The findings of the re-licensure survey, conducted 06/10/24 through 06/14/24, 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 for 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

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

A situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following areas:

OAR 411-054-0025 (4) Facility Administration: Operation; and

OAR 411-054-0055 (1)(f-h) Treatment Orders.

The facility put an Immediate Plan of Correction in place during the survey.

The findings of the first re-visit to the re-licensure survey of 06/14/24, conducted on 10/14/24, 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 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 provide effective administrative oversight to ensure the quality of services rendered in the facility. Findings include, but are not limited to:

1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas:

* C160: OAR 411-054-0025 (4) Facility Administration: Operation; and

* C303: OAR 411-054-0055 (1)(f-h) Treatment Orders.

An Immediate plan of correction was requested on 06/12/24. The facility provided a plan of correction on 06/12/24 at 1:25 pm. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation.  

2. Refer to deficiencies in the report.

It was determined the facility failed to provide effective administrative oversight to ensure the quality of services rendered in the facility.

1.Actions related to specific residents are addressed with the corresponding tags.

2.Corrections and systems implemented will be addressed with the corresponding tags.

3.Corrections and systems implemented will be monitored through regular audits by the administrator/designees and/or consultants for a minimum period of 3 months.

4.Administrator will be responsible to see that the corrections are monitored and completed.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required a modified diet texture. Resident 3 received inaccurate diet textures, placing him/her at risk for aspiration, choking and/or death. Findings include, but are not limited to:

Resident 3 was admitted to the facility 02/2024 with diagnoses including stroke with left sided hemiplegia.

Resident 3's clinical record was reviewed, interviews were conducted with staff and the resident, and observations were made. The following was identified:

During the acuity interview on 06/10/24, Staff 2 (RN) indicated that no residents in the facility required a modified diet texture.

Resident 3 had a signed physician order dated 02/16/24 for a mechanical soft diet texture. The resident was admitted to the facility seven days later, on 02/23/24.

The resident's 30-day evaluation, dated 03/21/24, and quarterly evaluation, dated 06/06/24, stated the resident required a mechanical soft diet texture.

The resident's lunch was observed being prepared and plated by Staff 16 (Cook) on 06/11/24 at 12:50 pm. He stated the kitchen staff were not aware of any modifications that needed to be made when preparing or plating food for Resident 3. The meal consisted of a 2 inch by 2 inch brownie, spaghetti and red sauce with noodles up to 1 1/2 inches long, ground beef chunks up to 3/4 inch in size, and a whole dinner roll.  

Prior to the meal being served to the resident, on 6/11/24 at 12:52 pm, Staff 1 (Executive Director) and Staff 2 were asked by the survey team whether the meal appeared appropriately plated for a resident with an order for a mechanical soft diet texture. Staff 1 stated that the facility did not provide meals with a mechanical soft diet texture.

Resident 3 was observed with the meal. The resident was served while lying in bed in his/her room. The head of the bed was elevated approximately 30 degrees, and the resident had slid down the bed, so that when the meal was placed onto the over-bed tray table, the resident was unable to see over the top of the plate.

During the 50 minutes s/he was observed, the resident attempted to eat only his/her brownie. The resident was observed to have difficulty feeding him/herself including difficulty coordinating lip and tongue movement in order to get food into his/her mouth, and difficulty keeping food in his/her mouth while swallowing. Approximately 30% of the food the resident attempted to eat ended up on his/her shirt. The resident was observed making coughing and hacking sounds twice during the time s/he was observed. The resident attempted to drink from his/her straw cup and demonstrated difficulty closing his/her lips around the straw and greater than 50% of the liquid spilled out the left side of his/her mouth when attempting to swallow.

During an interview on 06/11/24 at 1:58 pm, Staff 14 (MT) and Staff 18 (MT) stated the resident had difficulty swallowing and needed his/her medications administered in pudding in order to swallow them safely.

These observations and interviews were reviewed with Staff 1 and Staff 2 on 06/11/24 at 3:20 pm. They stated that none of the cooking staff were trained in how to prepare a mechanical soft diet texture. During this interview, they stated they would make sure the resident received the correct diet texture at dinner and all meals moving forward. At 3:56 pm, Staff 1 provided the survey team with the information that had been used to educate cooking staff which included a short handout and a video which described how to modify meat textures, but did not describe the other components of mechanical soft diet texture. There was no documentation of any education provided to care staff or updates made to the resident's service plan. Staff 1 and Staff 2 stated that for dinner the resident would be served refried beans and Spanish rice with ice cream for dessert. They stated the resident requested the main menu item which was a chicken quesadilla, but they told him/her they could not modify this for his/her diet texture needs.

At 5:10 pm on 06/11/24, the resident was served a bowl of refried beans, Spanish rice with no sauce or gravy, and ice cream. The resident again demonstrated difficulty getting food to his/her mouth and keeping food in his/her mouth when attempting to swallow, with approximately 30% of the food s/he attempted to eat ending up on his/her face and shirt. The resident ate three bites of beans, two bites of rice, and a small bowl of ice cream. The resident coughed and spit out food one time, which occurred while attempting to eat a bite of the rice.  

