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 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 re-visit to the re-licensure survey of 03/09/23, conducted 08/03/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to develop interventions for short-term changes of condition, communicate the interventions to staff on each shift, and monitor the conditions with progress noted at least weekly through resolution for 1 of 3 sampled residents (#1) who experienced changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2020 with diagnoses including  dementia.

The resident's 01/18/23 through 04/18/23 progress notes and temporary plans of care were reviewed and revealed the following:

* 02/13/23 - "Resident was observed to to be hallucinating cats this evening...";

* 02/19/23 - "During last rounds at 5:30 am, resident's face was found drooping on the left side. Resident was alert and responsive, but when asked to squeeze MT's hand [his/her] grip was weak for both left and right hands"; and

* 03/01/23 - "Medication changes, decrease midodrine from ten mg to five mg once daily."

There was no documented evidence interventions were developed, documented, communicated to staff on each shift and made a part of the resident's record with weekly progress noted until resolved for Resident 1's short-term changes of condition.

In an interview on 04/20/23, with Staff 1 (Opal Manager), she confirmed the lack of monitoring for the resident's conditions and medication change.

Resident 1's changes of condition, lack of interventions, and monitoring were discussed with Staff 1 (General Manager) and Staff 2 on 04/20/23. They acknowledged the findings.

Late entry will be documented in Resident 1's chart noting the survey citation as correction cannot be made for a situation that took place in January. General Manager retrained Opal Manager and care staff on monitoring and documentation requirements for short term and long term changes in residents. The Opal Manager/Licensed Nurse will be responsible for reviewing care plans daily to ensure person centered interventions have been established. General Manager and Opal Manager will hold weekly meeting to review all changes of conditions.  The General Manager will be responsible for oversight and compliance.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed on 04/19/23 and discussed with Staff 1 (General Manager). She reported the ABST was populated by the service plan for each resident.

There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using.

The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 (General Manager) on 04/20/23. She acknowledged the findings. Staff 1 was referred to the Department's ABST Policy Analyst.

The General Manager and HWM have been retrained to better explain the communities current use of staffing tool (ABST), within the Eldermark platform.

The evaluation tool includes all 22 required ADLs. The evaluation tool is used to drive an acuity score which equates to number of hours of direct care the community will schedule.

The General Manager and HWM will review communities current tool weekly and as needed to ensure that the community is staffing the appropriate staff based on acuity of residents.  

Operations Leader and General Manager reviewed company policy related to State staffing requirements as it prertains to Oregon. Community Evaluation tool consists of all 22 required ADLs to determine Acuity Based Staffing. IDR has been submitted to CBC on 5/8/2023.

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

Fire and life safety records from 10/2022 through 04/2023 were requested and reviewed:

* Although the facility provided fire and life safety instruction to staff on 11/17/22, there was no evidence of consistent instruction on alternating months of fire drills;

* There was no documented evidence fire drills were conducted on the unit every other month; and

* Staff interviewed on 04/18/23 were not knowledgeable of the designated point of safety.

Fire and life safety training and fire drill documentation requirements was discussed with Staff 1 (General Manager) on 04/20/23. She acknowledged the findings.

OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and instruction

A copy of the SOD is placed in the fire drill binder as corrections cannot be made for missed fire drills. General Manager has provided fire drill process and documentation education to Plant Operation Supervisor. Plant Operation Supervisor will ensure resident participation in relocation or evacuation and that details including escape route, education, and residents that participated or refused are recorded and will maintain documentation compliance with monthly drills.  General Manager will audit all fire drills post-drill quarterly to ensure documentation and detailed compliance.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction for residents at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records from 10/2022 through 04/2023 were requested and reviewed.

There was no documented evidence a written record of fire safety training for residents, including content of the training sessions and the residents who were in attendance, was completed at least annually.

On 04/18/23, the need to ensure residents were instructed on fire and life safety procedures, at least annually, was discussed with Staff 1 (General Manager). She acknowledged the findings.

OAR 411-054-0090 (5) Fire and LIfe Safety:Training for residents

SOD placed in fire drill binder as the violation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor and or MC manager will ensure resident has been instructed on the procedures per OFC within 24 hours of admission into Memory Care and will be re-insturcted annually. Documentation will be keep to reflect those trainings. Weekly meeting will be held between GM and Plant Operations Supervisor to monitor compliance.

General Manager will be reponsible for monitoring compliance.        

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:

Observations of the facility on 04/19/23 revealed the following:

* Outside benches and chairs were dirty;

* Fabric on a bench seat was torn;

* A large rock was observed in the middle of a pathway which was located in the secured courtyard posing a potential tripping hazard;

* Several walls throughout facility had scrapes and/or gouges;

* The dining room had dirt, dust, and debris on baseboards, floors and the tables without tablecloths;

* Furnace vents in the dining room and living room areas had built up dust observed; and

* Chairs in the dining room and activity room were stained.  

The environment was toured on 04/19/23 with Staff 3 (Plant Operations Manager). He acknowledged the above areas were in need of cleaning and repair. Staff 3 removed the potential tripping hazard immediately.

The need to ensure the facility's environment was kept clean and in good repair was discussed with Staff 1 (General Manager) on 04/20/23. She acknowledged the findings.

All identified items in SOD have been corrected. General Manager has reviewed community appearance standards with Memory Care Manager, care staff and Plant Operations Supervisor. Weekly walk through will be condcuted by General Manager with Memory Care Manager and Plant Operations Supervisor to ensure all areas are clean, tidy and in good repair. The General Manager is responsible to see that the corrections are completed/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 361, C 420, C 422, and C 513.

Refer to C361, C420, C422, and C513

Based on 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 270.

Refer to C270

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:

Observations of the environment on 04/19/23 were found to have four doors that exited from the Memory Care unit to a secured courtyard. Three of the four doors were locked which prevented residents to be able to utilize the outside space without staff assistance.

During a tour of the building on 04/19/23, Staff 3 (Plant Operations Manager) acknowledged that the three courtyard doors were locked and unlocked them.

The need to provide access to the secured outdoor space without staff assistance was discussed with Staff 1 (General Manager) on 04/20/23. She acknowledged the findings and reported they would be unlocked during the day.

The community has ensured that all doors are unlocked that lead to communities secured courtyard.  These doors will remain unlocked to ensure residents are able to utilize the couryard area without staff assistance.  During General Managers walk-through of the memory care environment this will also be monitored.  The community doors are only able to be locked with use of electronic security with limited access (General Manager and Plant Operations Manager) due to limited access this violation should not occur again. The General Manager is responsible to see that the corrections are completed/monitored.