The findings of the re-licensure survey, conducted 06/20/23 through 06/23/23, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities 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 revisit to the re-licensure survey of 06/23/23, conducted 12/20/23 through 12/21/23, 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 injuries of unknown cause and other incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office when required, for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2020 with diagnoses including Alzheimer's disease.

Observations of the resident, interviews with staff, review of the resident's 06/16/23 service plan, 05/05/23 through 06/17/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to have significant cognitive impairment, was unable to consistently communicate needs to staff, required full assistance of one to two staff for ADL care and transfers. The resident was no longer mobile and unable to feed himself/herself. The resident was additionally identified as having extremely fragile skin.

Review of the resident's records showed the following:

* A facility investigation dated 05/05/23 indicated staff saw the resident's leg was bleeding when they went to pick him/her up. An investigation note indicated the injury occurred during a transfer.

* A progress note dated 05/30/23 indicated the resident was found to have an additional skin tear to the left shin "3 inch half moon," discovered during 11:00 pm ADL care. There was no additional information provided on the incident. No investigation was completed for the 05/30/23 injury of unknown cause.

There was no additional information within the progress notes about the incidents, what occurred, how abuse and neglect was ruled out, the staff response to the resident incidents, and follow-up action related to the incidents.

The facility was asked to report both incidents to the local SPD office. A confirmation of the reports was provided to the survey team prior to exit.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1 (RCC/Administrator Designee), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional RN) on 06/22/23 and 06/23/23. The staff acknowledged the findings.

1. Investigations completed and reported to APS on 6/22/23 for the two incidents involving resident 1.

2.  All staff will complete in-servicing on abuse and reporting guidelines. The Executive Director, Director of Health Services (RN) and Resident Care Coordinator will review the Oregon Department of Human Service Abuse Reporting and Investigation Guide.

3. A review of incidents and incident reports will occur as a part of the 24 Hour Stand Up meetings. An Audit of our compliance with abuse investigation and reporting will occur weekly for 4 weeks then monthly thereafter.

4. Executive Director, facility RN, Resident Care Coordinator or designee will be responsible

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

On 06/20/23 and 06/21/23, the facility's kitchen was observed to need cleaning and/or repair in the following areas:

* Shelving throughout the kitchen and dry storage had food spills, white/gray accumulation, dust, and/or debris. An untreated wood shelf in the back of the kitchen had gouges and small chunks of missing wood;

* Shelves in the refrigerator and freezer had spills, white/brown accumulation, and debris. Food, dirt, and/or packaging debris was noted under shelves in the dry storage, refrigerators and freezer;

* Debris and spills were noted on storage shelves which held clean dishes, pots, and pans;

* Three large baking pans were noted with a thick black accumulation in the corners of the pan;

* Two large bags of rice and corn starch were open in the dry storage area outside the kitchen;

* Debris was noted in the interior of the ovens and stove burners;

*  Numerous lidded pitchers, as well as pitchers with no lids had broken and cracked bottoms, edges and/or handles;

* Numerous areas of the curved floor baseboard were cracked and separating at wall corners and edges throughout the kitchen, black/brown accumulation was noted along edges of the baseboards;

* A large tear in the linoleum was noted near the dishwashing area, flooring throughout the kitchen had gouges and large areas of black/gray discoloration along wall and cupboard edges as well as under equipment.

* Vents in the ceiling had dust and web accumulation on the slats;

* Handles to the freezer had dried on food and debris, spills were also noted on the doors and sides of the refrigerators and freezer;

* Two pans of unknown liquid and a package of cheese located in the refrigerator were uncovered, undated or not labeled;

* Drains under the prep table and dishwashing area had debris, dark accumulation on edges of the drain and on the cover;

* Broken plastic was noted on the corner of the counter closest to coffee makers as well as a large piece of missing laminate along the edge of the counter;

* Walls and the ceiling had spills, splatters and dust/webs throughout the kitchen;

* Cracked plastic lid over dry storage bin with missing pieces of plastic was noted;

* Food transportation carts were covered in spills, splatters and food debris for both days of observation. The smaller of the two carts had significant cracking on both shelves with the pieces lifting apart; and

* A broken light cover was noted nearest the dishwashing area.

