The findings of the re-licensure survey, conducted 12/26/23 through 12/28/23, 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, 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

MCCMemory 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 12/28/23, conducted 05/13/24 through 05/14/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 12/26/23 through 12/28/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to the deficiencies identified in the report.

1. Community will ensure adequate administrator oversight by ensuring they are present at minimum 40 hours per week in the Memory Care unit.

2. Administrator oversight will include review/observation of day to day operation and management of staff and routine oversight to assure adherence of the community plan of correction2.26.24.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to:

The facility was toured on 12/26/23 at 10:00 am. The following items were not posted as required:

* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility; and

* The facilities license.

The need to ensure all required items were posted was reviewed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), and Staff 4 (ED) on 12/28/23. Staff 1 acknowledged the items were not posted as required.

1. All required postings have been posted as required to include current facility license, name of administrator or designee in charge, current staffing plan, most recent re-licensure survey, Ombudsman poster and any other relevant notices.

2) Re-education has been provided to the Administrator/Designee on required posting to assure understanding.

Routine checking of these items will be conducted to assure they are posted, current and accurate.

3) Daily

4) Administrator/Designee

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

Resident 1's record indicated the resident was admitted to the MCC after having resided in the assisted living community. Resident 1's move-in evaluation was reviewed and the following deficiencies were identified:

a. The evaluation was dated five days after the resident was admitted to the MCC.

b. The evaluation failed to address the following elements:

* Mental health history of treatment and effective non-drug interventions;

* Cognition including memory, orientation and confusion;

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

* Hearing, vision and assistive devices;

* Ability to understand and be understood;

* ADLs including toileting, bowel/bladder management, hygiene, dressing, grooming and bathing;

* Ability to use the call system;

* Pharmaceutical and non-pharmaceutical interventions for pain;

* Nutrition habits and fluid preferences;

* Recent losses;

* Fall risk or history; and

* Elopement risk or history.

The need to ensure the move-in evaluation was completed prior to admission and addressed all required elements was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

1. Pre-move in evaluation tool will be updated to reflect resident use of devices and services not clearly defined in current tool.  Re-education has been given to the community staff who would be designated to complete this process to assure understanding of the appropriate timing and use of the updated version of the tool.

2) New resident charts will be reviewed to assure timely completion and thoroughness of the pre move in eval.

3) Within 48 hours of move in

4) Administrator, MCD or Designee

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

1. Resident 2 was admitted to the facility in 11/2022 with diagnoses including dementia.   

Observations of the resident, interviews with staff and review of the most current service plan, dated 09/13/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff and/or was not implemented in the following areas:

* Two person transfers;

* Wheel chair mobility assistance;

* Two person assistance with bed mobility and dressing;

* No-spill glass with straw for drinks;

* Safety monitoring instructions for use of side rails on the bed;

* Fall matt next to bed; and

* Emergency evacuation ability.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were implemented was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

2. Resident 1 was admitted to the MCC in 12/2023 with diagnoses including Parkinson's disease and dementia.

Observations were made, interviews with Witness 1 (Family Member) and facility staff were conducted, and the resident's most current service plan, dated 12/20/23, was reviewed during the survey.

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

*ADLs regarding toileting and level of assistance needed; and

* Level of assistance with dressing, grooming, and personal hygiene (i.e., cueing/prompting/staff set-up supplies).

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

1. Service plans for residents 1 & 2 have been updated.  A review of remaining residents service plans will be conducted to assure accuracey for current care and service needs and use of assistive devices.

2)  Re-education provided to MCD and community RN on service plan content to assure understanding.  Service plans will be updated at least quarterly or with a significant change of condition to include a review of happenings, care needs and device use prior to review with resident to assure accuracy. TCP's will be used in between formal updates to reflect changes, new devices etc.

3)  Quarterly or with a significant change of condition

4) Memory Care Director

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols during meal service. Findings include, but are not limited to:

During the survey, multiple meal observations on 12/26/23 through 12/28/23 were made of direct care staff providing meal service to residents. Staff were observed setting tables, serving meals,  and pouring beverages without wearing aprons or other barriers to prevent contamination between clothing and food. Staff were observed entering and exiting the MCC kitchen and changing tasks without performing hand hygiene. Meals and beverages on the food cart were not consistently covered to prevent contamination during delivery.

