The findings of the re-licensure survey, conducted 03/06/23 through 03/08/23, 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, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.  

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 first revisit to the re-licensure survey of 03/08/23, conducted 06/13/23, are documented in this report. It was determined the facility was in substantial 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.

Based on observation, interview and record review, it was determined the facility failed to ensure injuries of unknown cause and resident-to-resident altercations were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 2 of 3 sampled residents (#s 1 and 3) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia, agitation and seizure disorder.

Observations of the resident, interviews with staff, and review of the resident's 02/22/23 service plan, 12/31/22 through 03/06/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, required one staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident was vision impaired and hearing impaired. The resident wandered the memory care unit in and out of resident apartments and common areas. The resident required frequent reminders to use his/her walker and had frequent physical and verbal aggression towards staff including hitting, biting, pinching and ramming them with his/her walker.

a. Review of the resident's records showed the following:

* An incident report dated 12/20/22 indicated the resident was found on the ground and had stated another resident pushed him/her down. Resident 1 had hit his/her head and had complaints of side pain. The incident report indicated the altercation was reported to the local SPD, but no documentation could be located.

* An incident report dated 12/31/22 indicated the resident was being assisted to walk by staff when s/he started to fall. Staff intervened to slow the fall. The resident was found to have a skin tear to the right wrist. The investigation was unclear if all interventions were in place and if the staff member or the fall caused the injury. The incident report indicated the incident was reported to the local SPD office, but no documentation could be located.

* An incident report dated 01/18/23 indicated the resident reported his/her roommate had grabbed his/her arm "really hard." The resident's roommate confirmed s/he grabbed the resident after Resident 1 bumped the roommate with their walker. The incident report indicated the altercation was reported to the local SPD but no documentation could be located.

In an interview on 03/08/23, Staff 1 (ED) indicated she could not locate any further information on the reporting of the injury or resident altercations. Staff 1 checked with the local SPD but they had no record the incidents had been reported to them.

Staff 1 reported the three incidents and provided confirmation of the reports prior to survey exit.

b. Review of incident investigations for the last 90 days showed 12 incidents had no documented administrator review.

In an interview on 03/08/23, Staff 1 indicated she was in the process of getting caught up. Staff 1 stated the policy was for her to review within 24 hours to assist in determination of the need for reporting of any incidents.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect, reviewed by the administrator and reported to the local SPD as needed was discussed with Staff 1 (ED), Staff 2 (Wellness Nurse), Staff 3 (Wellness Director) and Staff 4 (Operations Specialist) on 03/07/23. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in December 2012 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 09/22/22 service plan, 11/02/22 through 03/01/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident required full assistance of two staff for ADL care and a Hoyer lift for transfers. The resident was confused with short and long term memory impairments.

a. An outside provider note dated 01/04/23 indicated the resident had a bruise to the left forearm.

There was no investigation completed for the injury of unknown cause.

The facility was asked to report the injury of unknown cause to the local SPD office, and confirmation of the report was received prior to exit.

b. Review of the resident's completed incident reports for the last 90 days showed two of four had no documented administrator review.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect, reviewed by the administrator and reported to the local SPD as needed was discussed with Staff 1 (ED), Staff 2 (Wellness Nurse), Staff 3 (Wellness Director) and Staff 4 (Operations Specialist) on 03/07/23. The staff acknowledged the findings.

1. The Executive Director completed self reports for the three incidents during survey. Pending incidents have been reviewed and signed by the Executive Director.

2. The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Abuse Investigations & Reporting Policy, and the Incident/Accident Report Policy. The Executive Director will receive additional training on the Oregon Abuse Reporting Guide.

3. The Wellness Director and Executive Director will review and investigate Incident Reports daily following 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 a resident's current care needs and provided clear direction to staff for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in October 2022 with diagnoses including a history of urinary tract infections. S/he was identified during the acuity interview on 03/06/23 as having an indwelling catheter.

Resident 2's current service plan, dated 02/21/23, was reviewed and found to lack clear direction to staff in regard to his/her catheter care.

In an interview with Staff 2 (Wellness Nurse) on 03/08/23, she reported that catheter care instruction was provided during staff meetings.

The need to ensure the service plan provided clear direction to staff on the delivery of services was discussed with Staff 1 (ED), Staff 2 (Wellness Nurse), and Staff 3 (Wellness Director) on 03/08/23. They acknowledged the findings.

1. All resident service plans will be reviewed to ensure the plans are reflective of resident needs and with clear instruction regarding delivery of service.

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy. All direct care staff will receive additional training on delivery of service.

3. The service plan schedule will be reviewed 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 interview and record review, it was determined 2 of 2 sampled, newly hired direct care staff (#s 13 and 14) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

The facility's training records were reviewed with Staff 4 (Operations Specialist) on 03/07/23.

Staff 13 (Med Tech) hired on 12/22/22 and Staff 14 (CG) hired on 01/31/23 did not have documentation of First Aid and abdominal thrust training completion within the required 30 days of hire.

The need to ensure First Aid and abdominal thrust training was completed within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Nurse), and Staff 3 (Wellness Director) on 03/08/23. 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 for applicable positions.

