The findings of the re-licensure survey, conducted 02/26/24 through 02/28/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for 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 survey to the re-licensure survey on 02/28/24, conducted 05/13/24 through 05/14/24, 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, OARs 411 Division 57 for Memory Care Communities, 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

The findings of the second re-visit survey to the re-licensure survey on 02/28/24, conducted 07/22/24, 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, OARs 411 Division 57 for Memory Care Communities, 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 ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and/or services were implemented for 3 of 5 sampled residents (#s 3, 4 and 6) whose service plans were reviewed.  

1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia and Parkinson's disease.

a. Observations of the resident, interviews with staff, review of the 02/15/24 service plan, Temporary Service Plans dated 12/28/23 through 02/20/24, and current evaluations identified Resident 4's service plan was not reflective of his/her needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas:

* Mobility and transfer assistance;

* Mood and behaviors;

* Toileting assistance;

* Fall risk, history, and interventions;

* Bathing assistance;

* Glasses;

* Dressing assistance;

* Grooming and hygiene;

* Pain: instructions for use of "rice pack";

* Dietary preferences and needs;

* Skin breakdown risk and interventions; and

* Weight loss history with interventions.

b. The handwritten updates to the temporary service plans did not include the date or initials of the staff who made the changes to the service plan.

On 02/28/24 at 11:06 am, the need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, and that the services were implemented was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings.

2. Resident 6 was admitted to the facility in 07/2023 with diagnoses including dementia.

Observations, interviews, and review of the current service plan, dated 01/17/24, revealed the service plan was not reflective of the resident care needs and/or did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas:

* Elopement history;

* Exit seeking behaviors;

* Wandering into other resident rooms;

* Repetitive false statements of staffs intent to harm him/her;

* Dressing; and

* Oral Hygiene.

On 02/28/24, the need to ensure service plans were reflective of resident care needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 7 (Regional Nurse Consultant). They acknowledged the findings.

3. Resident 3 was admitted to the facility in 12/2021 with diagnoses including dementia.

Observations, interviews, and review of the current service plan, dated 01/17/24, revealed the service plan was not reflective of the resident care needs and/or did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following area:

* Toileting assistance.

On 02/28/24, the need to ensure service plans were reflective of resident care needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 7 (Regional Nurse Consultant). They acknowledged the findings.

1.Residents 3,4 and 6 service plans will be updated and implemented to be reflective of their needs and preferences and provide cleear directiom to staff.

2. All handwritten updates to the TSP will include the date and initials of the staff who make the updates.

3.All other resident service plans will be reviewed and updated during their next quarterly evaluation.

4. All service plans will be reviewed by our designated service planning team at each quarterly review, on going.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition documented weekly progress noted until the condition resolved for 1 of 5 sampled residents (#4) who experienced short-term changes of condition. Findings include, but are not limited to:

Resident 4 moved into the facility in 12/2023 with diagnoses including dementia and Parkinson's disease.

Resident 4's 12/28/23 through 02/26/24 facility progress notes, incident reports, and Temporary Service Plans (TSPs) were reviewed and showed the following changes of condition:

* 12/28/23: New admission to facility;

* 12/28/23: Right knuckle and left arm skin impairment;

* 01/12/24: Fall with re-injury to a left knee wound;

* 01/14/24: Non-injury fall;

* 01/15/24: Fall with head strike and left wrist skin tear; and

* 02/05/24: New antidepressant medication ordered.

There was no documented evidence the changes were monitored at least weekly through resolution.  

The need to ensure short-term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 02/28/24. They acknowledged the findings.

1.All of Resident # 4 TSP's have been resolved

2. All other resident's current TSP's will be reviewed and monitored weekly by DON or designee, until resolution.

3. TSPs will be audited weekly for three months by the IDT to ensure compliance is achieved.

4. The administrator or designee will be responsible to see that the corrections are completed.

Based on interview and record review, it was determined the facility failed to include and document all required elements of fire drills, and to provide fire and life safety instruction to staff on alternate months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 02/27/24 identified the following deficiencies:

a. Documentation of fire drills failed to include the following required elements:

* Escape routes used, including alternate routes;

* Problems encountered, relating to residents who resisted or failed to participate;

* Evacuation time-periods needed; and

* Number of occupants evacuated.

b. There was no documented evidence that fire and life safety instruction was provided to staff on alternating months.

On 02/28/24, the need to document all required elements for fire drills and provide fire and life safety instruction to staff on alternate months, in accordance with the OFC, was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings.