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (RCC/Administrator Designee) and Staff 5 (DM) on 06/20/23 and 06/21/23. Staff 3 (Regional Director of Operations) was shown the areas in need of cleaning and repair on 06/23/23. The staff acknowledged the findings.

1: All Areas noted on the Kitchen Inspection under C240 2567 (including cleaning & repairs) completed

2. Cleaning schedules were updated and staff training was done to ensure splatters, spills, drips, and debris are cleaned in a timely manner on shelving (around the kitchen and inside both fridges), kitchen equipment, floors and walls, vents, baseboards and drains.

Inservice conducted on cleaning expectations with Kitchen Staff.

Work Order Training occurred with Kitchen Staff for reporting of uncleanable surface or damages.

All Kitchen staff in-serviced on proper labeling and storage of food items that are placed in the fridges.

Kitchen Audits updated with the above items.

3. Kitchen Audits will be completed weekly for four weeks then monthly as a part of our ongoing QA program.

4: Dining Manager and Executive Director will be responsible for ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:

During the survey, 06/20/23 through 06/22/23, observations of the unit showed no group activities were conducted inside the memory care unit. The television was intermittently on and staff would visit with residents, but no other activities were observed.

In an interview on 06/21/23, Staff 7 (Activity Director) indicated she was new to the facility but had completed an activity calendar for the memory care unit and provided instruction to staff on things to do. Staff 7 indicated she was normally in the memory care unit twice a week to do nails, aroma therapy and massage. She could not say why the staff were not providing activities.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (RCC/Administrator Designee), Staff 3 (Regional Director of Operations) and Staff 4 (Regional RN) on 06/23/23. They acknowledged the findings.

1: The New Activity Director updated the calendar and began implimenting new activities during survey.

2. Activities Director, MCU Cargivers and Med Tech staff has been in-serviced on the activity program. Our Monthly Activity Calendar is printed and posted in communal area in memory care. Staff will be made aware of scheduled and independent activity options.

3 We will Audit activities and calender for compliance weekly for four weeks then monthly thererafter as a part of our QA program

4: Activity Director and Executive Director will be responsible to ensure ongoing compliance.

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 implemented by staff for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2020 with diagnoses including Alzheimer's disease.  

Observations of the resident, interviews with staff and review of the service plan, dated 06/16/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not consistently implemented by staff in the following areas:

* Activities;

* Safety interventions including low bed and non-skid footwear

* 1 vs 2-person transfer assistance and gait belt use;

* Positioning when in bed and draw sheet use;

* Incontinent care process while in bed and safe positioning;

* Rigid body, contractures and arching back;

* Cup with straw use, health shake TID, snack administration and resident no longer chewing; and

* Nail care.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (RCC/Administrator Designee), Staff 3 (Regional Director of Operations) and Staff 4 (Regional RN) on 06/22/23. The staff acknowledged the findings.

1. Resident 1 service plan updated to reflect missing resident specific items from survey along with clear direction and instruction to staff.

2. Executive Director to conduct an in-service with the service planning team on the proper service planning process as well as review the service planning OAR.

3. Service planning team will audit 1 service plans per week to assure accuracy, reflectiveness and instruction/direction for staff.

4. Executive Director, facility RN, Resident Care Coordinator or designee are responsible.

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers, reviewed and updated the resident's service plan with new interventions, for 1 of 1 sampled resident (#1) who received home health services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2020 with diagnoses including Alzheimer's disease.   

During the acuity interview on 06/20/23, Resident 1 was identified as receiving outside provider services related to hospice services and wound care.  

Observations of the resident, interviews with staff, review of the service plan dated 06/16/23, progress notes and outside provider notes dated 03/08/23 through 06/17/23 were completed. The resident had a skin tear to the left lower leg, a skin tear to the right lower leg and an open area on the buttocks.  The dressings were observed during morning care on 06/22/23, each of the three bandages were clean, dry and intact.

