The findings of the re-licensure survey conducted 04/18/23 through 04/20/23 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with the letter 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 initial survey of 04/20/23, conducted 07/31/23, 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, OARs 411 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the initial survey of 04/20/23, conducted 10/19/23, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 3rd revisit to the re-licensure survey of 04/20/23, conducted on 12/07/2023 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.

3. Resident 3 was admitted to the facility in 01/2023 with diagnoses including blindness, dementia, confusion, Type II Diabetes, and was hard of hearing.

Review of Resident 3's Security System Agreement indicated Resident 3's family member decided Resident 3 would not be wearing an elopement risk wrist band and the document was signed by the family member and Staff 1.

Resident 3 did not wear a wrist band and could come and go from the facility through the open doors.

There was no documented evidence the resident was involved in the agreement and the licensing policy analyst was consulted to review alternatives before a risk agreement was signed.

The need to ensure residents were involved and the licensing policy analyst was consulted to review alternatives before a resident signed a risk agreement and risk agreements were not entered into or continued with, or on behalf of, a resident who was unable to recognize the consequences of their behavior or choices was discussed with Staff 1 and Staff 2 on 04/20/23. Staff 2 stated he was not aware the facility needed to consult with the policy analyst related to risk agreements.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were involved and the licensing policy analyst was consulted to review alternatives before a risk agreement was signed, and risk agreements were not entered into or continued with, or on behalf of, a resident who is unable to recognize the consequences of their behavior or choices for 3 of 3 residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:

Observations, interviews and record reviews revealed the following:

At the time of survey entrance on 04/18/23, the endorsed memory care community was home to 22 residents. An endorsed memory care community, as defined by OAR 411-057-011, means a special care unit in a designated, separated area for residents with Alzheimer's disease or other forms of dementia that is locked or secured to prevent or limit access by a resident outside the designated or separated area. For purposes of these rules an endorsed memory care community will be referred to as a memory care community.

During an interview on 04/19/23, Staff 1 (Administrator) and Staff 2 (CEO) stated memory care residents were evaluated to determine their risk for wandering behaviors and potential need for the resident to wear an elopement risk wrist band device to prevent elopement as the facility's exit doors were solely secured through the use of elopement risk wrist band devices. Each resident who was identified as a wandering and/or elopement risk was provided with an elopement risk wrist band.

The following information was documented on a "Security System Agreement":

"The Rock of Ages Memory Care Unit has changed the design of our door system locks. Our new system locks are open at all times to visitors and family members and those residents that we, the staff and the family, have determined are cognitively aware enough to go in and out of the facility as they please. Those residents that are not able to safely exit the facility will receive a wristband with a device that will trigger a signal on the door locks anytime they are near causing the doors to lock.

We determined this was the best fit for our facility because it allows us to protect those who are at risk for elopement and other wandering risks, while at the same time maximizing the resident choice to exit when they so desire. We are well aware that more independence can have a tremendous effect on the resident and be increase risk but it also enhances their life in a very positive way. We are in no way forcing families to allow their family to have this independence, it will obviously vary case by case.

This form is a way to make sure the family is aware of their family members' risks and a way to determine whether they wear an elopement risk wrist band or not."

1. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia and hearing loss.

During the acuity interview on 04/18/23, Staff 1 (Administrator) and Staff 5 (CG) identified Resident 2 as having behaviors of resisting care and aggression directed towards staff during care.

During observations 04/18/23 through 04/20/23, Resident 2 was observed using his/her feet to self propel in his/her wheelchair, while staff provided redirection and safety cues. An elopement risk wrist band was observed attached to the resident's wheelchair.

Review of Resident 2's Security System Agreement indicated Resident 2's family member determined Resident 2 would be wearing an elopement risk wrist band and the document was dated as signed by the family member and Staff 1 on 12/29/21. There was no documented evidence the resident was involved in the agreement and there was no documented evidence the licensing policy analyst was consulted to review alternatives before a risk agreement was signed.

