The findings of the Change of Ownership Survey, conducted 04/15/24 through 04/17/24, 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

The findings of the first revisit to the re-licensure survey of 04/17/24, conducted from 07/25/24 through 07/26/24, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

A review of a Resident Council meeting note dated 03/28/24 identified the following:

* "[Resident 3] would like to have a key to [his/her] room as [s/he] keeps forgetting to ask for one."

In an interview on 04/16/24 Resident 3 reported s/he did not have a key to his/her room.

On 04/17/24 Staff 1 (Executive Director) reported that she reviewed Resident Council minutes and addressed resident complaints as quickly as possible. She stated she thought Resident 3 had been provided a key by another staff member.

The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1, Staff 2 (RN), Staff 3 (LPN), and Staff 4 (Regional Nurse Consultant) on 04/17/24. They acknowledged the findings.

Residents will have full access to grievance forms via resident bulletin board area, forms will also be located at the front desk. After a resident has completed the grievance form, the resident then can put the form into the grievance box located by the resident bulletin board. This box will be clearly marked Grievance Form Return Box.

The ED will check the box daily to ensure all new grievances are answered in a timely manner.

The grievances will be evaluated daily, followed up with resolution until resolved in a grievance support team meeting after stand-up.  

The ED will have a grievance binder that will be kept in the ED office to store all grievance slips after they have been addressed by the ED or specific department. The ED will keep the grievance form active until the issue is resolved or corrected. ED will file after completed.   

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including diabetes, cerebral infarction, neurological neglect syndrome and left sided hemiparesis.

Observations and interviews with the resident, interviews with staff, review of the resident's service plan, dated 04/11/24, and progress notes, dated 01/04/24 to 04/15/24, were completed. Staff indicated the resident required full assist for ADL care and required two staff for transfers.

The resident's service plan was not reflective and lacked resident-specific direction for staff in the following areas:

* High sided divided plate for meals;

* Self-administration of prn inhaler;

* Left hand contracture;

* Use of walker;

* Use of four-point cane;

* Preference to sleep on couch;

* Use of wedge cushion for heel/feet elevation;

* Psychotropic medications and non-pharmacological interventions;

* Gait belt used in wheelchair; and

* Heel protectors.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN) and Staff 4 (Regional Nurse Consultant) on 04/16/24. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 02/2024 with diagnoses including COPD and anxiety.

The current service plan, dated 04/16/24, was reviewed. Observations and interviews with staff and Resident 1 were completed during the survey.

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Bladder incontinence;

* Toileting location, assistance level, and frequency per shift;

* Shower chair transfer requirements; and

* Precautions and risks associated with use of siderails on resident's bed.

The need to ensure service plans were reflective of the resident's current status and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN), and Staff 4 (Regional Nurse Consultant) on 04/17/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2024 with diagnoses including panlobular emphysema and stroke.

Observations and interviews with the resident, interviews with staff, and review of the resident's service plan, dated 03/14/24, were completed.

The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Siderails;

* Showers; and

* Toileting assistance.

The need for service plans to be reflective of the resident's current care needs and provide clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN), and Staff 4 (Regional Nurse Consultant) on 04/17/24. They acknowledged the findings.

Resident 2 service plan has been updated with the following information. Resident toileting schedule and requires assistance from staff multiple times daily. the use of a high sided divider plate for all meals. Stated that the resident has "L" hand contracture making it difficult for resident to complete ADL tasks independently. Mobility with use of walker in room and a quad cane for transfers. Included the resident's preference to sleep on her couch instead of bed. Also, the resident has heel protectors to reduce pressure on heels and at times uses a gait belt as a seatbelt in her wheelchair. Resident 3 service plan has been updated to reflect current care needs such as shower assistance from care staff and toileting assistance multiple times a shift. The use of assistive devices has also been added. Resident uses siderails for independent repositioning. Resident 1 service plan has been updated to reflect current care needs as well as the use of assistive devices. Residents' bladder incontinence as well as staff assistance, frequency and toileting location has been updated. The use of a shower chair during bathing and siderails on bed for independent repositioning. Nursing staff have completed a risk and restraint assessment with the resident to ensure safe use.        

