The findings of the initial licensure survey, conducted 02/12/24 through 02/14/24, are documented in this report. The survey was conducted to determine compliance with 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 first re-visit to the re-licensure survey of 02/14/24, conducted 07/31/24 through 08/01/24, 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 interview and record review, it was determined the facility failed to immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse for 2 of 2 sampled residents (#s 5 and 6) with medication errors. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2023 with diagnoses including Type 2 diabetes, atrial fibrillation, hypertension, and heart disease.

Progress notes and incident reports, dated 11/15/23 to 01/29/24, and MARs, dated 01/01/24 to 02/12/24, were reviewed.

A progress note dated 01/27/24 noted: "missed all morning meds on 1/26[/24]." A corresponding Medication Error Report dated 01/27/24 noted, "med tech did not watch resident take meds." The missed medications were listed on the report as follows:

* Aspirin (for heart health);

* Eliquis (a blood thinner);

* Jardiance (for congestive heart failure);

* Lisinopril (for hypertension);

* Metformin (for diabetes);

* Metoprolol (for hypertension);

* Rosuvastatin (for heart disease);

* Omeprazole (for gastroesophageal reflux disease);

* Senna (for constipation);

* Vitamin D3 (a supplement); and

* Multivitamin (a supplement).

During an interview on 02/13/24, Staff 3 (Wellness Director RN) stated the facility had concerns with Staff 10's (MT) job performance.

The missed medications constituted possible neglect with a risk of harm, which needed to be reported to the local SPD office. Survey requested the facility report the incident, and confirmation was received at 10:24 am on 02/14/24.

2. Resident 6 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes.

Progress notes and incident reports, dated 12/21/23 to 02/12/24, MARs dated 02/01/24 to 02/12/24, and physician orders dated 01/29/24 were reviewed.

The resident had a signed physician order for insulin aspart (for diabetes), inject eight units under the skin three times a day. A progress note dated 02/05/24 noted: "Wrong insulin given on 02/05/24 am". A corresponding "Medication Error Report" dated 02/05/24 noted, "I gave [him/her]...13 units of insulin glargine instead of insulin aspart."

During an interview on 02/13/24, Staff 3 (Wellness Director RN) stated the facility had concerns with Staff 11's (MT) job performance.

The medication error constituted a risk of harm which needed to be reported to the local SPD office. Survey requested the facility report the incident. Staff 3 contacted the local SPD and was awaiting instruction related to reporting the incident.

The need to ensure all incidents of abuse or suspected abuse were reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 02/14/24. They acknowledged the findings.

1. Med error for both residents (#5 and #6) reported to APS on 2/14/2024. Education and training provided to med tech (#10) who made the med error. Med tech (#10) also received a final corrective action on 2/7/2024 regarding the med error. Education and training provided to all med techs on 2/15/2024 by Jessica Burke, Wellness Director and Misty Nicholas-Liceaga, Associate Executive Director.

2. All medication errors will be reported to APS for the potential of harm.

3. Every incident report and as needed.

4. Wellness Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system for 2 of 5 sampled residents (#s 5 and 6) who had medications administered by the facility. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2023 with diagnoses including Type 2 diabetes, atrial fibrillation, hypertension, and heart disease.

Progress notes and incident reports dated 11/15/23 to 01/29/24 and MARs dated 01/01/24 to 02/12/24 were reviewed.

A progress note dated 01/27/24 noted: "missed all morning meds on 1/26[/24]." A corresponding "Medication Error Report" dated 01/27/24 noted, "med tech did not watch resident take meds."

2. Resident 6 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes.

Progress notes and incident reports dated 12/21/23 to 02/12/24, MARs dated 02/01/24 to 02/12/24, and physician orders dated 01/29/24 were reviewed.

The resident had a signed physician order for insulin aspart (for diabetes), inject eight units under the skin three times a day. A progress note dated 02/05/24 noted: "Wrong insulin given on 02/05/24 am". A corresponding "Medication Error Report" dated 02/05/24 noted, "I gave [him/her]  ... 13 units of insulin glargine instead of insulin aspart."

The need to ensure a safe medication and treatment system was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (Wellness Director RN) on 02/14/24. They acknowledged the findings.

Refer to C 231.