On 06/12/24 at 10:43 am, an immediate plan of correction was requested to address the increased risk for choking and/or death due to modified diet texture orders not being followed and the resident's difficulty eating independently. The facility provided a plan of correction on 06/12/24, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation.

The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 2 on 06/11/24 through 06/14/24. They acknowledged the findings.

The above findings were reported to APS by the survey team on 06/21/24 at 1:21 pm.

It was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required a modified diet texture. Resident 3 received inaccurate diet textures, placing him/her at risk for aspiration, choking and/or death.

1. Resident 3 expressed preference for a regular diet and prefers to eat in her room. She was re-evaluated by her provider and approved for regular diet, thin liquids with a new diet order in place. Service Plan to be updated and staff educated on diet and proper supervision and positioning for meals.

2. All resident diet orders were reviewed, no other residents have modified diet textures. RN, dietary and care staff educated on resident diets and importance of following diet orders. Larger board installed for dietary staff to track dietary needs for individual residents and to ensure food prepared for each resident is appropriate and matches dietary orders.

3. Administrator or designee will randomly audit resident meals for diet order accuracy for a period of 3 months.

4. Administrator will be responsible to see that the corrections are monitored and completed.    

Based on interview and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:

A group interview was conducted with nine of the 28 residents residing at the facility on 06/11/24. During the group interview, residents stated very few activities occurred during the week, and no activities occurred on weekends. Multiple residents stated they were "always bored" and "lonely".

During an interview with Staff 6 (Activities) on 06/13/24 at 2:05 pm, she stated that she was in the facility assisting with activities three days per week, and she assisted with other duties including setting up medical appointments and driving the facility bus on her other scheduled work days. She stated four days per week, residents were responsible for leading all activities.

Upon review of the activities calendar for the week of 06/09/24 through 06/15/24, 23 activities were scheduled. Of these activities, 13 were designated "resident-led". Staff 6 described that this meant the resident's were responsible for setting up and leading the activity, and no staff member would be present to ensure the activity occurred or assist the residents with activity set-up.

The need to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents was reviewed with Staff 1 (Executive Director) 06/14/24 at 11:30 am. She acknowledged the findings.

It was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents.

1. All residents have the potential to be negatively impacted by a lack of daily activities based on resident group and individual interests. Ensuring daily staff-led activities are taking place will benefit all residents.

2. Activity Director was educated on expectation that there are daily staff led activities to meet resident needs based on group and individual interests as determined by resident social histories. Activity calendar to be updated to reflect changes.

3. Administrator and/or designee will monitor and keep a log of daily activities to verify calendar is being followed and activities are staff led.  

4.  Administrator will be responsible to see that the corrections are monitored and completed.      

Based on observations, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and/or failed to ensure signed physician or other legally recognized practitioner orders were documented for all medications and treatments the facility was responsible for administering for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Resident 3 did not receive the correct diet as ordered by his/her physician, placing him/her at significant risk of aspiration, choking and/or death. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 02/2024 with diagnoses including stroke with left sided hemiplegia.

a. The resident had a signed physician order for mechanical soft diet texture dated 02/16/24.

The resident was observed being provided a meal which did not adhere to mechanical soft diet texture on 06/11/24. On 06/11/24 at 12:52 pm, Staff 1 (Executive Director) stated that the facility did not provide meals with a mechanical soft diet texture.

While attempting to eat on 06/11/24, the resident was observed to have difficulty feeding him/herself including difficulty coordinating lip and tongue movement in order to get food into his/her mouth, and difficulty keeping food in his/her mouth while swallowing. The resident was observed making coughing and hacking sounds twice while attempting to eat the meal which did not adhere to physician's orders.

On 06/12/24, an an immediate plan of correction was requested. The facility provided a plan of correction on 06/12/24 at 1:25 pm. The immediate risk was addressed, however, the facility will need to evaluate the overall system failures associated with the licensing violation.

Refer to C160.

b. The resident's MARs, dated 05/01/24 through 06/10/24, and physician orders were reviewed.

There was no documentation that the facility had a signed order for the following medications which were listed on Resident 3's MAR:

* PRN glycerin suppository (for constipation);

* PRN Mylanta, 30 ml by mouth every four hours (for gastrointestinal upset); and

* PRN acetaminophen 500 mg, 1 tablet by mouth every four hours (for pain or fever).

The need to ensure all orders were carried out as prescribed, and signed physician or other legally recognized practitioner orders were documented for all medications and treatment's the facility was responsible to administer was reviewed with Staff 1 and Staff 2 (Wellness Director/RN) on 06/11/24 through 06/14/24.  They acknowledged the findings.

2. Resident 2 was admitted to the facility in 05/2024 with diagnoses including dementia, COPD and hypertension.

Resident 2's MARs, dated 05/26/24 through 06/10/24, and all physician's orders were reviewed.

