The findings of the Change of Ownership survey, conducted 11/27/23 through 11/29/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the re-licensure survey of 11/29/23, conducted on 03/20/24, 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 and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and were updated as needed for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted in 02/2022 with diagnoses including dementia, hypertension, and acute coronary syndrome.

The resident's 08/01/23 service plan and Change of Care documents, dated from 10/13/23 through 11/20/23, were reviewed. Resident 1 was observed and staff were interviewed. The following areas were either not reflective on the resident's service plan or lacked clear direction to staff:

* Weekly visits from HHPT;

* Beverage preferences to maintain hydration;

* Behaviors relating to showers and effective interventions;

* Housekeeping;

* Laundry;

* Emergency evacuation instructions;

* Pain, including non-drug interventions;

* Instructions to staff if side rails were loose or in disrepair;

* The use of compression socks;

* Clear instruction on when to notify Staff 1 (Administrator) relating to "consistent" low blood pressure readings; and

* Status on oral surgery after a crown fell out.

The need to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided and were updated as needed was discussed with Staff 1 on 11/29/23. She acknowledged the findings.

2. Resident 2 was admitted in 07/2023 with diagnoses including vascular dementia, kidney failure, and edema.

The resident's 07/03/23 service plan and Change of Care documents, dated from 09/15/23 through 11/15/23, were reviewed. Resident 2 was observed and staff were interviewed. The following areas were either not reflective on the resident's service plan or lacked clear direction to staff:

* Durable medical equipment such as a tilt-in-space wheelchair and an air overlay, pressure relieving mattress for the hospital bed;

* Directions to staff if there were issues with the air overlay mattress;

* Instructions to staff if side rails were loose or in disrepair;  

* Ability to walk with a walker;

* Non-drug interventions for behaviors;  

* Instructions on who changes the filter and tubing on the resident's oxygen concentrator and how often the task was needed;

* What services hospice provided and how often;

* Housekeeping;

* Laundry;

* Pain, including non-drug interventions;

* Emergency evacuation instructions;  

* Portable oxygen instructions including liter flow;

* Leisure activities;  

* Instructions to staff relating to the care of compression stockings;

* Beverage preferences;

* Incontinent care needs including how the resident communicates s/he is in need of care and how often the resident needs to be checked on for assistance;

* Bed time routine including the liter flow of oxygen and the blue wedge pillow placement; and

* How often staff are to check on Resident 2 during the night.

The need to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided and were updated as needed was discussed with Staff 1 (Administrator) on 11/29/23. She acknowledged the findings.

We are in the process of doing Resident #1 and Resident #2's respective quarterly evaluations for their updated service plans. We are contacting Resident #1's Service Planning Team (Resident, RN, Family POA representative [husband], Lead CG, and Administrator); and Resident #2's Service Planning Team (Resident, RN, Family POA representative [daughter], Lead CG, and Administrator): for the purpose of documenting changes and updating Resident #1 and Resident #2's needs, and also to provide clear instruction to staff.

The Administrator and the Lead Caregiver will be coordinating and compiling any new information and/or changes. We are reviewing the state requirements to ensure that the additional elements are reflected in the Resident's Service Plans. The Administrator will give a copy to the resident and family, as well as provide staff with additional training as needed. The Service Plans will be evaluated thirty days after admission, then quarterly, and upon significant change of condition.

Based on interview and record review, it was determined the facility failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift with weekly progress noted through resolution for 2 of 2 sampled residents (#s 1 and 2) who were reviewed for changes of condition. Findings include, but are not limited to:  

1. Resident 1 was admitted in 02/2022 with diagnoses including dementia, hypertension, and acute coronary syndrome.

Resident 1's medical chart was reviewed and the following changes of condition were identified:

* 10/01/23 - "hard to transfer, very sleepy, leaning forward in chair, having [trouble sitting up];

* 10/13/23 - "some changes in medication" (not specified);

* 11/18/23 - return from the hospital after having a heart attack;  

* 11/20/23 - new medications added for aspirin (blood thinner), atorvastatin (lower cholesterol), clopidogrel (heart attack and stroke prevention), metoprolol (to treat high blood pressure); and

* 11/20/23 - change in medications for mirtazapine (antidepressant) and risperidone (for agitation), both scheduled and PRN.  

There was no documented evidence the resident's short term changes of condition had actions or interventions determined and communicated to staff on each shift nor were the changes monitored weekly through resolution.  

The need to ensure residents who experienced short term changes of condition, had actions or interventions determined, the actions or interventions were communicated to staff on each shift, and weekly progress was noted was discussed with Staff 1 (Administrator) on 11/29/23. She acknowledged the findings.

2. Resident 2 was admitted in 07/2023 with diagnoses including vascular dementia, kidney failure, and edema.

Resident 1's medical chart was reviewed and the following changes of condition were identified:  

* 09/12/23 - staff documented the resident had a fever of 99.8;

* 09/17/23 - staff "noticed a red spot on right buttcheek"; and

* 10/08/23 - fall out of bed.   

On 11/29/23 at 10:12 am, Staff 3 (MT/CG) verified that Resident 2 had no current skin issues.