1. Med tech was educated on safe medication administration and the importance of witnessing residents take their medications. Med tech (#10) was educated on the insulin error (Refer to POC for C231). Corrective actions were given for these two individual med techs for the two separate med errors.

2. Training for delegation is done semi-annually by Wellness Director. Wellness Director maintains continuous monitoring for diabetics and monthly med tech training to go over policies and procedures related to administering medications. Wellness Director held a med tech meeting on 2/15/2024 regarding the importance of a safe medication system.

3. Wellness Director will provide monthly training for med techs regarding safe medication system and Cascade Living Group's clinical policies and procedures.

4. Wellness Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure the staff person who administered medications visually observed the resident take the medications for 1 of 5 sampled residents (#5) whose medications were administered by the facility. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 02/2023 with diagnoses including Type 2 diabetes, atrial fibrillation, hypertension, and heart disease.

Progress notes and incident reports dated 11/15/23 to 01/29/24 and MARs dated 01/01/24 to 02/12/24 were reviewed.

A progress note dated 01/27/24 noted: "missed all morning meds on 1/26[/24]." A corresponding "Medication Error Report" dated 01/27/24 noted, "med tech did not watch resident take meds."

The need to ensure staff who administered medications observed the resident take medications was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (Wellness Director RN) on 02/14/23. They acknowledged the findings.

1. Med tech was educated on safe medication administration and the importance of witnessing residents take their medications. This med tech was given a corrective action for this med error. (Refer to POC for C300).  

2. Wellness Director held a med tech meeting on 2/15/2024 regarding all med errors and ensuring med techs understand the importance of witnessing residents take their medication.

3. Wellness Director will provide monthly training for med techs regarding safe medication system and Cascade Living Group's clinical policies and procedures.

4. Wellness Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 17 and 24) completed pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to:

Staff training records were reviewed with Staff 7 (Business Office Manager) on 02/14/24. The following was identified:

There was no documented evidence Staff 17 (MT) and Staff 24 (Housekeeper), hired 01/14/24 and 01/16/24 respectively, completed required pre-service orientation training topics prior to beginning job duties in one or more of the following areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention training; and

* Fire safety and emergency procedures.

The need to ensure staff completed all required pre-service orientation training prior to beginning job duties was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 02/14/24. They acknowledged the findings.

1. All missing trainings were assigned to those associates. Business Office Manager, Associate ED and ED audied all associate training files.

2. An excel spreadsheet was created with all of the required training and will be used by Business Office Manager when onboarding new associates as well as maintaining training compliance for all associates.

3. Business Office Manager will review the training required within 30 days weekly and send to department managers to schedule their associates for upcoming training.

4. Business Office Manager and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 17 and 19) demonstrated satisfactory performance in any duty they were assigned within thirty days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 7 (Business Office Manager) on 02/14/24. The following was identified:

There was no documented evidence Staff 17 (CG) and Staff 19 (CG), hired on 01/04/24 and 10/31/23 respectively, demonstrated competency within 30 days of hire in one or more of the following areas:

* Changes associated with normal aging;

* Identification, documentation, and reporting changes of condition;

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

* First aid/abdominal thrust training.

The need to ensure documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 02/14/24. They acknowledged the findings.

1. Associates (#17 and #19) were assigned missing trainings.

2. An excel spreadsheet was created with all of the required training and will be used by Business Office Manager when onboarding new associates as well as maintaining training compliance for all associates.

3. During the onboarding process and as needed to maintain training compliance.

4. Business Office Manager and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure documentation that 2 of 2 long term non-direct care staff (#s 22 and 23) completed annual infectious disease training, and 3 of 4 direct care staff (#s 12, 13, and 15) completed a minimum of 12 hours of in-service training on topics related to the provision of care for persons in a community-based setting, including training on chronic diseases in the facility population and dementia training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 7 (Business Office Manager) on 02/14/24. The following was identified:

1. There was no documented evidence Staff 22 (Concierge) and Staff 23 (Cook), hired 12/14/20 and 02/15/21, respectively, completed annual training on infectious disease outbreak and control.

2. There was no documented evidence Staff 12 (MT), Staff 13 (MT), and Staff 15 (MT), hired on 09/16/92, 04/18/15, and 12/07/16 respectively, completed

12 hours of annual training related to the provision of care in CBC, including six hours related to the care of residents with dementia.

