The findings of the Change of Ownership survey, conducted 06/06/23 through 06/08/23, 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 for 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 06/28/23, conducted 11/15/23 through 11/16/23 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 and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

During lunch observations on 06/26/23 and 06/27/23, caregivers serving food were not wearing aprons.

During interview on 06/27/23 at 12:55 pm, Staff 6 (Executive Chef) confirmed she was unaware aprons were required for caregivers serving food.

The importance of using aprons and that food must be served in accordance with OAR 333-150-0000 (Food Sanitation Rules) was discussed with Staff 1 (Memory Care Director) on 06/28/23 at 4:50 pm. She acknowledged the findings.

Staff are wearing cloth or plastic aprons when serving meals and room trays. Signs have been posted for reminders near kitchens.

Supervisor will over see during meal times daily to ensure care staff are wearing apron. Signs have been posted for reminders. upon hire will be trained to wear apron when serving meals.

It will be evaluated daily during meal time.

supervisors on the floor and management.

Based on observation, interview and record review, it was determined the facility failed to ensure actions or interventions needed for a resident following short-term changes of condition were determined, documented and communicated to staff, and monitored for effectiveness until the condition resolved for 1 of 2 sampled residents (#2) with documented short-term changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia and had a history of falls.

Review of the resident's record, including progress notes, alert charting notes, incident reports, the current service plan and interim service plans, identified the following:

a. The resident had three falls during the review period, occurring on 05/01/23, 05/29/23 and 06/23/23.

Following the first fall, the investigation, documented in the facility charting notes, identified interventions of ensuring the resident wore "non-slip socks or no socks" and "placing shoes or slippers in reach". The record lacked documented evidence the interventions were communicated to staff and monitored for effectiveness. Following the second fall, the facility documented new interventions on an interim service plan that stated "leave bathroom light on at night, continue frequent checks and make sure floors are free from spills." Following the third fall, the facility documented a new intervention of "check about every 30 minutes and assist to restroom about every two hours." Investigations of the second and third falls did not include a review of current fall interventions and the record lacked evidence whether fall interventions were being implemented or were effective.

b. On 04/09/23, staff documented the resident was involved in an incident with another resident that resulted in Resident 2 experiencing "tearfulness and in a fragile emotional state". The resident made statements of wanting to die and was documented as being "quiet and rather emotional." The facility developed interventions that were documented on two interim service plans on 04/09/23 and 04/10/23 that included "staff to monitor closely, watch for upset behaviors, keep an eye when interacting with male resident and encourage visits in common area,...". On 04/16/23, a second incident occurred involving Resident 2 and the same unit resident. The record lacked documented evidence that current interventions were reviewed for effectiveness, new interventions were developed if needed, communicated to staff or implemented, and monitored for effectiveness.

The interventions for preventing falls and resident to resident incidents were not included in the resident's current service plan, which had been updated on 05/15/23.

During an interview with Staff 1 (Memory Care Director), Staff 2 (Health Services Director), and Staff 17 (Nurse Consultant) on 06/28/23, the facilities' process for identifying changes of condition, developing interventions, communicating them to staff and monitoring to be sure interventions were implemented and effective was discussed. Staff acknowledged the findings.

Change of condintion has been completed

Change of condition will be completed with in 24 hrs.ISP  will be put in place as soon as an issue /concern arises. If it's a short term will only need ISP. for long term will in put into service plan with in 24 hrs.

Training staff to document if interventions put on ISP work.RN will document on high risk about change of condition and interventions.

When an issue or concern on resident is not baseline;weekly by management during high risk and daily by staff.

Facility RN,RCC, memory care director

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and staff instruction for 1 of 2 sampled residents (# 2) whose medication administration records were reviewed. Findings include, but are not limited to:

Resident 2 moved into the facility in 06/2022 with diagnoses including chronic kidney disease.

Resident 2's physician orders and 06/01/23 through 06/27/23 MAR/TARs were reviewed. Resident 2 had a physician's order for furosemide (for edema). The order instructed: "take 1 tablet (40 mg) by mouth every morning. Hold once leg swelling resolves." The resident had received the medication every day during the review period.

There were no resident specific parameters or instructions for direct care staff to determine what constituted "swelling" and when to hold versus administer the medication.

During an interview with Staff 2 (Health Services Director), it was determined the resident had been receiving the furosemide for at least "several months". Staff 2 was unable to determine the status of swelling for Resident 2's legs and acknowledged the order required clear parameters and instructions for staff to follow.

