service (Care) Plans will be reviewed and updated with an individualized nutrition and hydration plan.    

2.  The Executive Director, Wellness Director(s), Wellness Nurse will receive additional training on the Service (Care) Plan Policy and Procedure.

3.  The Wellness Director will review weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 5 sampled residents (#s 3, 4, 5, and 6) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 3, 4, 5 and 6's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following components:

* Residents' current preferences;

* Abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities.

The need to evaluate and develop individualized activity plans, including all required components for each memory care resident, was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist) during the survey. They acknowledged the findings.

1. An Activity Assessment will be completed for all memory care residents and the individualized plan will be updated in the resident Service (Care) Plan.

2.  The Executive Director and Life Enrichment Director will receive additional training on the Activities Guide.   

3.  The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.