The findings of the re-licensure survey, conducted 10/30/23 through 11/02/23, 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 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 re-visit to the re-licensure survey of 11/02/23, conducted 03/13/24 through 03/14/24, 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 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements for 1 of 2 sampled residents (#4) who recently moved into the facility. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 10/2023 with diagnoses including depression. Review of his/her initial evaluation, dated 10/02/23, revealed the following required elements were not addressed:

* History of treatment for depression;

* Effective non-drug interventions for depression;

* Decision-making abilities; and

* Personality, including how the person copes with change or challenging situations.

The need to ensure all required areas were addressed in initial evaluations was discussed with Staff 1 (Operations Director/Acting ED) and Staff 3 (Wellness Director) on 11/02/23. They acknowledged the findings.

1)Resident #4's service plan was updated to reflect history of depression, effective non-drug interventions for depression, decision-making abilities, and personality, including how they cope with change or challenging situations.

2)Initial evaluations will be completed prior to move in and reviewed to ensure all items are completed and addressed in the service plan.

3)Evaluated prior to each move in

4)ED, WD, RSD

2. Resident 1 was admitted to the facility in 03/2011 with diagnoses including hypertension, Parkinson's Disease, and osteoporosis.

Resident 1's most recent service plan was dated 07/04/23. There was no documented evidence the service plan had been reviewed and updated quarterly, as required.

In an interview on 10/30/23, Staff 2 (RN Oversight) and Staff 3 (Wellness Director) acknowledged Resident 1's service plan had not been updated quarterly. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, were reviewed quarterly, and/or a copy was provided to the resident's legal representative for 2 of 3 sampled residents (#s 1 and 3). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2016 with diagnoses including dementia.

a. Review of the resident's clinical record and interviews with the resident and staff revealed the service plan was not reflective of the resident's past history of placing his/her feces in atypical and sometimes concealed areas of his/her apartment. There was no direction to staff about how they should monitor the resident for this behavior or how to respond if the behavior occurred again.

b. According to a progress note, the resident's service plan was updated and reviewed on 09/18/23. In an interview with Witness 1 (Family), s/he reported the resident's power of attorney was not involved in that review and had not received a copy of the current service plan.

On 11/02/23 the need to ensure service plans were reflective of current status, presented clear directions to staff, and were provided to the resident or the resident's legal representative was discussed with Staff 1 (Operations Director/ Acting ED) and Staff 3 (Wellness Director). They acknowledged the findings.

1)Resident #3's service plan was updated to reflect their history of placing feces in atypical or concealed places, including staff direction for monitoring managing resident behavior. Power of attorney will be notified of all service plan updates, offered to attend the care conference and be provided a copy of the current service plan. Resident #1's service plan was updated to reflect current care needs.

2)Due dates for service plans will routinely be reviewed to ensure adequate time to update service plans quarterly to meet resident's current needs.

3)Due dates reviewed at least monthly.

4)ED, WD, RSD

Based on interview and record review, it was determined the facility failed to ensure a service planning team consisting of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or who provided services to the resident was involved in updating the service plan for 1 of 3 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2016 with diagnoses including dementia.

The resident's current service plan was reviewed. The care plan was not dated; however, there was a progress note stating the service plan had been reviewed and updated on 09/18/23.

On 10/31/23 Staff 3 (Wellness Director) reported she was unable to find documentation of a service planning team for the resident's current service plan.

In an interview on 11/01/23, Witness 1 (Family) reported neither the resident's legal representative or the family was involved in the 09/18/23 service plan update.

The need to include the resident or their representative, and anyone else the resident requested, in updating service plans was discussed with Staff 1 (Operations Director/Acting ED) and Staff 3 (Wellness Director) on 11/02/23. They acknowledged the findings.

1)Resident #3's Service planning team reviewed, updated and dated the service plan to include current resident needs. The service planning team included the resident or their representative and anyone else the resident requested. Facility will document members who attended the service planning meeting.

2)Due dates for service plans will be reviewed in advance to ensure that the service plan team has adequate time to prepare and participate in the service plan meeting prior to the due date. Due dates will be reviewed. Service plan team will be notified at least a week prior to scheduled care conference.