The need to ensure an accurate MAR that included resident specific parameters and clear instructions for staff was discussed with Staff 1 (Memory Care Director) and Staff 2 on 06/28/23. They acknowledged the findings.

PCP was faxed to review medication and RN explained concerns of orders. Medications have been DC'd

Facility RN,RCC,memorycare dirctor and ED will review medications when new orders come and weekly  during high risk meeting. Will contact PCP of any medication concerns. PCP quarterly review

Weekly during high risk, quarterly by pcp and with new orders

Facility RN, RCC, Memory care director, and ED

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

Fire and life safety records from 12/2022 through 06/2023 were requested and reviewed:

* There was no documented evidence fire drills were conducted on the unit;

* There was no documented evidence of fire and life safety instruction for staff on alternating months; and

* The facility's fire drill documentation form did not include evidence alternate routes were used during the fire drills.

In an interview on 06/27/23 at 1:00 pm, Staff 4 (Maintenance Director) acknowledged the fire drill form lacked the required components and that fire drills had not been conducted in the Memory Care Community.

The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, to document all required elements for fire drills, and to document the use of alternate exit routes as required by the OFC was discussed with Staff 1 (Memory Care Director) and Staff 4 on 06/27/23. They acknowledged the findings.

fire drills have been getting done on different shifts. Staff meeting on fire life and safety alternate month. Binder has been put in place to document time, location and who attends drill with divider for Alf,memory care and resident training.

On going fire drills every other month different shifts and in person staff meeting fire life and safety training opposite months.Binder with dividers for training documentation.

Every month one month with fire drill other month staff meeting training.

Maintenance director will be doing drills and training and document and place in binder.H  

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction for residents at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records from 12/2022 through 06/2023 were requested and reviewed.

There was no documented evidence a written record of fire safety training for residents, including content of the training sessions and the residents who were in attendance, was completed at least annually.

During an interview on 06/27/23 at 1:00 pm, Staff 4 (Environmental Services Director) confirmed the facility did not have a process to ensure annual fire safety training for residents was completed.

On 06/27/23, the need to ensure residents were instructed on fire and life safety procedures, at least annually, was discussed with Staff 1 (Memory Care Director) and Staff 4. They acknowledged the findings.

Holding a meeting with residents go over fire life and safety and fire drills. Placing emergency exit sheets in each residents apartment.

Upon move in will go over information get signed documentation resident has been informed of fire life and safety and continue yearly for all residents. Emergency exit sheet in all apartments.

Upon move in and yearly.

Maintenance director will correct and monitor  

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 MCC outdoor patio was toured on 06/26/23. The following issues were identified:

* There was a concrete slab, approximately three foot square, that was raised approximately 3/4 inch above the adjacent patio surfaces. This uneven surface created a tripping hazard for residents.

* There were drop-offs along the rear pathway of between one and four inches measured from the pathway surface to the planting bed. This created a potential hazard for residents.

The patio was toured with Staff 1 (Memory Care Director), Staff 4 (Environmental Services Director) and Staff 18 (Marketing Director) on 06/27/23. They acknowledged the findings.

calling concrete companies to have tree root removed and new concrete placed. currently have area block with caution type for resident  safety. Getting soil to fill side garden beds to level out beds and sidewalk.

Removal and inspection of tree roots. monitoring concrete for lifting. Flower beds leave with side walk

Out side is monitored daily by supervisor on shift and weekly by management.

Maintenance director and memory care director

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 240, C 420, C 422 and C 510.

Memory care director completed infection control training

Memory care director will keep required training current, continue with on going training as required

Will review training monthly and complete required training as required.

Memory care director, office manager and human resourse  

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed for 2 of 3 newly hired employees (#s 13 and 15), demonstrated competency in assigned duties within 30 days of hire for 1 of 2 newly hired direct care staff (# 13), and annual training, including six hours related to dementia care topics for 2 of 3 long-term direct care staff (#s 9 and 16). Findings include, but are not limited to:

Staff training records were reviewed with Staff 3 (Business Office Manager) on 06/28/23 and the following deficiencies were identified:

a. Staff 13 (CG/MT) hired 01/03/23 and Staff 15 (Dietary Aide) hired 05/23/23, lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Resident rights and values of community based care;

* Fire safety and emergency procedures; and

* Infectious disease prevention.

b. Staff 13 and Staff 15 lacked documented evidence all required topics of pre-service dementia training was completed prior to independently providing care and services to residents.

c. Staff 13 lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care;

* Changes associated with normal aging; and

* General food safety, serving, and sanitation.

d. Staff 9 (CG/MT), hired 04/04/22 and Staff 16 (MT), hired 05/19/15, lacked documented evidence of completion of 16 hours of annual in-service training which included at least six hours of training related to dementia care.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Memory Care Director) and Staff 3 on 06/28/23. They acknowledged the findings.