The need to ensure residents were involved and the licensing policy analyst was consulted to review alternatives before a resident signed a risk agreement and risk agreements were not entered into or continued with, or on behalf of, a resident who was unable to recognize the consequences of their behavior or choices was discussed with Staff 1 and Staff 2 on 4/20/23. Staff 2 stated he was not aware the facility needed to consult with the policy analyst related to risk agreements.

2. Resident 1 was admitted to the facility in 01/2018 with diagnoses including dementia.

Resident 1's service plan dated 01/18/23 identified Resident 1 as having an elopement risk wrist band.

During an interview on 04/18/23 Staff 12 (CG) stated Resident 1 had an elopement risk device but the resident was not a significant risk for elopement as the resident required the use of a wheelchair and staff's assistance for mobility.

Review of Resident 1's Security System Agreement indicated Resident 1's family member determined Resident 1 would be wearing an elopement risk wrist band and the document was  signed by the family member and Staff 1. The document was not dated. There was no documented evidence the resident was involved in the agreement and the licensing policy analyst consulted to review alternatives before a risk agreement was signed.

The need to ensure residents were involved and the licensing policy analyst was consulted to review alternatives before a resident signed a risk agreement and risk agreements were not entered into or continued with, or on behalf of, a resident who was unable to recognize the consequences of their behavior or choices was discussed with Staff 1 and Staff 2 on 4/20/23. Staff 2 stated he was not aware the facility needed to consult with the policy analyst related to risk agreements.

The facility is changing the security system for all exit doors. Due to this, we won't require a security agreement with the initial admission documents. No resident will wear an elopement wristband. All exit doors in the memory care department will be locked

and need a code to go in and out.

Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) assessment for each resident and failed to review the ABST assessments quarterly for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

Interviews and record review revealed the following:

Review of the facility's census dated 04/18/23, and review of the facility's ABST report on 04/19/23, revealed the following:

a. ABST assessments for six residents listed on the facility's census were not included in the facility's ABST.

b. Resident 1 was admitted to the facility in 12/2018 and Resident 2 was admitted to the facility in 01/2022. There was no documented evidence the ABST assessments for Resident 1 and Resident 2 had been reviewed quarterly from 10/25/22 through 04/19/23.

During an interview on 04/20/23, Staff 1 (Administrator) acknowledged ABST assessments for six residents had not been completed and entered into the facility's ABST system, and ABST assessments for Resident 1 and Resident 2 had not been reviewed quarterly between 10/25/22 through 04/19/23.

The need to ensure the facility completed an ABST assessment for each resident and reviewed the ABST assessments quarterly was discussed with Staff 1 and Staff 2 (CEO) on 04/20/23. They acknowledged the findings.

The facility has updated the ABST assesment for the six residents that were not in the facility's ABST before.

Administrator and RMC to review this quartely.

Based on interview and record review, it was determined the facility did not ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill records were reviewed from 10/01/22 through 04/01/23.

* There was no documented evidence the facility was conducting fire and life safety instruction on alternating months from fire drills; and

* The evacuation/drill documentation did not contain information on the escape route used, problems encountered, and evidence alternate routes were used.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 04/20/23. She acknowledged the findings.

We will ensure not to leave empty spaces and add more detailed information if needed to the monthly fire documentation record. The safety committee will plan all staff fire and life meetings every other month.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to Z 155.

Referred to Z 155 PoC:

We will train all new Caregivers with the Oregon Cares required training in the immediate future. We will establish a new training program after we gain further information from Relias on the modules that they offer. A new training program will be in place by the September 14 deadline.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to Z 155.

Referred to Z 155 PoC: We are now working with Oregon Care Partners. We will train all staff with the required modules. All staff should be done by the November 18th deadline.

Based on observation and interview, it was determined the facility did not provide storage for all maintenance equipment and maintain all exterior pathways in good repair. Findings include, but are not limited to:

The memory care community (MCC) was toured on 04/18/23, and was home to 22 residents with dementia.

Residents could access an interior courtyard and also an exterior patio that wrapped around the front of the building.

Some residents wore a wrist band that electronically locked the patio exit doors and signaled a staff pager when they approached, other residents did not wear a wrist band and could come and go through the doors at any time.

