The findings of the relicensure survey, conducted 01/04/22 through 01/06/22, 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 01/06/22, conducted on 03/17/22, 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 57 for Memory Care Communities.  

Based on interview and record review, it was determined the facility failed to ensure the resident move-in evaluation included information on all required elements, for 1 of 1 sampled resident (#3) who was recently admitted to the facility. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 11/2021 with diagnoses including dementia, osteoarthritis and hypertension. Review of the facility's move-in evaluations, which included the electronic "Resident Health Evaluation/Assessment and Service Plan - Oregon - V2," handwritten "Resident Health Evaluation/Assessment" and "Fall Risk Evaluation - V5," indicated the following elements were either not included on the various forms or no information regarding the element was documented:

* Customary routines for sleeping, eating and bathing;

* Effective non-drug interventions for mental health issues (sundowning);

* Personality including how the resident copes with change or challenging situations;

* Pharmacological and non-pharmacological interventions for pain;

* Nutrition habits and fluid preferences; and

* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature.

The need to ensure all elements of the move-in evaluation were addressed with sufficient information to develop an initial service plan was reviewed with Staff 1 (Director), Staff 2 (Operations Specialist) and Staff 3 (Assistant Health Services Director) on 01/05/22. They acknowledged the elements were lacking from Resident 3's move-in evaluation documents.

In reference to:

OAR 411-054-0034 (2-4) Resident Move-in and Eval: Res Evaluation

1. Resident evaluations have been reviewed have been updated to further elaborate on customary routines, effectvie non-drug interventions, resident personality, pharmacological and non-pharmacological interventions, nutrition habits and fluid preferences and environmental factors that impact resident behavior.

2. Electronic medical records system to be updated to include areas to further elaborate on  customary routines, effectvie non-drug interventions, resident personality, pharmacological and non-pharmacological interventions, nutrition habits and fluid preferences and environmental factors that impact resident behavior.

3. This will be monitored during each evaluation period and as needed.

4. Monitored by RN, LPN and Director.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were person-centered and individualized, reflective of the resident's current status and care needs, and provided clear instructions for care staff regarding the delivery of services, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's current service plans were reviewed during the survey. Observations were made of the residents and interviews were conducted with care staff and the residents.

1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia with behavioral disturbance, early onset Alzheimer's disease, osteoporosis and lower pack pain. The current service plan was not reflective of his/her current status or lacked accurate information or instructions for caregivers in the following areas:

* Procedure for ensuring resident dresses in clean clothes each day;

* Explanation of how the resident uses specific words due to loss of language skills;

* Sensitivity to textures and how this affects teeth brushing and food preferences;

* Sensitivity to highway noises outside the building;

* Behaviors exhibited when angry;

* Preferred clothing items;

* Routine of setting tables prior to meals; and

* Preferences for which staff are allowed to assist with showers.

The need to ensure Resident 1's service plan contained accurate and individualized information and specific instructions for staff for providing care and assistance was reviewed with Staff 1 (Director), Staff 2 (Operations Specialist) and Staff 3 (Assistant Health Services Director) on 01/05/22. They acknowledged the information that was inaccurate or lacking from the service plan.

2. Resident 3 was admitted to the facility in 11/2021 with diagnoses including dementia, osteoarthritis and hypertension. The current service plan was not reflective of his/her current status or lacked accurate information or instructions for caregivers in the following areas:

* Current ability to toilet self, resistance to toileting assistance and use of incontinent undergarments;

* Resistance to showers and interventions to help caregivers complete the task with the resident;

* Current ability to dress and undress self;

* Current ability to complete grooming tasks;

* How the resident expresses or is unable to express pain;

* Sleep routine; and

* Mealtime routine, triggers for escalated behavior and interventions for caregivers.

The need to ensure Resident 3's service plan contained accurate and individualized information and specific instructions for staff for providing care and assistance was reviewed with Staff 1 (Director), Staff 2 (Operations Specialist) and Staff 3 (Assistant Health Services Director) on 01/05/22. They acknowledged the information that was inaccurate or lacking from the service plan.

3. Resident 2 was admitted to the memory care in March 2021 with diagnoses including dementia and congestive heart failure.