There was no documented evidence the resident's short term changes of condition had actions or interventions determined and communicated to staff on each shift nor were the changes monitored weekly through resolution.  

The need to ensure residents who experienced short term changes of condition, had actions or interventions determined, the actions or interventions were communicated to staff on each shift, and weekly progress was noted was discussed with Staff 1 (Administrator) on 11/29/23. She acknowledged the findings.

We have a written communication system to ensure Resident #1, Resident #2, and all other Residents, change of condition information and required interventions, will be documented. A review of our reporting policies will be conducted with caregivers to ensure that each change of condition is followed through to completion.

Each caregiver on every shift is now requried to report in writing, instead of verbally, on the status of Resident #1, Resident #2, and all other residents, regarding progress, until any conditions are resolved.

The designated person that will review the progress notes is the Administrator. The Lead Caregiver will also do the same. The Adminstrator is available 24/7 to take calls regarding Resident #1, Resident #2, or any other resident, as well.

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:

On 11/27/23, the facility was asked to provide documentation of the Residential Care Facility Administrator license.

There was no documented evidence Staff 1 (Administrator) had a Residential Care Facility Administrator license that met the department's requirements.  

The need to ensure the facility's administrator had a Residential Care Facility Administrator was discussed with Staff 1 on 11/28/23. She acknowledged the findings.

The Owner/Administrator has met all of the requirements for the Administrator License, including a high school diploma, 2 years of management experience, completing the department-approved Administrator training program of 40 hours and subsequent test, and criminal records requirements were met and approved.

I, the Administrator, have met the requirements and demonstrated the capabilities of an effetive administrator. I respectfully request that the Administrator License would be issued.

Please note that we have contacted our policy anaylist, Vanessa Emry, as well as a Qualifications Specialist from the Oregon Health Licensing Office, Derek Fultz, in regards to this matter.  

Based on observation, interview, and record review, it was determined the facility failed to develop an acuity-based staffing tool (ABST) that included the 22 required components, reflected an accurate time frame needed for each component, and was updated with significant changes of condition and at least quarterly to generate an accurate staffing plan. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 2 (Administrative Assistant) on 11/28/23. The following was identified:

a. The facility's ABST did not include the following required components:

* If multiple staff are required to assist with transferring and completing tasks, how much additional time is needed;

* Providing non-drug interventions for pain management;

* Providing treatments (e.g. skin care, wound care, antibiotic treatments); and

* Completing resident specific housekeeping performed by care staff (laundry was addressed on the facility's tool).

b. The minutes assigned to the components were not reflective of the time it would take to complete the task. Examples include:

* Five minutes a day to complete laundry services for each resident;

* Five minutes a day, per resident, to respond to call lights in a 24 hour period;

* Forty minutes a day for supervising, cueing, or supporting while eating three meals and two snacks in a 24 hour period.

Per observation, not all seven of the residents were being supervised, cued, or supported while eating breakfast, lunch, and a snack between the hours of 8:45 am and 3:15 pm. However, all seven residents were assigned 40 minutes per day for this activity.

When asked how long it would take staff to assist a resident to the bathroom after the resident used their call light, Staff 2 agreed the assistance needed would take longer than five minutes each time.

c. It was confirmed by Staff 2 on 11/28/23 at 12:10 pm that the ABST was not updated with significant changes of condition or quarterly.

The need to ensure the facility included all 22 required components in their ABST, the minutes were reflective of the time needed to complete each task, and was updated with significant changes of condition and at least quarterly was discussed with Staff 1 (Administrator) on 11/29/23 and Staff 2 on 11/28/23. Staff 2 asked for resources relating to using the state's ABST, which the survey team provided.

We are reviewing the facilitiy's ABST form and will be including any additional required components. We will also be reviewing the time required for each various category. The ABST form will be updated every 90 days or with each significant change of condition. The Administrator and/or the Administrative Assistant will be responsible for updates.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) were kept in good repair. Findings include, but are not limited to:

The facility's environment was toured on 11/28/23 and the following was observed:

* Room two had a deep gouge in the wall behind a recliner;

* The door leading into the hall where the residents' units were had paint chipping;

* There were multiple areas where paint was chipping down the hallway where the resident units were located; and

* Multiple door frames down the resident units hall were observed with splintering wood and/or chipped paint.

The need to ensure the facility's interior environment was kept in good repair was discussed with Staff 1 (Administrator) who acknowledged the findings.

We have created a task list with the maintenance items mentioned in the SOB. We will contact our maintenance person to remedy these findings, so that the interior environment of our home is kept in good repair. In the future, we will contact our maintenance person as needs arise. The Administrator will be responsible for monitoring corrections.

Based on record review and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to:

Review of records for Residents 1 and 2 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.

On 11/29/23 at approximately 11:15 am, Staff 1 (Administrator) confirmed the residents had not received a key to their room nor had they been evaluated for the ability to manage a key.

The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 11/29/23. She acknowledged the findings.

We are assessing the resident's abilities to manage a key and will provide key(s) to their rooms after evaluation. If a resident is unable to manage their own key, they will be asked if they wish their POA or legal representative to have a key. In the future, evaluation of key management will be upon move-in and reviewed upon significant change of condition. The Administrator will be responsible for this correction.