2. The Executive Director and Business Office Director will receive additional training on Training 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 observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:

Observations of the facility's assisted living and memory care sections on 03/06/23 and 03/07/23 showed the following areas were in need of cleaning or repair:

* Two stains, one black and one red, were noted on the carpet in the common TV area in the assisted living section;

* Multiple dining room chairs in both dining rooms had dark stains and food debris on the seats or chair backs;

* Furniture in the TV room/common area of the memory care section had large tears to the seat backs of the recliners;

* Dark accumulation was noted along baseboards in the dining room, common areas and common bathrooms. Flooring in common bathrooms was missing caulking and pulling apart at the seams in both sections of the facility;

* Spills, splatters, dark streaks, scrapes and chunks of missing plaster were noted on walls in the dining rooms, hallways and behind charting stations in both sections of the facility;

* Multiple dining room tables in the assisted living and memory care sections had missing laminate along the edges or tabletops with exposed wood/particle board surfaces;

* Common bathrooms in both sections of the building had missing and discolored caulking around the toilet and cracked and discolored caulking at the edge of the shower;

* Spills and debris were noted in windowsills in both dining rooms and the TV rooms;

* A large section of drywall and concrete was missing under the dining room sink in the memory care section;

* Multiple cupboards and drawers in both dining rooms had spills, stains or debris;

* Two large patch sections to the ceilings of the private dining room and the memory care dining room were observed. Two holes were noted to the patch area in the memory care;

* The main laundry had scrapes, dings and chipped plaster along the walls and corners. The washing machines had white/gray accumulation around the lid of the machine and the floor had multiple areas that were cracked, pulling apart at the seams or cracked at the wall edges; and

* Rooms 127 and 126 had chips and scrapes to wall edges near doorways. The toilets had missing pieces of caulking as well as brown/black discolored caulking. Flooring was cracked at wall edges, pulling apart at the seams and cracked and discolored at the edge of the shower stalls.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED), Staff 4 (Operational Specialist) and Staff 5 (Maintenance Director) on 03/07/23. They acknowledged the findings.

1. All common areas and furniture that noted debris has been deep cleaned. Drywall has been repaired and touch up painting completed. Common area bathroom and laundry floors will be replaced or repaired and recaulked as needed. Furniture will be repaired as needed. Dining tables will be replaced. Washers have been deep cleaned.

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 quartelry per the Quarterly Building Inspection.

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 372 and C 513.

Refer to C 231, C 372, C 513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled, newly hired staff (#s 13, 14 and 15) completed all required pre-service orientation and pre-service dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 03/07/23 with Staff 4 (Operations Specialist). Staff 13 (Med Tech) was hired on 12/22/22, Staff 14 (CG) was hired on 01/31/23, and Staff 15 (Life Enrichment Assistant) was hired on 12/16/22. The following were identified:

1. There was no documented evidence Staff 13, Staff 14, and Staff 15 completed the required pre-service Infectious Disease Prevention training.

2. There was no documented evidence Staff 13, Staff 14, and Staff 15 completed the required pre-service dementia care training in:

* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food and fluid, preventing wandering and elopement, and use of a person-centered approach.

The need to ensure newly hired staff completed all required orientation and pre-service dementia training before independently providing personal care or other services was reviewed with Staff 4 on 03/07/23 and with Staff 1 (ED), Staff 2 (Wellness Nurse), and Staff 3 (Wellness Director) on 03/08/23. They acknowledged the findings.

1. All employee records will be reviewed to ensure documented completion of pre-service orientation, pre-service dementia training, and pre-service Infectious Disease Prevention training are completed.

2. The Executive Director and Business Office Director will receive additional training on General & Memory Care Orientation, and pre-service trainings provided by the communities contracted education program.

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.

Refer to C 260.

Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height and constructed to reduce the risk of elopement. Findings include, but are not limited to:

A tour of the facility's memory care courtyard on 03/06/23 showed two gates within the perimeter fencing that were approximately 5 foot 4 inches in height.

A large section of fencing/wall around one side of the courtyard consisted of a short brick wall approximately 2 feet 4 inches in height with a metal fence on top of the wall, that was approximately 4 feet tall. The metal fencing and brick wall had a large gap between them with a wide, flat surface on the top of the wall. The top of the brick wall could easily be stepped onto and stood on by an individual to climb or fall over the 4 foot section of metal fencing.

No residents were observed in the courtyard during survey. Observations of the current residents who resided in the memory care unit and interviews with staff showed none of the residents appeared to have the strength, balance or mobility to step up on onto the brick wall at that time.

The fencing sections that were less than six feet in height and the wall/fence construction which created a potential elopement risk, was shown to and discussed with Staff 1 (ED), Staff 4 (Operations Specialist) and Staff 5 (Maintenance Director) on 03/07/23. They acknowledged the findings.

1. The gate will be adjusted or replaced to ensure a minimum of 6 feet height from the ground. The fencing will be adjusted to ensure there is 6 feet height from the lowest access point from ledge.

2. The gate and fencing will be adjusted with a permanent structure that will prevent the violation from occurring again.

3. The Maintenance Director and Executive Director will review quartelry per the Quarterly Building Inspection.

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