During a tour of the outdoor areas on 04/18/23, the sidewalk connecting the front door patio with the north door patio were noted to have drop-offs of up to four inches from the edge of the sidewalk (measured from the concrete surface to the planting bed surface) and a section of sidewalk was lifted approximately one inch. These areas represented potential tripping hazards for residents.

On 04/18/23, a six foot ladder was noted leaning against the side of the building, and another ten foot ladder was observed on the ground near the front door.

The sidewalk drop-offs and ladders were discussed with Staff 1 (Administrator) on 04/20/23. She acknowledged the findings.

Maintenance was notified and has worked on the four-inch dropoffs on the side of the sidewalk outside.

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

The memory care community (MCC) was toured on 04/18/23, and was home to 22 residents with dementia.

Residents could access an interior courtyard and also an exterior patio that wrapped around the front of the building.

Some residents wore a wrist band that electronically locked the patio exit doors and signaled a staff pager when they approached, other residents did not wear a wrist band and could come and go through the doors at any time.

The two doors exiting to the front patio were closed but not latched, leaving them partially propped open when observed at 11:00 am, 12:30 pm and 3:00 pm.

At 3:00 pm, Staff 1 (Administrator) and Staff 4 (Maintenance) were shown the doors, and they discovered when the doors failed to latch closed they also failed to lock when approached by residents with wrist bands.

Staff 4 confirmed the door latches were malfunctioning and the door latches were repaired by 3:30 pm on 04/18/23.

The findings were reviewed with Staff 4 (Maintenance) and Staff 1 (Administrator) on 04/18/23. They acknowledged the findings.

The exit doors have been repaired, and they close and latched and will only open with a code once the contractor has completed his work.

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exit the Memory Care Community (MCC). Findings include, but are not limited to:

The MCC was toured on 04/18/23, and was home to 22 residents with dementia.

Residents could access an interior courtyard and also an exterior patio that wrapped around the front of the building.

Some residents wore a wrist band that electronically locked the patio exit doors and signaled a staff pager when they approached. Other residents did not wear a wrist band and could come and go through the doors at any time.

The front door and two other doors exiting to the patio did not have a system that would alert staff when a resident left the building when observed at 11:00 am, 12:30 pm and 3:00 pm.

At 3:00 pm Staff 1 (Administrator) and Staff 4 (Maintenance) were shown the doors and exit door alarms were installed by 3:30 pm.

The need to provide an alarm for each of the exit doors was reviewed with Staff 4 (Maintenance) on 04/18/23.

The findings were reviewed with Staff 1 (Administrator) on 04/19/23. She also acknowledged the findings.

Door alarms were installed on 4/18/23 when surveyors came to the facility.

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 265, C 361, C 420, C 510, C 513 and C 555.

C265- Our facility has operated with the present locking door system because we

wanted to give as much independence and dignified care to the level a person can be

capable of. Because now we will have locked doors, the risk management piece of Z 265

will not be required.

C361- We are now doing the ABST assessment quarterly.

C420-Additional training on fire documentation is complete.

C510- The four-inch side dropoff has been addressed to maintenance and completed.

C513- Exit doors were addressed and completed on 4/18/23.

C555- Exit door alarms were installed and completed on 04/18/23.

Based on interview and record review, it was determined the facility did not ensure 3 of 3 sampled, newly hired staff (#s 7, 8, and 9) completed all required pre-service orientation and pre-service dementia training. Findings include, but are not limited to:

Staff 7 (Caregiver) was hired on 01/06/23, Staff 8 (Caregiver) was hired on 12/22/22, and Staff 9 (Caregiver) was hired on 09/14/22.

Staff training records were reviewed on 04/19/23 with Staff 16 (Office Manager).

The following was identified:

1. There was no documented evidence Staff 7, Staff 8, and Staff 9 completed the required pre-service Infectious Disease Prevention training.

2. There was no documented evidence Staff 7, Staff 8, and Staff 9 completed the required pre-service dementia care training in:

* Environmental factors that are important to a residents well-being (e.g. staff interactions, lighting, room temperature, noise);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the residents condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia including an orientation to the residents service plan;

* Use of supportive devices with restraining qualities in memory care communities;

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification documentation and reporting changes of condition; and

* Conditions that require assessment, treatment, observation, and reporting.