An audit was done to ensure all missing service plan components were triggered to be on the service plan and to provide clear directions and interventions for staff to follow. All service plans have been updated to reflect the residents needs and preferences. The service plans will be updated via ISP/TSPs, quarterly, and with any change of condition.    

This will be monitored ongoing by the ED, RCC, and Nursing staff during pre admission, addmission, 30 day, quarterly, and change of condition.

ED will be responsible to ensure POC is followed.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, staff were informed of new interventions, and the service plan was adjusted if necessary for 2 of 2 sampled residents (#s 1 and 3) who received outside services. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 02/2024 with diagnoses including COPD and was identified during the acuity interview as receiving outside provider services due to recent lower extremity amputation surgery.

Progress notes and outside provider notes dated 02/19/24 to 04/09/24, service plan dated 04/16/24, and Temporary Service Plans were reviewed.

There was no documented evidence staff were informed of new interventions, and the service plan was updated for the following recommendations:

* 02/28/24 - HH OT noted, "Please encourage [Resident 1] to lower the bed in small increments for transfers so that [s/he] can gain proficiency to transfer to a specialized shower chair and car seat";

* 03/01/24 - HH RN noted, "encourage high protein food for wound healing";

* 04/08/24 - HH PT noted, "Please remind [resident] to do [his/her] home exercise program daily. Copy of [exercises] left to [resident] in [his/her] room"; and

* 04/09/24 - HH OT noted, "please transfer [resident] to commode once per shift preferably after meals to commode. [CG] has been trained and able to train others."

The need to ensure staff were informed of new interventions and the service plan was updated as necessary after on-site health services were provided was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN), and Staff 4 (Regional Nurse Consultant) on 04/17/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2024 with diagnoses including panlobular emphysema and stroke.

The resident's progress notes, dated 03/14/24 through 04/15/24, indicated Resident 3 received Home Health physical therapy services. There was no documented evidence the following recommendations, included in the Home Health Care visit notes, were communicated to staff or the service plan updated:

* 03/19/24: "Encourage [resident] to ask for pain med if having unacceptable pain when [resident] is having therapy [given at least 1 hour prior to PT] to improve."

* 03/22/24: "Please encourage [resident] to do sitting exercises per handout."

* 03/27/24: "Please walk [resident] to a couple meals a day."

* 03/29/24: "Please walk [resident] to 2 meals a day using gait belt, cane and wheelchair follow."

The need to ensure the facility had a system for reviewing outside provider orders and recommendations, informing staff of new interventions and updating the service plan as necessary was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (LPN), and Staff 4 (Regional Nurse Consultant) on 04/17/24. They acknowledged the findings.

Resident 1 outside provider notes with recommendations have been added to this resident's service plan. Encourage resident to lower the bed in small increments for transfers so that resident can gain proficiency to transfer to a specialized shower chair and car seat. Staff to transfer resident to commode once per shift preferably after meals. Staff to give reminders to resident to do home exercise program daily. Resident 3 service plan has been updated to reflect PT recommendations for the following. Encourage resident to ask for pain med if having unacceptable pain. Pain meds given 1 hour prior to PT. Staff to encourage resident to complete sitting exercises and to walk to at least 2 meals a day using a gait belt, cane and staff to follow with wheelchair.

Each agency is required, by the front reception, before leaving to leave a provider report/summary visit sheet. This form is for the outside provider to not only leave notes on their visit, but to provide instructions on any orders/ or recommendations so they are able to be followed up in a timely manner. Going forward, the outside provider summary notes will go through the triple check process at the community. The medtech will review it first and implement and recommendations and or changes, then it will be doubled checked by a medtech and the triple check completed by one of the nurses

We will monitor and evaluate provider notes daily and implement and recommendations via ISP/TSP during the triple check process with clear written instructions to/for carestaff.

