The findings of the re-licensure survey conducted 9/20/21 through 9/22/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

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 9/22/2021, conducted on 1/24/2022, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OAR's 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health of residents, related to infection control practices. Findings include, but are not limited to:

The interior of the building was toured on 9/20/21 at 11:15 am. In the facility laundry room, where resident laundry was processed, there were two large yellow plastic trash cans labeled "Soiled Linens" which were loaded with resident clothing and bedding that had been intermingled. There was a smaller white plastic storage tote that contained resident items in a sealed plastic bag - there was dried brown material smeared on the inside of the tote. There were three pairs of shoes in a utility sink. There was a small pile of resident clothing on the floor next to the sink.

In an interview on 9/20/21 at 12:25 pm, Staff 7 (CG) explained that when staff identified soiled laundry (meaning clothing or bedding contaminated with bodily fluids) they were supposed to place the soiled items in a large garbage bag, seal the bag and immediately bring the bag to the laundry room. If the washing machine was available, the staff person was to rinse the soiled items in the hopper sink, if necessary, and then wash the items separately from non-soiled items. If the washer was not available, staff were to label the bag with the resident's room number and place the bag in the yellow "Soiled Linens" bin to be washed later. Staff 7 acknowledged the various clothing and bedding items found in the laundry room during the tour were not stored properly.

The laundry room was toured with Staff 1 (ED) on 9/20/21 at 12:45 pm. She confirmed that Staff 7's explanation of how laundry should be handled and stored was accurate, and acknowledged how the laundry was left in the laundry room was not acceptable and represented poor infection control practices.

Laundry identified during survey was immediately corrected. Linen containers were cleaned, and all brown substance removed by 9/25/2021. Staff in-services on proper process for handling of soiled lined in the October All Staff Meeting (no later than 10/25/2021). Environmental Service Director or designee will check the cleanliness of soiled linen containers daily and clean containers at least weekly as needed. Procedure for soiled linen processing will be added to new hire orientation. ED or designee will observe laundry room for compliance at least weekly and quarterly checks on new hire orientation documentation.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear instructions for staff and were followed for 1 of 6 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in September 2016 with diagnosis of dementia. During the acuity interview on 9/20/21 the resident was identified with weight loss and needing meal assistance.

Observations of resident ADL care on 9/20/21 through 9/22/21, interviews with staff, and review of the resident's current service plan and temporary service plans were conducted during the survey.

a. The service plan dated 9/1/21 was not reflective of the resident's status and lacked clear instructions to staff in the following areas:

* Hospice provided showers and bed baths; and

* Staff were providing hand over hand meal assistance.

b. The service plan was not implemented in the following areas:

* Obtaining weekly weights;

* Monitoring and reporting food refusals and percentages to MT; and

* Providing thickened liquids.

The need to ensure service plans were reflective of the resident's current status, provided clear instructions for staff and were followed was discussed with Staff 1 (ED) on 9/22/21. She acknowledged the findings.

Resident # 2 Service Plan was updated to reflect current ADL care needs, to include weight changes, dining, liquid consistency, hospice service revocation, and all changes. Resident had a full change in condition assessment conducted on 9/21/2021. Health Services Director and Executive Director have reviewed all Residents by 10/10/2021 to ensure no additional Residents require Service Plan updates as identified in this citation. Residents will be reviewed as a team within 72 hours of admission to ensure service plan is reflective of all care needs. ED or designee will monitor service plans at least quarterly

Based on observation, interview and record review, it was determined the facility failed to ensure a significant change of condition was thoroughly assessed by an RN, with resident status documented, interventions developed as a result of the assessment and an update to the service plan, for 1 of 3 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 2016 with a diagnosis of dementia.

Residents 2's weight was documented to be 179.8 pounds on 8/1/21.

On 8/24/21, Resident 2 was admitted to the hospital for decline and low oxygen saturation levels. S/he returned to the facility on 9/1/21. No weight was obtained when the resident was readmitted.

An interim service plan was written on 9/5/21 instructing staff to report food refusals and percentages to MT. There was no evidence meal monitoring percentages were consistently being documented.  

Resident 2's weight on 9/14/21 was documented to be 166 pounds. This constituted a 13.8 pound, or 7.675% total body weight loss within one month. This was considered a significant change in condition and required a facility RN assessment.

On 9/14/2, a chart note by Staff 2 (Health Services Director), indicated she was aware of the weight loss however, there was no documented RN assessment of the resident's current weight status, interventions reviewed, and new interventions developed as a result of the significant weight loss.

During an interview on 9/21/21, Staff 15 (MT), reported Resident 2 had not been the same since returning from the hospital and caregivers were providing hand over hand meal assistance when needed during meals.

Resident 2 was observed on 9/22/21 to eat 100% of breakfast meal with staff providing meal assistance.

The surveyor requested a current weight during the survey on 9/21/21. Staff 14 (CG) weighed Resident 2. Resident 2's weight was recorded at 169.4 pounds.