The need to ensure documentation that all staff completed annual infectious disease training and direct care staff completed a minimum of twelve hours of annual training related to the provision of care for persons in a community-based setting was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 02/14/24. They acknowledged the findings.

1. All associates were assigned missing trainings.

2. An excel spreadsheet was created with all of the required training and will be used by Business Office Manager when onboarding new associates as well as maintaining training compliance for all associates. (Refer to POC for C372).

3. During the onboarding process.

4. Business Office Manager and Executive Director.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:

On 02/13/24, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 6 (Plant Operations Director).

Staff 6 reported he did not have documented evidence of instructing residents within 24 hours of admission, or evidence of annual instruction.

During an interview on 02/13/24, five un-sampled residents stated they were not aware of general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The need to ensure residents were instructed within 24 hours of admission, and re-instructed at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire was reviewed with Staff 1 (ED) on 02/14/24. She acknowledge the findings.  

1. Plant Ops Director and Plant Ops Associate are meeting with all residents individually to educate them on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This will be documented and placed in resident files.

2. Annually, Plant Ops Director will meet with residents to be re-instructed on these topics and will be documented. Plant Ops will be instructing residents within 24 hours of admission.

3. Upon admission of new residents and annually for each resident.

4. Plant Ops Director and Executive Director.

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 231 and C 422.

Refer to C422.

Based on interview and record review, it was determined the facility failed to ensure staff completed pre-service orientation training as required in OAR 411-054-0070(3) prior to performing any job duties, including information concerning specific aspects of dementia, and direct care staff completed training within 30 days after hire as outlined in OAR 411-054-0070(5). Findings include, but are not limited to:

Staff training records were reviewed with Staff 7 (Business Office Manager) on 02/14/24. The following was identified:

1. There was no documented evidence Staff 16 (MT), Staff 20 (CG), and Staff 21 (CG), hired 05/25/23, 12/14/23, and 01/18/24 respectively, completed all required areas of pre-service orientation training including:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Written job description;

* Dementia disease process;

* Addressing pain in dementia and using a person-centered approach;

* Environmental factors important to a resident's well-being;

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

* How to provide personal care to a resident with dementia.

2. There was no documented evidence Staff 16 demonstrated competency in medication administration within the first 30 days of hire. During an interview at 12:50 pm on 02/14/24, Staff 5 (Memory Care Wellness Director) and Staff 9 (MCC RCC) stated Staff 16 would be observed demonstrating competency in medication administration prior to passing medications to residents.

The need to ensure documentation that all staff completed required pre-service orientation training and demonstrated competency in all areas of job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 02/14/24. They acknowledged the findings.

1. All associates were assigned missing trainings.

2. An excel spreadsheet was created with all of the required training and will be used by Business Office Manager when onboarding new associates as well as maintaining training compliance for all associates.

3. During the onboarding process and as needed to maintain training compliance.

4. Business Office Manager and Executive Director.

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 2 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 evaluations 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;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

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 more individualized activities.

On 02/14/24, the failure to ensure all residents had individualized activity plans developed and implemented, based on their activity evaluations, was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Wellness Director RN), Staff 4 (Associate Wellness Director LPN), and Staff 5 (Memory Care Wellness Director LPN). They acknowledged the findings.

1. Residents (#1 and #2) activity evaluations were reviewed and completed on 2/14/2024.

2. All resident activity evaluations will be completed by compliance date. Each service plan is updated every 90 days or as needed and when they are updated, the activity evaluation will be updated at that time.

3. Life Enrichment Director and Wellness Director will meet monthly to go over any changes in activity evaluations for residents that have upcoming service plan updates due.

4. Life Enrichment Director, Wellness Director and Executive Director.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance. Findings include, but are not limited to:

Observations during the survey between 02/12/24 and 02/14/24 found the door to the exterior courtyard was locked and did not allow residents to exit and return.

In an interview on 2/12/24, Staff 1 (ED) and Staff 2 (Associate ED) explained the doors required a code to unlock and they were in contact with the alarm company to address the issue. They acknowledged residents could not independently access the secure courtyard.

1. Alarm company provided access code for alarm to be unlocked. The doors have been permanently fixed.

2. Alarm company gave community access code so this will not be an issue going forward.

3. Weekly.

4. Executive Director.