All staff  are working on completing required training they have been given till August 10th or will be taken off the floor.

New hire will complete required training prior to working floor. Memory care director and Rcc will review transcript before scheduling to work.

memory care director , RCC will review monthly to ensure staff stay current with training sending out friendly reminders to staff to complete training weekly.

Office manager, memory care director, and RCC

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 270 and C 310.

Review of service plan, medication, documentation completed change of condition Charted how interventions are affective or not.

More information on ISP and service plans document if interventions affective or not. Weekly review by RN, RCC, memory care director, ED

Weekly during high risk meeting, Change of condition will be completed in 24 hours

Med tech with documentation or start of ISP

RN, RCC,Memory care director, and ED

Based on observation, interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1 moved to the memory care facility in 10/2021 and Resident 2 moved to memory care facility in 06/2022, each with diagnoses including dementia. Resident 1 and 2's service plans offered some information about the residents' historical interests, however, the facility had not documented an evaluation of the resident's current abilities and activity needs, including:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations; and

* Adaptations necessary for the resident.  

There was no individualized activity plan that detailed what, when, how and how often staff should offer and assist each resident with individualized activities s/he would benefit from.

Observations and interviews indicated the residents were dependent on staff to provide all activities.

On 06/28/23, the need to ensure the facility documented evaluations and developed an individualized activity plan for each resident was discussed with Staff 1 (Memory Care Director), who acknowledged the findings.

More information added to service plan Activity person centered past and present. Questioniare for each resident made a binder for activities.

getting information on each resident past and current made a binder. add detailed information to service plan .made a form for documentation on each resident to track activities daily.

It will be evaluated daily for activities , upon move in and quarterly for service plan.

Life style director and memory care director

Based on observation, interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled residents (# 3) with documented behaviors. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2020, with diagnoses including Alzheimer's disease with behavioral disturbance.

The resident's current service plan, dated 06/09/23, indicated "persisting behaviors of a sexual nature focused toward female staff and peers." The interventions included the following:

* Monitor for behaviors, sexual gestures or comments;

* Be aware of who resident interacts with, keep a close eye on him/her when interacting with females;

* Check on resident every 15 minutes when in his/her room; and

* Encourage resident to visit with female staff and peers in common area.

Resident 3's progress notes and incident reports from 03/28/23 to 06/25/23 revealed the following behaviors:  

* 04/08/23: "Resident sat next to [unsampled] resident and placed [his/her] hand between [his/her] legs.";

* 04/09/23: Med tech found [Resident 2] in [Resident 3's] room kissing.";

* 04/12/23: "Resident has been trying to hug and sit next to [unsampled residents] a few times this shift.";

* 04/14/23: "Resident was sitting next to [unsampled resident] and tried putting his/her hand on his/her leg.";

* 04/16/23: Was found standing in [Resident 2's] room with no pants or underwear on and rubbing [Resident 2's] stomach;

* 04/15/23: Resident asked unsampled resident to go to his/her room and brushed his/her hand on the side of his/her hair and face."; and

* 06/05/23: Was observed kissing an unsampled resident and was trying to get him/her to go to his/her room.

During interviews on 06/27/23 and 06/28/23, direct care staff confirmed Resident 3 displayed sexual behaviors intermittently. Staff reported they would redirect the resident when s/he was displaying sexual behaviors and checked on him/her approximately every 15 minutes. Staff reported Resident 3 was receptive to redirection.

Resident 3 was observed on 06/27/23 and 06/28/23 and spent most of his/her time in the common areas napping and within view of staff.

There was no documented evidence the facility had evaluated the above noted behaviors or made efforts to coordinate outside consultation to address the behaviors to develop a behavior plan.

The need to develop and include an individualized behavior plan for residents with behavioral symptoms and coordinate outside consultation as needed was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Services Director), Staff 7 (RCC), and Staff 17 (Nurse Consultant) on 06/28/23. They acknowledged the findings.

different Interventions put in place and continue to add for the safety of each resident. Reached out for out side consultation (behavior specilist) , PCP and case worker.

Continue to monitior interventions and residents whats effective and add more information to service plan.

Reached outside consultation for guideance and assistance. Place resident on behavior monitoring Interventions.

Daily by staff and weekly as needed by managers.And  outside consultation as they advises.

All staff, RN,Memory care director, RCC