Observations of the resident, interviews with staff, and review of the residents clinical record, including review of the service plan, dated 12/16/21, and interim service plans showed the service plan was not reflective of the resident's current care needs, had not been updated as needed when the resident experienced a significant change of condition and did not provide clear direction to staff in the following areas:

* Change in sleep pattern;

* Cognition, including memory, orientation, confusion and decision making ability;

* Communication;

* Toileting assistance while in bed;

* Bed baths;

* Weight bearing status;

* Full assistance with dressing and grooming while in bed;

* Two person transfer; and

* Diet and food texture modification.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to:

OAR 411-054-0036 (1-4) Service Plan: General

1. Resident care plans have been reviewed and updated to elaborate and further personalize individualized needs, care preferences and resident status and provide clear instructions for care staff.

2. System in which care plans are created to be updated for the ability to properly reflect required items.

3. Care Plans are to be reviewed and updated at least quarterly and with change of condition.

4.This will be monitored by RN, LPN and Director during weekly resident review meeting.  

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated and referred to the RN for assessment for 1 of 1 sampled resident (#2) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in March 2021 with diagnoses including dementia and heart failure.

A review of the resident's clinical records, including progress notes, dated 10/02/21 through 01/04/22, service plan dated 12/16/21, service plan addendums, incident reports and "Resident Health Evaluation" dated 12/16/21, and interviews with staff identified the following changes of condition:  

On 12/05/21 staff heard resident "crying out" for help. Staff entered the resident's room and found the resident on the floor on his/her side complaining of "pain in [his/her] legs." Resident was sent to the emergency department for evaluation and was diagnosed with "contusion of the right knee."

Between 12/05/21 and 12/10/21, when resident was admitted to hospice, staff documented:

* Resident needed help with all "ADL's", assistance with getting up and out of bed, and reminders to stay standing;

* Resident was "really tired", did not want to go to the dining room for meals and if s/he did go to the dining room it was in a wheelchair; and

* Required the assistance of two staff members for transfers.

During an interview conducted 01/05/21, Staff 5 (MT) stated prior to the residents fall on 12/05/21, s/he was able to ambulate with his/her walker, could get in and out of bed independently, did not have difficulty standing and was able to go to the bathroom and shower with staff assistance. Staff 5 further stated the resident was now primarily bed bound and needed full assistance with all ADL's.

Resident 1 was observed in bed throughout the duration of the survey.

There was no documented evidence the facility had evaluated the resident's change of condition, referred to the facility nurse, documented the change, or update the service plan to reflect the residents overall decline and increased need for staff assistance.

The need to ensure residents with a change of condition were evaluated and referred to the RN if needed for a significant change of condition was discussed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to: OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. Current resident chart notes reviewed, and additional narrative assessment added by RN in regards to any resident change of condition.

2.Resident evaluation to be configured for a separate identifiable change of condition component. This will allow for additional RN narrative detail and instruction regarding resident condition and care change.

3.This is to be monitored and reviewed by RN and Director

4.Monitored on a daily basis.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was performed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 1 of 1 sampled resident (# 2) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in March 2021 with diagnoses including dementia and heart failure.

Review of the resident's clinical records indicated s/he had experienced a steady decline in his/her health and increased need for assistance with all ADL's after a fall with injury on 12/05/21. On 12/10/21 the resident was admitted to hospice. This represented a significant change of condition.

There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

1. All resident charts reviewed for any change of condition not previously addressed.

2. RN change of condition assessment process updated allowing for better communication in regards to change of condition and to ensure for timely, thorough narrative assessment.

3.This will be monitored by RN and Director

4. Monitored on a daily basis.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 7, 9 and 11) completed First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Director) and Staff 4 (Office Manager) on 01/04/22. Staff 7 (CG), hired on 09/10/21, Staff 9 (MT),  hired on 11/10/21 and Staff 11 (CG), hired on 11/02/21, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need to ensure staff completed all required training within 30 days of hire was discussed with Staff 1 on 01/06/22. She acknowledged the findings.

In reference to: OAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff

1.All staff have completed first aid training with abdominal thrusts.

2.Trackcing system put into place to ensure conmpliance.

3.This is to be monitored by director, business office manager, staffing coordinator and executive director.

4.To be audited and monitored monthly and after each new hire probationary period.

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

Fire drill and fire and life safety training records for the previous six months were requested on 01/04/22. Review of the documentation provided identified the following deficiencies:

* There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills; and

* Fire drill records did not indicate number of occupants evacuated.

The requirements regarding fire and life safety instruction for staff and fire drill components were reviewed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to: OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and Instruction

1. Staff monthly training curriculum updated to include alternate month fire and life safety instruction.

2.Documentation for fire drills updated to include number of occupants evacuated.