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 16 (Office Manager) and Staff 2 (Administrator) on 04/20/23. They acknowledged the findings.

The facility has incorporated training on pre-service infectious diseases prevention training in ROA staff training initial form. Staff will need to complete the initial 30-day competency test after being trained. To be reviewed at the end of training.

Based on interview and record review, it was determined the facility failed to ensure staff members completed department approved training for pre-service dementia and infectious disease. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 07/31/23. There was no documented evidence the facility was using department approved trainings to complete pre-service dementia or department approved infectious disease prevention trainings.

In an interview on 07/31/23, Staff 2 (CEO) reported the facility was using "Collins Training" to complete pre-service dementia trainings and infectious disease prevention.

On 07/31/23, the need to ensure the facility completed department approved pre-service dementia trainings and infectious disease prevention trainings was discussed with Staff 2. He acknowledged the findings.

We will train all new Caregivers with the Oregon Cares required training in the immediate future. We will establish a new training program after we gain further information from Relias on the modules that they offer. A new training program will be in place by the September 14 deadline.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff member (# 18), completed department-approved pre-service training for infectious disease prevention and dementia care. This is a repeat citation. Findings include, but are not limited to:

Training records for Staff 18 (CG), hired 09/01/23, were provided. There was no documented evidence Staff 18 had completed the required pre-service orientation and dementia training.

In an interview with Staff 1 (Administrator) on 10/19/23, she stated the facility had not implemented a new training program which included pre-service infectious disease prevention and dementia training from Department-approved providers. She indicated they were "working on" changing providers, but they had not completed the process, nor had any newly hired staff completed the appropriate pre-service training.

The need to implement a new training program using Department-approved providers, which was the facility's plan of correction, and the need for all new employees to complete the pre-service training in the time frames required, was discussed with Staff 1. She acknowledged the findings.

We are now working with Oregon Care Partners. We will train all staff with the required modules. All staff should be done by the November 18th deadline.

Based on interview and record review, it was determined the facility failed to ensure activity evaluations and activity plans were individualized and included information that reflected all required components for 3 of 3 sampled residents (#s 1, 2, and 3) whose evaluations and service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, and 3's records were reviewed during the survey. There was no documented evidence the activity evaluations and service plans were individualized to reflect the following required components:

* Current abilities and skills;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

On 04/19/23, the need to ensure activity evaluations and individualized activity plans included information for all required components was discussed with Staff 1 (Administrator). She acknowledged the findings.

RN, administrator, and RCM will add individualized current abilities, physical abilities, limitations, and necessary adaptations for residents to participate in activities and services for each resident to their care plans. Staff is to notify Med-aide if any change of

condition affects a resident's physical ability to participate in activities. A temporary care

plan will follow and will be updated to the care plan if needed. Administrator, RN, and

RCM to review care plan quarterly.

Based on observation and interview, it was determined the facility did not ensure fencing was no less than six feet in height and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The memory care community (MCC) was toured on 04/18/23, and was home to 22 residents with dementia.

Residents could access an interior courtyard and also an exterior patio that wrapped around the front of the building.

Some residents wore a wrist band that electronically locked the patio exit doors and signaled a staff pager when they approached. Other residents did not wear a wrist band and could come and go through the doors at any time.

A tour of the facility exterior patio on 04/18/23 revealed the fencing around the perimeter of the exterior wraparound patio was less than six feet in height. The shortest sections were approximately three feet.

There were four patio chairs and a patio table which were easily moveable and not of sufficient weight or design to prevent potential elopement.

The requirement to ensure outdoor courtyard fencing was no less than six feet in height and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement was discussed with Staff 1 (Administrator) and Staff 2 (CEO) on 04/18/23. They acknowledged the findings.

Security system will lock all exit doors. Fence less than six ft and furnature outside the memory care was not designed to be part of secured area. We have a contractor working on the door system that will require a pad entry code to go in and out. The courtyard

in the memory care unit will be the secure outdoor seating for residents. Projected completion 05/22/23