The need to ensure a significant change of condition RN assessment was completed, and a review of the weight loss interventions with an update to the service plan was discussed with Staff 1 (ED) on 9/21/21 and Staff 2 on 9/22/21. They acknowledged the findings.

Resident #2 had comprehensive evaluation initiated on 9/21/2021 (see service plan C260) to cover his change in condition RN conducted assessment and documentation on 9/22/2021. Resident is being followed at least weekly by RN to monitor changes in current condition and plan of care. Residents with changes in condition (improvement or declines) will be followed documented on by the RN and be reviewed in the community High Risk Meeting. Residents with weight loss will have specific interventions put on interim service plan and staff monitoring of interventions to ensure they are effective. Residents with significant weight loss will be followed in High Risk Meeting weekly until weigh is stable. Staff will be re-educated on process for reporting noted changes in resident condition (improvements or declines) to the RN or ED. ED or designee will monitor change in condition and intervention documentation (as needed ) at least monthly during High Risk Meeting

Based on observation, interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were carried out as prescribed for 1 of 2 sampled residents (#2) who were reviewed for special diet orders. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 2016 with diagnoses including dementia.

Review of Resident 2's current physician orders and MAR dated 9/1/21 through 9/20/21 identified Resident 2 was prescribed nectar thickened liquids.

In an interview on 9/22/21, Staff 11 (CG), reported Resident 2 drank regular water and juice, "we don't give [him/her] thickened liquids."

On 9/22/21 at 9:30 am, Resident 2 was served non-thickened water and a non-thickened red colored juice during the breakfast meal. At 10:25 am Resident 2 was served non-thickened water with a straw.

On 9/22/21 the need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (ED). She acknowledged the findings.

Resident's liquid consistency has been updated on all diet communication. All Residents with altered consistency diets or modified consistency liquids were reviewed and compared to orders. No discrepancies were noted. Health Service staff and Dietary Staff in-serviced on provided only Physician ordered diets as indicated on diet lists by 10/25/2021. ED or designee will review diet list at least monthly for accuracy.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications that were ordered by a legally recognized prescriber and were administered by the facility for 1 of 6 sampled residents (#3) whose records were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2019 with diagnoses including Alzheimer's, chronic obstructive pulmonary disease (COPD) and hypertension. Review of Resident 3's MAR, dated 9/1/21 to 9/20/21 identified the following:

* Staff failed to document that one dose of gabapentin (for pain/restless leg syndrome) was administered on 9/3/21;

* The MAR lacked clear instructions for administration of PRN diclofenac gel (for neck pain);

* The MAR listed different numbers for maximum dose of acetaminophen (for pain). The regular MAR entry stated "do not exceed 3000 mg in 24 hours", while a separate order note stated "do not exceed 4000 mg in 24 hours"; and

* The MAR lacked accurate parameters for use of the PRN bowel medications Miralax and bisacodyl. It stated bisacodyl was to be administered "12 hours after Milk of Magnesia" (Milk of Magnesia was not listed on the orders or MAR).

On 9/22/21 the need to keep an accurate MAR of all medications that were ordered by a legally recognized prescriber and were administered by the facility was discussed with Staff 1 (ED). She acknowledged the findings.

Resident # 3 - o Caregiver that failed to sign out gabapentin was provided with verbal coaching by 10/15/2021 o Diclofenac gel PRN parameters updated by 10/8/2021 o Acetaminophen order clarified by 10/8/2021 o PRN Bowel regimen clarified by 10/8/2021 All Resident PRNs will be reviewed, and orders clarified by 11/1/2021. All Medication variances reviewed from 9/1/2021-10/8/2021. MD Notifications were made as required. Med Techs will be re-educated on change of shift review of EMAR by 10/25/2021. Medication variance report will be reviewed at least weekly by Health Service Director or Executive Director. PRN Parameters will be reviewed during triple check order review Licensed Nurse approval of order and with Recap order process at least quarterly.

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

Fire and life safety records, from 4/2021 through 9/2021, were reviewed with Staff 5 (Environmental Service Director) on 9/21/21. The following were identified:

1. Fire and life safety instruction was not consistently provided to staff on alternating months; and

2. Fire drills lacked documentation of the following required components:

* Location of simulated fire origin;

* Escape route used;

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

* Evacuation time-period; and

* Number of occupants evacuated.

In an interview on 9/21/21, Staff 5 and Staff 1 (ED) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months of fire drills and fire drill records lacked documentation of the required components.

Updated Fire Drill will be done at least every other month on different shifts including evening and nights to consist of all required elements below: o Date and time of day; o Location of simulated fire origin; o The escape route used; o Problems encountered and comments relating to residents who resisted or failed to participate in the drills; o Evacuation time period needed; o Staff members on duty and o participating; and o Number of occupants evacuated All new staff will be educated on fire drills during orientation, current staff will be re-educated by 10/30/2021. ED or designee will monitor fire drills for completeness and accuracy of drills within 72 hours of their occurrence.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff 5 (Environmental Service Director) on 9/21/21. Staff 5 reported the facility was not activating the alarm and were not evacuating or relocating residents during fire drills. The facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills;

* Annual fire and life safety training for residents; including all required training topics;

* Problems encountered with residents who were unwilling to participate in fire drills; and

* Immediate changes made to ensure the evacuation standard could be met.