3.This to be monitored monthly

4. Monitored by director, maintenance director and executive director.  

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Review of Fire and Life Safety Records on 01/04/22 and 01/05/22 identified no documented evidence of the following:

* Fire and life safety procedures for residents within 24 hours of admission and re-instruction at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and

* A written record of fire safety training for residents, including content of the training sessions and the residents attending.

The requirements regarding general fire and life safety instruction were reviewed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to: OAR 411-054-0090 (1(e-h))-(2-5) Fire and Life Safety: General

1. Written record of fire and life safety education updated to include signature of POA at time of move in.

2. Added to resident's care plan evacuation status is the ability to retain knowledge of evacuation procedures.

3. This to be monitored at time of move in, quarterly, with any change of condition and annually.

4. Monitored by director and RN.

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

The exterior patio was observed on 01/04/22 at 10:30 am. The following issues were identified:

* There were drop-offs of up to 1 ½ inches along the edges of the pathways; and

* There was an uneven sidewalk joint that was 1 ½ inch in depth.

The drop-offs created a tripping hazard for residents.

The need to ensure all exterior pathways were in good condition and free from drop-offs was discussed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to: OAR 411-054-0200 (3) General Building Exterior

Pathway drop off ledges filled in. Uneven sidewalk joint replacement scheduled.

This is to be monitored by director and maintenance director on a quarterly basis.

2. During a tour of the unit on 01/04/22 the following was observed:

* Chairs in common areas of the facility by the fireplace and in the TV/activities area had dry, soiled stains; and

* The couch in the common area by the fireplace had a 6 inch by 2 inch tear and the inside upholstery was exposed.

The areas needing cleaning or repair were shown to and reviewed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

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

1. During a tour of the kitchenette and dining room on 01/05/22 the following was observed:

* Food splatters throughout, on walls, cabinets, refrigerator, tablecloths, and dining room furniture;

* Scratches on dining room chairs and tables;

* Multiple deep gouges in circular pattern on floor near entry of dining room;

* Gouge in island cabinetry approximately 1" in diameter and ½" deep;

* Varnish worn off cabinetry in multiple areas, exposing rough wood;

* Multiple cabinet doors would not fully close, remaining ajar up to 3";

* Dark brown debris and litter on floor between refrigerator and cabinetry;

* Lazy Susan shelves unable to be rotated without kitchenware falling out;

* Microwave plastic door release button broken off;

* Chipped countertop laminate in front of sink;

* Brown debris along caulking at seam of backsplash and wall behind sink;

* Dark brown debris on cabinetry beveling;

* Food debris in cupboards;

* Food bags open; and

* Uncovered food in refrigerator.

The areas needing cleaning and repair were shown to and reviewed with Staff 1 (Director) on 01/05/22. She acknowledged the findings.

In reference to: OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors.

Kitchenette deep cleaned by housekeeping staff, microwave replaced, area is scheduled for complete refurbish to include new flooring, paint, furnishings and kitchenette laminate. Staff in-service held by food service director on proper food storage and labeling. Common area furnishings deep cleaned and cushion repaired while awaiting new furnishings.

This to be monitored by director, maintenance director and executive director on an on-going basis during refurbish and quarterly there after.

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 372, C 420, C 422, C 510 and C 513.

In reference to: OAR 411-057-0140(2) Administration Compliance.

Please refer to POC for: C372, C420, C510 and C513

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 5, 7 and 9) completed all required pre-service orientation training prior to providing care and services independently, completed demonstrated competency in all required areas within 30 days of hire, and 2 of 2 sampled direct care staff (#s 6 and 8) did not complete a total of 16 hours of in-service training annually. Findings include, but are not limited to:  

1. On 01/04/22, the facility training records for Staff 7 (CG) hired on 09/10/21, Staff 9 (MT) hired on 11/10/21, and Staff 11 (CG) hired 11/02/21 were reviewed with Staff 1 (Director) and Staff 4 (Office Manager). The following deficiencies were identified:

a. Staff  7, Staff  9 and Staff 11 lacked documentation they completed pre-service training in all required areas prior to beginning performance of job duties. Staff 7, Staff  9 and Staff 11 lacked documentation that training in standard precautions for infection control was provided.  Staff 7 lacked documented evidence of a written job description.

b. Staff 7, Staff 9 and  Staff 11 lacked documentation they completed any pre-service dementia training.

c. Staff 7, Staff 9 and Staff 11 lacked documentation they had completed competency training in all required areas within 30 days of hire. Staff 9 was administering medications and the facility lacked documentation she had completed competency for administration of medication and treatments.

During an interview with Staff 1 (Director) on 01/04/22 at 4:00 pm, survey requested Staff 9 cease administering medications until the facility ensured and documented her competency in administration of medication or treatments.