The need to ensure staff followed infection prevention and control practices during meal service was reviewed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN), and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

1. Community has re-initiated the use of clean aprons to be used by carestaff during the meal process.  Re-education has been provided to staff on proper handwashing frequency and technique as well as proper food storage applicable to the meal process.

2)  Meal observations will be conducted (rotating meals) to evaluate staff adherence to training.

3) 3/week at rotating meals for 30 days

4) Memory Care Director  

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally-recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 2 sampled residents (#s 1 and 2) for whom the facility administered medications and treatments to. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2022 with diagnoses including dementia, hypertension and osteoarthritis.

A review of the resident's clinical record was completed and revealed there was no written, signed prescriber's order for all the medications/treatments on Resident 2's MAR/TAR.

On 12/26/23, Staff 3 (RN) reported being unable to find current signed physicians orders for Resident 2. On 12/27/23, a copy of the newly signed physician orders were received.

The need to ensure the facility obtained written signed orders for medications and treatments it provided was reviewed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/27/23 and 12/28/23. They acknowledged the lack of signed orders in the resident's facility record.

2. Resident 1 was admitted to the facility in 12/2023 with diagnoses including Parkinson's disease and dementia.

On 12/26/23,  Resident 1's facility record was reviewed and revealed signed physician orders dated 07/03/23, and noted the medication orders were active for 90 days.

There was no documented evidence of signed physician orders after the 90 days (10/01/23) in the resident's facility record for the following medications:

* Alpha Lipoic acid 600 mg - Take one capsule by mouth twice daily for nerve pain;

* Aspirin 81 mg - Take one tablet by mouth once daily for heart health;

* Atorvastatin calcium 80 mg - Take one tablet by mouth once daily for high cholesterol;

* Gabapentin 300 mg - Take three capsules by mouth every morning, three capsules every afternoon, and three capsules every night for nerve pain; and

* Memantine 10 mg - Take one tablet by mouth every morning and every evening for dementia.

On 12/26/23, current signed physician orders for Resident 1 were requested, and on 12/27/23, the facility received signed physician orders from the pharmacy.

The need to ensure signed physician orders were in the residents' facility record for all medications and treatments the facility was responsible to administer was discussed with  Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN), and Staff 4 (ED) on 12/28/23.

1) Signed orders were obtained for sampled residents. An audit conducted of remaining residents to verify presence of signed physicians orders was completed.

2) Re-education provided to MCD and Community RN on the 90 day physicians order process.  Once PO's are sent out MCD will track their return until all have been obtained.

3) Every 90 days

4) MCD/Community RN

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-pharmaceutical interventions to attempt prior to administering the medication for 1 of 2 sampled resident (#1) who was prescribed PRN psychotropic medication. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2023 with diagnoses including Parkinson's disease and dementia.

A review of the resident's 12/2023 MAR revealed s/he was prescribed PRN trazadone 50 mg, 1/2 tablet by mouth three times a day as needed for agitation or anxiety.

The MAR lacked instruction related to non-pharmacological interventions for staff to attempt prior to administration of the medication and failed to identify how the resident's agitation and anxiety was displayed.

Resident 1 was administered PRN trazodone on 12/02/23, 12/11/23, 12/12/23, and 12/15/23. There was no documentation that non-pharmacological interventions had been attempted without success prior to administration.

During an interview on 12/28/23, Staff 1 (Memory Care Director) and Staff 3 (RN) confirmed there were no resident-specific parameters for the resident's PRN psychotropic medication.

The need to include resident-specific parameters on the MAR for all PRN psychotropic medications was reviewed with Staff 1, Staff 2 (Health and Services Director), Staff 3, and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

1. Resident #1's MAR has been updated to reflect resident specific non-drug interventions to use before administering PRN medications for behaviors.  Remainig residents with PRN Psychotropic orders have been reviewed to assure presence of required information.

2. Re-education has been provided to MCD and RN re rquired information to accompany PRN psychotropic orders.  Orders will be reviewed upon initial transcription and through routine MAR audits to assure presence of required information for behaviors and interventions

3) Daily initial order transcription review/twice monthly MAR audits.