The need to ensure all fire drills were conducted in accordance to the OFC, was discussed with Staff 1 (ED) and Staff 5 on 9/21/21. They acknowledged the findings.

Updated fire and life safety practice began in October 2021. The community is activating the alarm, alternative exit routes have been identified and will be noted on the fire drill record, Residents specific details regarding challenges with evacuation is being evaluated as part of their initial evaluation and at least annually. Challenges will be identified in the resident service plan and in the community disaster plan. Staff will be educated on updates to fire and life safety practices by 10/31/2021.ED or designee will monitor service plans and disaster plan at least quarterly. Fire drill practice and records will be monitored per C420.

Based on observation and interview, it was determined the facility failed to have an exit door alarm or other acceptable system which alerted staff when residents exited the RCF. Findings include, but are not limited to:

The building was toured on 9/20/21 at 11:15 am. The building layout consisted of two separate units, each arranged in a square with an interior courtyard that bisected each unit. There was an exit door on each end of the courtyard. When the surveyor exited the unit into the courtyard, no alarm was audible.

In an interview on 9/22/21 at 9:00 am, Staff 9 (MT) stated there was no alert sent to the Medication Aide pager notifying them someone had exited the building into the courtyards. In an interview on 9/22/21 at 11:55 am, Staff 5 (Environmental Services Director) confirmed there was no system on the courtyard doors to alert staff when a resident exited the units.

The lack of an alarm system on the courtyard doors was discussed with Staff 1 (ED) on 9/22/21 at 12:05 pm. She acknowledged the findings.

The courtyard doors had alarms added that now sound when the doors are opened. ESD or desigee will check the doors at least quarterly for operability.

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 C160, C 420, C 422 and C 555.

Refer to C160, C 420, C 422 and C 555.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 10, 16, 17 and 18) completed all required pre-service and competency training and 3 of 3 sampled direct care staff (#s 19, 20 and 21) completed a total of 16 hours of in-service training annually, including six hours of dementia care training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (ED) on 7/21/21 and 7/22/21. The following deficiencies were identified:

1. Staff 16 (Laundry Aide) was hired 4/16/21. Staff 10 (CG), Staff 17 (MT) and Staff 18 (MT) were hired on 5/27/21, 7/6/21 and 7/7/21, respectively. Records lacked documentation they had completed the following pre-service training:

* Staff 16: Abuse reporting requirements, standard precautions in infection control, fire safety and emergency procedures, a written job description, environmental factors that are important to resident's well-being, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.

* Staff 10: Resident rights and values of CBC care, fire safety and emergency procedures, approved pre-service dementia training, environmental factors that are important to resident's well-being, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.

* Staff 17: Resident rights and values of CBC care, approved pre-service dementia training, environmental factors that are important to resident's well-being, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.

* Staff 18: Information concerning specific aspects of dementia care and ensuring safety of residents with dementia, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.

2. Records lacked documentation Staff 10, 17 and 18 completed the following required training within 30 days of hire:

* Staff 10, 17 and 18: Changes associated with normal aging.

* Staff 10's demonstrated competency was not signed as completed until 8/2/21 - more than 30 days after her hire date.

3. Staff 19, 20 and 21 had been employed as direct care staff in the facility since at least 2019. Review of annual training records for 2020 and 2021 indicated all three sampled staff lacked documentation of having completed a total of 16 hours of in-service training, including six hours of dementia care training.

Deficiencies with the training program was reviewed with Staff 1 on 9/22/21 at 9:35 am. She acknowledged the lack of documentation of completed training.

Staff 16: Had the following required training completed by 10/1/2021: Abuse reporting requirements, standard precautions in infection control, fire safety and emergency procedures, environmental factors that are important to resident's well-being, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment. Staff 16 had a written job description signed by 10/1/2021. Staff 10: Had the following training by 10/1/2021: Resident rights and values of CBC care, fire safety and emergency procedures, approved pre-service dementia training, environmental factors that are important to resident's well-being, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment. Changes associated with normal aging.

Staff 17: Had the following training by 10/1/2021: Resident rights and values of CBC care, fire safety and emergency procedures, approved pre-service dementia training, environmental factors that are important to resident's well-being, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment. Changes associated with normal aging.

Staff 18: Had the following training by 10/1/2021: Information concerning specific aspects of dementia care and ensuring safety of residents with dementia, family support and the role the family may have in the care of the resident, and how to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment. Changes associated with normal aging. Staff 19, 20 and 21 - Completed required 16 hours of training for 2021 by 10/31/2021. This included the 6 Hours of Dementia training. All Staff training files to be audited by 10/20/2021. Staff with missing training hours, unsigned job descriptions or checklists will be required to complete missing items within 30 days. ED or designee to monitor all employee education and records based on hired date and anniversary date.

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 280, C 303 and C 310.

Refer to C 260, C 280, C 303 and C 310