3)At least monthly

4)ED, WD, RSD

Based on interview and record review, it was determined the facility failed to evaluate short-term changes of condition, determine actions or interventions for changes, communicate interventions to staff on all shifts, and monitor changes through resolution for 1 of 3 sampled residents (#3). Findings include, but are not limited to:

Resident 3 moved into the facility in 2016 with diagnoses including dementia. Review of the resident's clinical record revealed the following:

a. Entries on a "Wellness Notes" form indicated that on two separate occasions (07/25/23 and 08/21/23) Staff 7 (Care Associate) discovered the resident's feces in the bathroom, once in a cup on the counter and once in a drawer.

There was no documented evidence these behaviors were evaluated, actions or interventions were determined and communicated with staff, or were monitored through resolution.

On 10/31/23, Staff 2 (RN Oversight) reported she was unaware of these behaviors. Staff 3 (Wellness Director) indicated the resident had not demonstrated the behavior prior to 07/25/23 or since 08/21/23.

b. A 09/25/23 progress note indicated the resident had "a bump protruding from [his/her] belly near [his/her] belly button."

There was no documented evidence the facility evaluated this change of condition, determined actions or interventions, communicated interventions with staff on all shifts, or monitored the change through resolution.

On 11/01/23, Staff 3 (Wellness Director) indicated she was not informed by staff of the bump on the resident's belly.

The need to evaluate all changes of condition, determine and communicate to staff actions or interventions, and to monitor changes through resolution was discussed with Staff 1 (Operations Director/Acting ED) and Staff 3 (Wellness Director) during the survey. They acknowledged the findings.

1)Resident #3 will be evaluated for behaviors, specifically leaving feces in various places in apartment, and a bump on resident's abdomen. All changes in condition will be evaluated to determine staff actions or interventions and monitor changes through resolution.

2)Direct Care staff will be inserviced on placing all residents with changes in condition on monitoring. All residents on monitoring will be reviewed and assessed as indicated at least weekly through resolution. Documentation will include interventions and monitoring criteria.

3)Weekly

4)WD, RN, RSD

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 6 and 10) completed all required pre-service orientation, and 1 of 2 newly hired direct-care staff (#6) completed all required dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:

Staff training records, reviewed on 11/01/23 with Staff 9 (Business Office Manager), identified the following:

1. There was no documented evidence Staff 6 (Med Aide) or Staff 10 (Care Associate), hired on 08/22/23 and 09/21/23, respectively, completed the following required pre-service orientation topics:

* Fire safety and emergency procedures; and

* Written job description.

2. There was no documented evidence Staff 6 completed the following pre-service dementia training topics:

* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;

* Strategies for addressing social needs & engaging them in meaningful activities; and

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.

The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1 (Operations Director/Acting ED) on 11/02/23. She acknowledged the findings.

1)All staff files were reviewed for pre-service orientation. Missing trainings will be assigned to staff and completed to include: fire safety and emergency procedures, and written job description. All staff files were reviewed for pre-service dementia training topics. Missing pre-service dementia trainings were assigned and completed including, dementia disease process including progression, memory loss, psychiatric and behavior symptoms; strategies for address social needs and engaging them in meaningful activities; and specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering and the use of person-centered approach.

2)All new hired staff will complete all required training prior to providing care and services to residents.

3)Reviewed prior to new staff starting training.

4)ED, WD, RSD

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 10 and 11) demonstrated competency in their job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 11/01/23 with Staff 9 (Business Office Manager).

1. Staff 6 (Med Aide) was hired 08/22/23. There was no documented evidence Staff 6 demonstrated competency in their job duties within 30 days of hire in the following areas:

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition; and

* Conditions that require assessment, treatment, observation, and reporting.

2. Staff 10 (Care Associate) was hired 09/21/23. There was no documented evidence Staff 10 demonstrated competency in their job duties within 30 days of hire in the following areas:

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

* Conditions that require assessment, treatment, observation, and reporting;

* General food safety, serving, and sanitation; and

* First aid/abdominal thrust.

3. Staff 11 (Med Aide/Care Associate) was hired 09/27/23. There was no documented evidence Staff 11 demonstrated competency in their job duties within 30 days of hire in the following areas:

* Conditions that require assessment, treatment, observation, and reporting;

* General food safety, serving, and sanitation;

* First aid/abdominal thrust; and

* Other duties as applicable - medication administration.