On 06/08/24, the facility made the following changes to Resident 2's MAR:

* Added PRN tramadol 50 mg (for pain); and

* Discontinued daily cholecalciferol (for Vitamin D deficiency).

There was no documented evidence the facility had a signed physician's order for the above changes. The resident was administered PRN tramadol four times between 06/08/24 and 06/10/24.

During an interview with Staff 2 (Wellness Director/RN) on 06/12/24 at 3:21 pm, she stated the facility had made changes to the MAR based on an after-visit summary which was not signed by a physician.

The need to ensure all orders were carried out as prescribed, and signed physician or other legally recognized practitioner orders were documented for all medications the facility was responsible to provide, was reviewed with Staff 1 (Executive Director) on 06/14/24 at 11:30 am. She acknowledged the findings.   

3. Resident 1 was admitted to the facility in 11/2021 with diagnoses including heart failure and dementia.

Resident 1's MAR and signed physician's orders were reviewed. A signed physician order, dated 05/20/24, indicated the resident was to receive Sertraline 25mg at bedtime for depression. Record review indicated the facility failed to transcribe the medication to the MAR and had not been administering the medication.

During an interview on 06/14/24, Staff 2 (Wellness Director/RN) reported the facility had missed the order and Resident 1 had not been receiving the medication.

On 06/14/24, the need to ensure all medications and treatments were being administered as prescribed was discussed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

It was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and/or failed to ensure signed physician or other legally recognized practitioner orders were documented for all medications and treatments the facility was responsible for administering for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Resident 3 did not receive the correct diet as ordered by his/her physician, placing him/her at significant risk of aspiration, choking and/or death.

1. Resident 3 expressed preference for a regular diet and prefers to eat in her room. She was re-evaluated by her provider and approved for regular diet, thin liquids with a new diet order in place. Service Plan to be updated and staff educated on diet and proper supervision and positioning for meals.

2. All resident diet orders were reviewed for accuracy. RN, dietary and care staff educated on resident diets and importance of following diet orders. Larger board purchased for dietary staff to track dietary needs for individual residents and ensure food prepared for each resident is appropriate and matches orders. Medication and treatment recap to be completed for every resident to ensure accuracy of all orders. Staff to be re-educated on Triple check process to ensure accuracy of new orders.

3. Admin or designee will monitor completion of medication and treatment recaps and perform weekly audits of a representative sample of new resident orders for accuracy for 3 months.

4. Administrator will be responsible to see that the corrections are monitored and completed.     

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long-term direct care staff (#s 8, 9, 11 and 14) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care (CBC) setting, including six hours related to dementia care. Findings include, but are not limited to:

Staff training records were reviewed on 06/13/24 and 06/14/24.  

Staff 8 (CG), hired 08/13/21, Staff 9 (CG), hired 04/12/22, Staff 11 (CG), hired 08/14/21, and Staff 14 (MT), hired 02/21/22, lacked documented evidence of completing a minimum of 12 hours of in-service training annually, based on date of hire, including six hours related to dementia care.

The need to ensure all direct care staff complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including six hours related to dementia care, was discussed with Staff 1 (Executive Director and Staff 3 (Business Office Manager) on 06/14/24 at 11:00 am and 11:30 am, respectively. They acknowledged the findings.

It was determined the facility failed to ensure 4 of 4 long-term direct care staff (#s 8, 9, 11 and 14) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care (CBC) setting, including six hours related to dementia care.

1. All residents have the potential to be negatively impacted when staff are not properly trained.

2. Business Office created a matrix to track staff compliance with training requirements. Staff will be removed from the schedule when they fail to meet training requirements.

3. Administrator or designee will audit 3 staff files weekly for training compliance.

4. Administrator will be responsible to see that the corrections are monitored and completed.       

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. Findings include, but are not limited to:

On 06/10/24 and 06/11/24, facility fire and life safety records were reviewed and lacked documented evidence the following required elements were completed:

*Instruction to Resident 2 on fire/life safety procedures within 24 hours of admission; and

*A written record, including content, of annual instruction to Resident's 1 and 4 on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

During a group interview on 06/11/24 at 2:00 pm, eight unsampled residents indicated they had not been instructed annually on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

On 06/14/24 at approximately 12:00 pm, the need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 1 (Executive Director). She acknowledged the findings.

It was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually.

1. Lack of timely fire and life safety training puts all residents at risk, timely training will enhance resident safety.

2. Current residents will receive fire and life safety instructions. New residents will receive fire and life safety training as part of the admission process and included on the admission checklist. Business Office Manager will maintain a calendar to track when the training is due for each resident. Annual training will be completed prior to each resident's move-in anniversary.

3. Administrator or designee will audit all resident charts to verify completion of fire and life safety training. Administrator or designee will verify new residents received training and audit 3 resident charts weekly for 3 months to verify ongoing compliance.