ED, RN and LN are reponsible to ensure the proccess is completed.

2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including diabetes, neuritis, neuralgia, bi-polar disorder and cerebral infarction.

The resident's 01/04/24 through 04/15/24 progress notes and physician communications, signed physician orders, and the 04/01/24 through 04/15/24 MARs were reviewed and revealed the following:

* The MAR showed nine of the resident's prescribed medications had no reason for use;

* The MAR included two prn orders for the same anti-anxiety medication: Clonazepam 0.25 mg daily as needed, and Clonazepam 0.5 mg daily as needed. There was no documented reason for use, no specific instructions for staff on what to watch for prior to administering the medication, or parameters for determining which dose to administer; and

* Multiple prn bowel care medications lacked parameters for administration.

The need to ensure the MAR included reasons for use for all medications being administered, resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN) and Staff 4 (Regional Nurse Consultant) on 04/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included documented reasons for use and provided clear instruction and parameters for administration of PRN medications for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2024 with diagnoses including COPD and anxiety.

The resident's physician orders and 04/01/24 through 04/15/24 MARs were reviewed and the following was identified:

* Budesonide/formoterol aerosol 160/4.5 mcg twice daily;

* Metoprolol 50 mg once daily;

* Pantoprazole 40 mg every morning before breakfast;

* Semglee (insulin glargine-yfgn) 100 u/ml pen every twelve hours;

* Sertraline HCl 100 mg every morning;

* Spiriva aerosol 1.25 mcg twice daily;

* Torsemide 20 mg once daily; and

* Trulicity 0.75 mg/0.5 ml once weekly.

There was no reason for use documented on the MARs for these medications.

The need to ensure all medications on the MAR included the reason for use was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN) and Staff 4 (Regional Nurse Consultant) on 04/17/24. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 03/2024 with diagnoses including panlobular emphysema and stroke.

A review of Resident 3's 04/01/24 through 04/15/24 MAR identified the following medications lacked reason for use:

* Aripiprazole 5mg tabs;

* Atorvastatin 80mg tabs;

* Combivent Respimat 20-100 mcg/act aers;

* Diltiazem 60mg cap;

* Divalproex 500 mg tabs;

* Eliquis 5 mg tabs;

* Fluticasone-salmeterol 115-21 mcg/act aero; and

* Albuterol HFA 108 (90 base) mcg/act aers.

The need to ensure MARs included reason for use for all medications was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (LPN), and Staff 4 (Regional Nurse Consultant) on 04/17/24. They acknowledged the findings.

Implementing PCC has assisted with fixing the reason for use for each prescribed medication, as you can not confirm an order in this system without one being assigned. The PRN medications all have instructions for use as they have been updated in the  PCC system.

The new PCC system that we are using automaticly flags missing reasons for use as well has the PRN instructions. The medication can not be confirmed in the system without having all components filled in These orders will be cross checked with original orders .

The RCC and Social Services director will audit weekly and bring the findings to the clinical team to correct if a for use is found that is inaccurate. The community will also  monitor these orders with the triple check process and any order changes that occur daily.

ED and RN will oversee this POC.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) quarterly and with a significant change of condition, and failed to have an accurate number of minutes for each resident to ensure the staffing plan developed met the 24 hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:

The ABST for Residents 1, 2 and 3 were reviewed during survey after observations and interviews with residents and staff, and service plans and progress notes were reviewed. The ABST was identified to not include an accurate number of minutes for the residents as follows:

* Time for treatments provided for Residents 1 and 2;

* Toileting assistance for Resident 3; and

* Pet care assistance for Resident 2.

The ABST was not updated quarterly and/or with a significant change of condition for Residents 2 and 4.