2. Annual training records for Staff 6 (CG) and Staff 8 (MT) were reviewed on 01/04/22. The facility lacked documentation Staff 6 and Staff 8 completed 16 hours of annual training related to the provision of care in CBC, including six hours related to dementia care.

The need to ensure staff complete all pre-service, competency and annual training in all required areas was discussed with Staff 1 (Director) on 01/05/22. She acknowledged the findings.

In reference to: OAR 411-057-0155(1-6) Staff Training Requirements.

1. All staff training audited.

2.All staff have completed 6 hours of dementia training and a comprehensive annual training program has been put into effect with ongoing tracking.

3. This is to be monitored monthly

4.Monitoring to be done by director.

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 252, C 260, C 270 and C 280.

In reference to: OAR 411-057-0160(2b) Compliance with Rules Health Care.

Please refer to POC for C252, C260, C270 and C280.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Director) and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to: OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration.

1. All residents were evaluated and nutrition and hydration.

2. individulaized plans were completed for all residents and reviewed by staff.

3. This is to be monitored by RN and director

4. To be monitored at move in, quarterly and with any changes.  

Based on observation, interview and record review, it was determined the facility failed to evaluate each Memory Care Community resident for activities and develop an individualized activity plan for each resident based on their activity evaluation, for 2 of 3 sampled residents (#s 2 and 3) whose activity plans were reviewed. Findings include, but are not limited to:

There were 12 residents who were diagnosed with dementia who resided in the MCC at the time of the survey. The residents' ability to participate in the activities that were offered on the unit during the survey varied. Some residents stayed in their rooms and did not participate in any scheduled activities while others joined group activities but needed some degree of assistance to understand and participate in the activities.

The activity information that was documented and included in Resident 2 and 3's service plans consisted of a list of activities the residents currently enjoyed or enjoyed in the past. There was no documentation the following areas had been evaluated:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

The facility had not developed an individualized activity plan for either resident based on a comprehensive activity evaluation.

The need to conduct a comprehensive activity evaluation and develop an individualized activity plan was reviewed with Staff 1 (Director), Staff 2 (Operations Specialist) and Staff 3 (Assistant Health Services Director) on 01/05/22. They acknowledged the facility needed to conduct a more thorough evaluation and use the information to develop more individualized activity plans.

In reference to: OAR 411-057-0160(2d) Activities.

1. All residents were evaluated for activity preferences.

2. individulaized plans were completed for all residents and reviewed by staff.

3. This is to be monitored by RN and director

4. To be monitored at move in, quarterly and with any changes.  

Based on observation, interview and record review, the facility failed to maintain a written policy as to when the exit doors to the outdoor courtyard would be locked or unlocked. Findings include, but are not limited to:

During the survey, the exit doors leading to the outdoor courtyard were observed to be locked.

Staff 1 (Director) and Staff 2 (Operations Specialist) were interviewed on 01/04/22. They stated the exit doors were kept locked for resident safety because unauthorized persons had entered the facility. They stated staff provided assistance when residents wished to go out to the courtyard.

The facility's policy for when resident access to the outdoor areas would be restricted was requested by the surveyors. The policy that was provided failed to include specific reasons for restricting resident access and procedures for when the patio doors should be locked and unlocked.

The need to maintain a policy and procedure for when exit doors to the courtyard would be locked and unlocked was discussed with Staff 1 and Staff 2 on 01/05/22. They acknowledged the findings.

In reference to: OAR 411-057-0170(6) Secure Outdoor Recreation Area.

Policy and procedure put into effect regarding securing courtyard doors for resident safety due to transient tresspassing.

This will be monitored by director on an on-going basis.

Based on observation and interview, it was determined the facility failed to ensure locking devices used on exit doors/gates were electronic and released upon activation of the fire alarm or sprinkler system,  power failure or by activating a key button or key pad. Findings include, but are not limited to:

On 01/04/22 it was observed that the gate in the facility courtyard was locked with a metal padlock that required a key to open.

Staff 1 (Director) was interviewed on 01/04/22 and she stated that the key to the padlock on the gate in the courtyard was kept on the medication cart.

The need to ensure there was an electronic locking device on the gate that released as required was discussed with Staff 1 and Staff 2 (Operations Specialist) on 01/05/22. They acknowledged the findings.

In reference to: OAR 411-057-0170(10) Exit Doors.

Outside contractor has been retained to convert current gate lock to electronic release tied into fire and sprinkler system.

This will be monitored by director and maitenance director on an on-going basis.