The findings of the relicensure survey, conducted 05/06/24 through 05/08/24, 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 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 revisit to the re-licensure survey of 05/08/24, conducted 07/23/24 through 07/24/24, 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 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's needs, provided clear direction to staff regarding the delivery of services, and were implemented for 1 of 2 newly admitted sampled residents (# 5), whose service plans were reviewed. Findings include, but are not limited to:   

Resident 5 was admitted to the facility in 05/2024 with diagnoses including dementia with behavioral disturbance, chronic urinary tract infections and was receiving hospice services.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's current service plan, dated 05/02/24,  facility progress notes from and outside provider visit notes from 05/02/24 through 05/06/24 were reviewed.

The resident's service plan was not reflective, did not include clear instruction for staff, and/or was not implemented in the following areas:

* Hospice services including the tasks they were responsible to provide and how to contact the hospice provider;

* Elevation of hands on pillows for edema;

* Reclining wheelchair with pressure reducing air cushion;

* Meal assistance;

* Continuous Positive Airway pressure (CPAP) machine use and instructions;

* Oxygen use and instructions;

* Foley catheter instructions for care and monitoring;

* Interventions for sexual behaviors;

* Pushing of fluids throughout each day;

* Air mattress on bed;

* Turning and repositioning in bed;

* Pain;

* Assistance needed to participate in activities; and

* Emergency evacuation assistance.

The need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, and services were implemented and was discussed with Staff 1 (Administrator),  Staff 2 (Health Services Director/LPN) and Staff 3 (RCC) on 05/08/24. They acknowledged the findings.

C 260

1. Care plan was updated with specific instructions. (Resident # 5)

2. HSD, RCC, and ED will ensure that specific clear instructions are outlined in resident care plans. Including Hospice / outside provider services what tasks we are to provide and how to contact the hospice provider. Service plans will reflect residents needs and preferences and will provide clear direction of services.

3. This will be evaluated for each resident prior to admit, 30 days, quartely, and with any change.

4. HSD, RCC, and ED will be responsible to see that corrections are completed and monitored.  

Based on observation, interview, and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) to accurately reflect all the ADLs for each resident, including the amount of staff time needed to provide care for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Findings include, but not limited to:

Interviews with staff, observations of the residents, review of current service plans, and progress notes were completed. The facility ABST showed numerous ADL care areas which were not reflective of the sampled residents' current care needs. The number of staffing minutes noted on the ABST did not accurately reflect the amount of time staff spent with residents providing care.  

The need to ensure all time needed for providing ADL care to residents was accurate in the ABST tool was reviewed with Staff 1 (Administrator) on 04/07/24, and Staff 1, Staff 2 (Health Services Director/LPN) and Staff 3 (RCC)  04/08/24. The staff acknowledged the findings. No additional information was provided.

C 361

1. ABST has been updated to include items discussed upon exit. Not only for Residents #1, 2, 3, 4, and 5 but for all residents.

2. ABST had been being updated with input from direct care staff. We have created an ABST team that will include input from staff in various positions.

3. HSD, RCC, and ED will ensure that ABST is reflective of each residents need in all elements on ABST prior to admit, 30 days, quarterly, and with any significant change.  

4. HSD, RCC, and ED will be responsible to see that corrections are completed and monitored.

Concerns were identified in the following areas and the facility was provided with technical assistance:

H 1517: Individual Privacy: Own Unit. OAR 411-004-0020(2)(d):

(d) Each individual has privacy in his or her own unit.

Concerns were identified in the following areas and the facility was provided with technical assistance:

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

Concerns were identified in the following areas and the facility was provided with technical assistance:

H 1580: Limitations: Threats to health and safety. OAR 411-004-0020(2)(d) to (2)(j):

Ensure the residential setting applies individually based limitations when conditions may not be met due to threats to the health and safety of an individual or others.

Based on observation, interview, and record review, it was determined the facility failed to provide non-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 361.

Z 142

Please refer to C 361

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.

Z 162

Please refer to C 260

Based on observation, interview, and record review, it was determined the facility failed to document individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose evaluations and service plans were reviewed. Findings include, but are not limited to:

Observations and interviews were completed between 05/06/24 and 05/08/24. Service plans and evaluations were reviewed for Residents 1, 2, 3, and 4. The following were identified:

Review of the "Social, Spiritual and Recreational Activities" section of the service plans and also the "Resident Interest Chart" for the sampled residents showed the evaluations were lacking one more of the following components:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities for behavior interventions.

There was no documented evidence that individualized activity plans were developed based on the residents' activity evaluation.

The need to ensure the facility evaluated each of the required components and developed individualized activity plans based on the evaluation for each resident was discussed with Staff 1 (Administrator) and Staff 3 (RCC) on 05/08/24. They acknowledged the findings.

Z 164

1. Program Director created resident activity care plans that are acessible by all staff. This was completed not just for residents # 1, 2, 3, and 4 but for all residents.

2. HSD, RCC, and Program Director will colaborate to ensure that not only interests are listed in the care plan but that the following will be reflective as well; current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate, and activities for behavior interventions.

3. This will be evaluated prior to admit, 30 days, quarterly, and with any changes.

4. HSD, RCC, and Program Director are responsible to see that the corrections are completed and monitored.