The findings of the initial survey conducted 02/21/24 through 02/23/24 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 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 02/23/24, conducted on 05/22/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

2. Resident 2 was admitted to the facility in 07/2023 with diagnoses including paroxysmal atrial fibrillation, cataract, and Alzheimer's disease.

Interviews with facility staff and review of the current service plan revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:

* Skin integrity and instructions on whom to report skin impairments;

* Instructions on whom to report weight gain or loss;

* Instructions for bleeding precautions and interventions while on anticoagulation therapy; and

* Number of staff needed to assist with activities of daily living.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 02/23/24. They acknowledged the findings. No further information was provided.

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

1. Resident 1 moved into the memory care facility in 07/2023 with diagnoses including Alzheimer's disease.

In an interview on 02/22/24, Staff 7 (CNA) stated Resident 1 required the assistance of one staff during showers. The resident was able to assist with some aspects of bathing and would also assist, when cued, with some aspects of getting dressed.

Observations of the resident and a review of the current service plan, last updated 01/04/24, and interim service plans (ISP'S) showed the service plan lacked clear direction regarding the delivery of services in the following areas:

* Bathing assistance: "moderate assistance with bathing, 1 person assist";

* Skin care: "maximum assistance with skin care";

* Dressing assistance: "maximum assistance with dressing";

* Facial hair removal" "maximum assistance with facial hair removal"; and

* Oral care: "maximum assistance with oral care".

The need to ensure the service plans provided clear instruction, including what, when, how, and how often the services should be provided was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 02/23/24. They acknowledged the findings.

Resident #1's care plan will be modified to include clear instruction.  Resident #2's service plan will be modified to ensure the service plan reflected residents' current needs and provide clear instruction to staff regarding delivery of services.

Administrator of designee to complete 100% audit of ADL service plans.

Administrator or designee will in-service staff who complete service plans on including clear instruction and reflecting residents' current needs.

Administrator or designee will conduct service plan audits weekly for 4 weeks then monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.

Based on observation, interview, and record review, it was determined the facility failed to have policies to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care for 1 of 1 sampled resident (# 2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease and age-related osteoporosis.

During the acuity interview on 02/21/24, Resident 2 was identified as receiving regular PT visits from the outside HH provider.

Review of clinical records, including the service plan dated 11/05/23, and progress notes from 11/26/23 through 02/19/24, revealed the following information:

A progress note dated 11/26/23 stated "Resident has a PT appoint with [name] from ...Home Health at 10am on 11/27/23."

The only written information regarding HH visits found in the resident's medical chart was one Outside Provider Communication note dated 11/27/24 and scanned into the electronic records system. During an interview on 02/22/24, Staff 2 (LPN) confirmed Resident 2 was being seen by HH from the outside provider, but he did not know where notes from the HH visits were located.

The need to have policies to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (Administrator) and Staff 2 on 02/23/24. They acknowledged the findings. No further information was provided.

Resident #2's therapy visit notes has been requested from provider.

Administrator of designee to complete 100% audit of notes being obtained from residents who utilize outside provider services.

Administrator or designee will in-service staff to obtain provider notes when outside services are utilized.

Administrator or designee will conduct service plan audits weekly for 4 weeks then monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

During a  review of the ABST tool and discussion with Staff 1 (Administrator) it was determined the facility had not fully implemented an ABST for the memory care unit. The facility was using the Oregon Department of Human Services (ODHS) tool for the campus; however, the memory care did not have a separate ABST, nor were residents entered into the tool.

The requirements of the ABST were discussed with Staff 1 and Staff 2 (LPN) on 02/23/24. They acknowledged the findings.

Facility number has been obtained for Memory Care and ABST is updated under proper facility number.

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 02/21/24, fire and life safety records for the previous six months were requested.

Review of the documentation provided revealed:

1. There was no documented evidence the facility provided fire and life safety training on alternating months for memory care staff; and

2. Staff did not evacuate or relocate MCC residents during the fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered, and comments relating to residents who resisted or failed to participate in the drills.