4) MCD/Nurse

Based on interview and record review, the facility failed to review the ABST (Acuity Based Staffing Tool) before a resident moved in and following a significant condition for 1 of 2 sampled residents (# 1) whose ABST data was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed on 12/27/23. The following was identified:

Resident 1 was admitted to the MCC on 12/12/23 and had triggered a significant change of condition on 12/20/23. The resident's ABST was not updated prior to move-in or following the significant change of condition.

The need to ensure the facility's ABST was updated before a resident moved into the facility and following a significant change of condition was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

1. ABST tool reviewed for accuracy for Res #1.  ABST tool reviewed to assure accuracy for remaining residents with changes of condition in the last 14 days.

2. The Health & Wellness Director will update the ABST tool weekly with all resident updates from quaterly service plan updates.

3)  ABST tool will be reviewed with all new move ins, those returning from hospital/nursing facility or those with significant changes in condition.

MCD/Wellness Director

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and fire and life safety instruction was provided to staff as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of fire and life safety records for June 2023 through December 2023 revealed a lack of documented evidence the facility conducted fire drills every other month and provided fire and life safety instruction to staff on alternate months.

On 12/28/23 Staff 15 (Maintenance) confirmed the facility was not conducting fire drills on the memory care unit, nor had staff been receiving fire life and safety instruction on alternate months.

The need to ensure the facility conducted fire drills on the memory care unit and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

1) Fire drill completed in memory care as of February 15, 2024.

2) Re-educated MCD and Maintenance of the need for individual fire drills for the SCU unit.  Schedule has been created to assure fire drills are completed and documented in accordance with regulations.

Monthly

Administrator, MCD and Wellness Director  

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to:

Facility fire and life safety records were reviewed on 12/28/23. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and annually.

The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

Resident instruction on fire and life safety procedures was completed on February 8, 2024.

Re-education provided to the MCD and Maintenance Director for annual training requirements. Schedule has been created for annual training.

Review of documents reflecting initial (move in) and annual training will be reviewed monthly for compliance

MCD/Administrator.

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 150, C 152, C 295, C 361, C 420, and C 422.

See C150, C152, C295, C361, C420 and C422.

Based on interview and record review, it was determined the facility failed to ensure staff completed all required annual training for 3 of 3 staff (#s 8, 10 and 12) whose training records were reviewed. Findings include, but are not limited to:

A review of staff training records on 12/27/23 with Staff 5 (Assistant ED) revealed the following:

* Staff 8 (CG)  hired 02/16/18, Staff 10 (MT) hired 01/20/20, and Staff 12 (MT) hired 07/20/19 had not completed the required 10 hours of annual training related to provision of care for residents.

The facility's failure to ensure staff completed all required annual training was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director) and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

.Annual training hours have been verified for sampled staff.  Audit of remaining applicable staff completed to assure verification of annual training hours.

Routine auditing of all staff will be conducted to verify completion of annual training hours.

Twice monthly

Administrator/MCD/Wellness 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 303, and C 330.

1. See C252, 260, 303 & 330.

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service or care plan for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.  

The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service or care plan was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN), and Staff 4 (ED) on 12/28/23. They acknowledged the findings.

Service plans for sampled residents have been updated.  A review of remaining resident service plans will be conducted to assure adequate information is present for individualized nutrition plan.

Re-education provided to MCD on how to appropriately reflect each residents individualized nutrition plan to assure understanding.

Routine auditing of service plans quarterly or with a change in care needs will be conducted to maintain compliance.

Quartelry or with a change in service need.

MCD/Wellness Director/Nurse  

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

Though Resident 2's service plan offered some information about the resident's interests, the facility had not evaluated:

* 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 specific activity plan which detailed what, when, how and how often staff should offer and assist Resident 2 with more individualized activities.

The need to ensure the facility evaluated all residents for activities and developed individualized activity plans was discussed with Staff 1 (Memory Care Director), Staff 2 (Health and Services Director), Staff 3 (RN) and Staff 4 (ED) on 12/28/23. Staff acknowledged the findings.

1. Resident #2's activity and social profile has been updated to reflect current preferences and needs to include social, emotional, physical and spiritual needs as well as any limitations and adaptation needed to accommadate the resident appropriately.

2. All resident activity and social profiles have been updated to reflect current preferences and needs to include social, emotional, physical and spiritual needs as well as any limitations and adaptation needed to accommadate the resident appropriately.

3. Resident charts will be audited quarterly to assure completion of the social profile.

MCD