The need to ensure the ABST was updated quarterly and with a significant change of condition and was accurate for the staffing plan to meet the 24 hour scheduled and unscheduled needs of residents was discussed with Staff 1 (ED) and Staff 4 (Regional Nurse Consultant) on 04/16/24. They acknowledged the findings.

The management team has pulled all services plans and reviewed them with care staff to ensure accuracy of all cares, treatments, pet assistance, and unscheduled needs. The RCC, nursing staff and ED, will reviewed each resident in the ABST and match care needs and services according to the updated service plans.   

ED has given access to the ABST to nursing staff, RCC, and Social Services Director. The ABST will be updated Quarterly, with a significant change of condition and pre-move in.  

The ED as well as the nursing team will review and update the ABST as changes are made to the service plan via ISP/TSP or with any Sig. changes. Service plan changes and ISP/TSPs will be reviewed during the daily clinical meetings and the ABST will be updated accordingly.

ED and nursing staff will oversee this POC.  

Based on observation and interview, it was determined the facility failed to ensure garbage was stored in covered refuse containers. Findings include, but are not limited to:

The exterior of the building was toured on 04/15/24. A dumpster was observed to have large black garbage bags stacked approximately three feet above the top rim of the dumpster, preventing the dumpster lid from closing.

Staff 8 (Maintenance Director) stated in an interview on 04/15/24 that the facility had garbage picked up two times a week, and that the dumpster was frequently overfull. Staff 8 had submitted a request to administration to have the pickup days increased or to obtain a larger dumpster. On 04/16/24 Staff 1 (Executive Director) provided email documentation dated 02/02/24 of the request. No further information was provided.

The need to ensure refuse containers were covered was reviewed with Staff 8 and Staff 1 on 04/15/24. They acknowledged the findings.

A 4 yard can was ordered for both garbage and recycling services. The new cans were delivered on 4/23/2024.

The new cans are twice as big and will still be picked up twice a week.

Santiam Maintenance staff will monitor both cans weekly to unsure that both lids can be kept fully closed at all times.

This ED has ensured that the corrections have been made. ED and Maintenance will monitor weekly moving forward.   

Based on observation and interview, it was determined the facility failed to ensure soiled laundry was laundered with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:

The facility laundry process was observed on 04/17/24. The main laundry room contained an automatic detergent dispensing system that supported a large washing machine and a standard size washing machine. The large washing machine had a disinfectant product added to the wash, but the standard size washing machine did not. A second laundry room, which contained a standard size washing machine and was accessible to residents, did not have an automatic detergent dispensing system.

Staff 8 (Maintenance Director) stated on 04/17/24 that the water line which supported the washing machines was the same water line for the rest of the facility, and that the water never exceeded 120 degrees.

In an interview on 04/17/24 Staff 18 (housekeeping) stated she used both laundry rooms for resident laundry, and she did not add a disinfectant to the standard washing machines.

Staff 17 (CG) reported in an interview on 04/17/24 that she only used the main laundry for resident laundry and linens, and that she used both the large and standard size washing machines for soiled linen. She did not add a disinfectant to the standard size washing machine.

The need to ensure a chemical disinfectant was used when washing soiled linens and soiled clothing when water temperature was under 140 degrees was discussed with Staff 8 (Maintenance Director) on 04/17/24 and with Staff 1 (Executive Director) on 04/18/24. They acknowledged the findings.

A wall mounted disinfectant unit has been added to the standard size washing machine to disinfect soiled laundry and linens.

All soiled laundry and linens will be bagged before leaving a resident's room. The bag will be clearly marked soiled, with residents RM # until placed in the washing machine.

Maintenance and ED will review weekly to ensure all functions are working correctly.

Maintenance and ED will oversee POC.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1518 Individual Door Locks: Key Access:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1521 Visitors at any time:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(h) Each individual may have visitors of his or her choosing at any time.

Technical assistance was provided in the following area related to H 1518:

H 1580 Individual Based Limitations

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.