1. Unannounced Fire drills will be conducted by the maintenance team or designee every other month and will be documented with all the required elements.  

2. Every other month at our all staff meetings our maintenance team or designee will present a training on fire and life safety, ongoing.

3. Fire drills and life safe training will be reviewed monthly, and signed off by the administrator or designee.

4.  The administrator will be responsible to ensure that the corrections are completed and maintained ongoing.

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

Refer to Z 164.

See plan of correction Z-164

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

Observations of the facility on 02/26/24 showed the following areas in need of cleaning or repair:

* Multiple walls and door frames in resident hallways had scrapes and gouges;

* Discoloration/stains on built-in wood bench in TV area;

* Worn white discoloration on wood handrails through much of building;

* Floor moldings/baseboards damaged or separated from wall in several areas;

* Tears and damage to vinyl couch in sitting room;

* Heavy gouges on wood piano and bench in activity room; and

* Several pieces of wood furniture throughout the facility had scratches or gouges.

On 02/28/24, the areas in need of cleaning or repair were shown to and discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director). They acknowledged the findings.

1.Walls and door frame scrapes and gouges will be repaired by the maintenance director or designee.  Discoloration/Stains on built-in wood bench repaired. Handrails throughout the building will be re-stained by maintenance director or designee. Floor moldings and baseboard damages have been repaired.  Replacement furniture was ordered on February 9, 2024 and is expected to arrive and installed by May 17, 2024.  The piano will be evaluated and either repaired or replaced.  

2.  Staff will be educated on notifying the maintenance team of maintenance needs and repairs.  

3.  A monthly audit will be done by the administrator or designee  to ensure the facility is clean and in good repair.  

4.  The administrator or designee will ensure that the corrections are completed and 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 420 and C 513.

See plan of correction for C420 and C513

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 and C 270.

See plan of correction of C260 and C270

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 5 sampled residents (#s 2, 3, 4 and 6) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 2, 3, 4 and 6's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components:

* Residents' current preferences;

* Abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

The need to evaluate and develop individualized activity plans, including all required components for each memory care resident was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations) on 02/28/24. They acknowledged the findings.

1.Resident 2,3,4 and 6 will have an activity evaluation completed and service plans individualized for their activitiy needs.

2.All other residents will be reviewed, by the activity director or designee, during their quarterly evaluation and their service plans individualized as needed.

3.Activity plans will be audited by administrator or designee monthly, times three months, then quarterly after that, on going.

4.  The activity director will be responsible to ensure that the corrections are completed and monitored ongoing.  

Based on interview and record review, it was determined the facility failed to evaluate all required elements for activities and to develop an individualized activity plan from the evaluation for 3 of 3 sampled residents (#s 2, 7, and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

A review of the activity evaluation and service plan for Residents 2, 7, and 8 revealed the following:

1. The activity evaluations did not adequately address the following required elements:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions.

2. There was no documented evidence individualized activity plans which addressed what, when, how, and how often staff should offer and assist the residents with activities, and which reflected the residents' activity preferences and needs, were developed from the activity evaluations.

The need to ensure an activity evaluation addressing all required elements was completed for each resident and an individualized activity plan was developed from the evaluation was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Business Office Director), Staff 6 (Activity Director), and Staff 20 (Dining Services Manager) on 05/14/24. They acknowledged the findings.

1.Resident 2 and 7 will have an activity evaluation completed and service plans individualized more specifically for their activity needs. Included but not limited to, what, when, how, and how often. Along with the specific categories like, past and current interest, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate, and activities that could be used as behavioral interventions. Resident 8 is no longer with us.

2.All other residents will be reviewed, by the activity director or designee, during their quarterly evaluation and their service plans individualized as needed.

3.Activity plans will be audited by administrator or designee weekly, times 4 weeks, then monthly after that, times 2 months, then quarterly on going.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to:

During the survey, observations of resident rooms revealed they were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open all residents' rooms, and walkie-talkies were used to communicate when a resident's room needed to be unlocked.

In an interview on 02/27/24, Staff 1 (Administrator) and Staff 3 (RCC) explained how the current system was designed for the purpose of preventing intrusive wandering on the MCC unit.

On 02/28/24, the need to ensure residents were not locked outside their rooms was discussed with Staff 1, Staff 2 (RN), Staff 3, Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings.

1.Staff will not lock residents doors preventing them from entering their rooms without assistance.

2. Staff were educated on the door locking policy

3. Administrator or designee will do a weekly audit x 4, then a monthly audit x 2, to ensure compliance.

4. The administrator will be responible to see that the corrections are completed and monitored.