Facility documentation was unclear what dressing changes and treatments the facility was responsible for completing for the resident's skin tears and open area on the buttocks.

Recommendations from the outside provider included the following:

*  A nursing visit note dated 05/18/23, indicated hospice wound care visits would continue twice a week. Staff to contact hospice if dressing became soiled, wet, came off or signs/symptoms of infection were present.

* A nursing visit note dated 05/25/23, indicated staff were to observe for signs/symptoms of infection, redness, warmth, swelling, drainage, odor or pain. Provide wound care as follows for wet, soiled or loose dressing:  cleanse with wound cleanser, normal saline or warm water and mild soap, rinse out soap, pat dry, apply antibacterial ointment, cover with non-stick pad and secure with tape. Contact hospice with concerns.

* A nursing visit note dated 06/06/23, indicated staff were to cleanse with wound cleanser or water and mild soap, rinse soap with warm water, pat dry, apply Xeroform or antibiotic ointment, cover with Allevyn 5 x 5 or nonstick pad and tape. "Change every 5-7 days and PRN for soiled, wet, loose. Contact Hospice with questions or concerns. Report signs and symptoms of infection to Hospice."

There was no indication the recommendations were communicated with staff and implemented.

The resident's May and June MAR and TARs did not reflect any hospice instructions for wound care treatment.

In an interview on 06/22/23, Staff 4 (Regional RN) indicated hospice was in charge of the regular changing of the dressings to all three of the resident's wounds. Staff 4 stated facility staff would only redress the wound if the bandages became soiled or fell off. Staff 4 further stated she could not say why the information was not on the resident's TAR, but she would make sure the system was updated.

The need to ensure on-going coordination of care recommendations were implemented was discussed with Staff 1 (RCC/Administrator Designee), Staff 3 (Regional Director of Operations) and Staff 4 (Regional RN) on 06/22/23.

1. Resident 1's hospice notes have been reviewed and documentation completed reflecting outside provider recommendations were added to the TAR on 6/22/2023. Staff have been made aware of changes, via a temporary service plan.

2. 24 hour Stand Up Meeting process and the Outside Provider Binder to be reviewed with Med Techs, RCC, DHS and Executive Director regarding new outside provider notes or recommendations being reflected in the residents service plan, and TAR if appropriate.

3. Review of the outside provider binder as a part of the 24 Hour Stand Up Meetings 2 times per week for 4 weeks then weekly thereafter as part of our ongoing QA plan.

4. Executive Director, facility RN, Resident Care Coordinator or designee are responsible.

Based on interview and record review, it was determined the facility failed to ensure resident entries were reflective of resident care needs for 1 of 1 sampled resident (#1).  Findings include, but are not limited to:

Review of one sampled residents' record, interviews with staff, and observations of the resident noted ABST entries were not reflective of the current care needs.  The ABST data showed multiple areas which reflected zero minutes when the resident required limited to extensive staff assistance with those activities. Additional areas showed minimal minutes, three and five minutes respectively, were needed to provide care including toileting and transferring, but observations of care showed 2-3 times the minutes noted were required to properly assist the resident.

Inaccuracies on resident entries for the ABST tool was discussed with Staff 1 (RCC/Administrator Designee), Staff 3 and Staff 4 (Regional RN) on 06/23/23. They acknowledged the findings.

1: Sample resident # 1 ABST was updated to reflect her individual care needs.  

2: ABST will be reviewed and updated for Memory Care residents to ensure it is reflective for their individual care needs.

3: ABST will be audited weekly for 4 weeks then monthly as a part of our ongoing QA

4: Executive Director or Designee will update the ABST every quarter or as a result of changes of condition.

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 C231, C240, C242 and C361.

Please refer to facility POC for C231, C240, C242 and C361

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 C260 and C290.

Please refer to facility POC for C260 and C290