Documentation was provided by Staff 1 (Operations Director/Acting ED) on 11/01/23 that Staff 11 would not be allowed to perform medication administration duties until evidence of competency was obtained.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 11/02/23. She acknowledged the findings.

1)All staff files will be reviewed for completed demonstrated competency of job duties required within 30 days of hire. Missing training will be assigned to staff and completed, including: Changes associated with normal aging; identification, documentation and reporting of changed of condition; conditions that require assessment, treatment, observation and reporting; role of service plans in providing individualized care; changes associated with normal aging; general food safety, service and sanitization; first aid/abdominal thrust and other duties as applicable such as medication administration for medication staff. Medication staff providing medication administration will have documented competency prior to being allowed to pass medications.

2)Training will be scheduled upon hire and reviewed prior to meeting 30 days. All medication training will be reviewed for demonstrated competency prior to med staff working unsupervised administering medications.

3)Upon hire, prior to 30 days after hire

4)WD, RSD

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 12 and 13) completed a minimum of six hours of annual in-service training on dementia care, and 1 of 2 long-term staff (#12) completed a minimum of 12 hours of annual in-service training on topics related to the provision of care for persons in a community-based care (CBC) setting. Findings include, but are not limited to:

Staff training records were reviewed on 11/01/23 with Staff 9 (Business Office Manager).

1. There was no documented evidence Staff 12 (Care Associate/Med Tech) completed a total of 12 hours of annual in-service training which included a minimum of six of hours of training related to dementia care.

2. There was no documented evidence Staff 13 (Care Associate) completed a minimum of six hours of training related to dementia care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Operations Director/Acting ED) on 11/02/23. She acknowledged the findings.

1)All employee files will be reviewed for completed required trainings including direct-care staff annual 6 hour minimum training related to dementia care and 12 hours minimum annual training on topics related to provision of care for person in CBC setting. Missing training will be assigned to staff and completed.

2)Staff files will be reviewed annually for completion of required trainings. Trainings will be logged and tracked.

3)Prior to each staff's anniversary date.  

4)ED, WD, RSD

Based on interview and record review, it as determined the facility failed to provide fire and life safety instruction to staff on alternate months, failed to conduct unannounced fire drills on all shifts every other month, and failed to document all required elements of fire drills, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 10/31/23, and the following was identified:

* There was no documented evidence staff were instructed on fire and life safety on alternate months from fire drills;

* Fire drill records did not include evidence fire drills were being conducted every other month on all shifts; and

* Fire drill records did not include documentation of the escape route used, staff members on duty and participating, and evidence alternate routes were used during drills.

The need to follow the OFC requirements for fire drills and fire and life safety instruction for staff was discussed with Staff 1 (Operations Director/Acting ED) on 11/01/23. She acknowledged the findings.

1)Fire drills will be completed on alternate months and include: all shifts, escape route used, staff members on duty and participating, evidence alternate routes were used during the drill.

2)Staff will implement Oregon Fire Drill form and track trainings.

3)Monthly

4) On alternate months of fire drills Staff to review a Emergency and Disaster Policy at the all Staff Meeting.

5)ED, POD

Based on observation and interview, it was determined the facility failed to keep all interior surfaces in good repair, including maintaining cleanable walls in the laundry room. Findings include, but are not limited to:

The interior of the building was toured on 10/30/23. The following areas needed repair:

* The wall in the laundry room behind washing machines showed cracked, crumbling sheet rock and visible water damage; and

* A different wall on the left side of the laundry room showed multiple small holes and marks on drywall, creating an uncleanable surface.

On 10/31/23, the laundry room deficiencies were discussed with Staff 1 (Operations Director/ Acting ED) and Staff 5 (Vice President of Operations). They acknowledged the findings.

1)Laundry room walls behind washing machines will be repaired, including cracks, crumbling sheet rock and water damage. Wall to the left of the laundry room will be repaired and made cleanable, including repair of small holes and marks.

2)Routine walk through of community for items needing repairing. Staff to report all concerns to plant operations through community reporting protocol.

3)Monthly

4)ED, POD