The need to provide fire and life safety instruction to staff on alternate months and the requirements regarding fire drills were discussed with Staff 1 (Administrator) and Staff 3 (Facilities) on 02/22/24. They acknowledged the findings. No further information was provided.

Fire Drill alternating month requirement, as well as the need to evaluate or relocate residents during the fire drill have been corrected within internal processes.  

Administrator or designee will in-service staff on fire drill process.

Memory care staff will receive fire and life safety instruction on alternating months at the monthly all-staff meeting.

Administrator or designee will conduct fire drill audits monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.

Based on 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 361 and C 420.

Facility number has been obtained for Memory Care and ABST is updated under proper facility number.

Fire Drill alternating month requirement, as well as the need to evaluate or relocate residents during the fire drill have been corrected within internal processes.  

Administrator or designee will in-service staff on fire drill process.

Administrator or designee will conduct fire drill audits monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 9 and 10) completed all required pre-service training prior to beginning job duties independently, and 1 of 2 (# 10) newly hired staff demonstrated competency within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 02/22/24, and the following were identified:

Staff 9 (CG) was hired 11/09/23, and Staff 10 (CG) was hired 12/04/23.

a. There was no documented evidence Staff 9 and Staff 10 completed the required pre-service training prior to providing personal care independently in the following areas:

* Use of supportive devices with restraining qualities in memory care communities; and

* Environmental factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.).

b. There was no documented evidence Staff 10 completed the required pre-service training prior to providing personal care independently in the following areas:

* Family support and the role the family may have in the care of the resident; and

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment.  

c. There was no documented evidence Staff 10 demonstrated competency within 30 days of hire in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

The need to ensure newly hired direct care staff completed all pre-service training topics prior to beginning any job duties and demonstrated competency within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 02/23/24. They acknowledged the findings. No further information was provided.

Staff #9 and #10 will complete in-service training in use of supportive devices and environmental factors.  Staff #10 will complete in-service training on family support and the role of the family and how to recognize

The missing in-service trainings will be included in our electronic training system.  30 day training checklist to be updated.

Administrator of designee to complete 100% audit staff who have not completed the incomplete in-services listed.

Administrator or designee will in-service staff to complete all required trainings timely.

Administrator or designee will conduct audits of in-service training weekly for 4 weeks then monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.

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 290.

Resident #1's care plan will be modified to include clear instruction.  Resident #2's service plan will be modified to ensure the service plan reflected residents' current needs and provide clear instruction to staff regarding delivery of services.

Administrator of designee to complete 100% audit of ADL service plans.

Administrator or designee will in-service staff who complete service plans on including clear instruction and reflecting residents' current needs.

Administrator or designee will conduct service plan audits weekly for 4 weeks then monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.

Resident #2's therapy visit notes has been requested from provider.

Administrator of designee to complete 100% audit of notes being obtained from residents who utilize outside provider services.

Administrator or designee will in-service staff to obtain provider notes when outside services are utilized.

Administrator or designee will conduct service plan audits weekly for 4 weeks then monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 3 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans and "life story" documents were reviewed. There was no documented evidence the facility had fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations; and

* Adaptations necessary for the resident to participate.

There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with individualized activities.

On 02/23/24, the need to ensure all residents had individualized activity plans developed and implemented, based on their activity evaluations, was discussed with Staff 1 (Administrator) and Staff 4 (Activities Coordinator). They acknowledged the findings.

Resident #1 and #2's care plan will be updated to include documented evidence of specific activity plans which detailed what, when, how and how often staff should offer and assist the residents with individualized activities.

Activity Assessment form will be updated to include more specific details around resident's individualized activity needs.

Administrator of designee to complete 100% audit of activity care plans to ensure specific details around resident's individualized activity needs are included.

Administrator or designee will in-service activity staff on including specific details around resident's individualized activity needs

Administrator or designee will conduct service plan audits weekly for 4 weeks then monthly for 3 months to ensure ongoing compliance.

Any adverse findings will be addressed immediately, and then presented at the following Quality Assurance (QA) meeting.