The findings of the initial survey conducted 03/21/23 through 03/24/23 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.

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 03/24/23, conducted 08/09/23 through 08/10/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were investigated to rule out abuse and reported to the local SPD office when abuse was not reasonably ruled out for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2022 with diagnoses including a traumatic brain injury, low back pain, osteoarthritis of the knee, and a history of falls.

Review of the 03/03/23 service plan, 12/21/22 through 03/21/23 temporary service plans, and incident investigations, and interviews with staff revealed the following:

A 2/14/23 progress note indicated alert charting was initiated for "Skin problem: right outer buttox [sic] and thigh, red an [sic]broken skin";

* Staff documented on the resident's skin condition on multiple occasions between 02/14/23 and 02/26/23;

* There was no documented evidence in the resident's facility chart that stated how the resident obtained the wound; and

* There was no documented evidence the facility investigated the injury of unknown cause to rule out abuse or reported it to the local SPD if unable to reasonably rule out abuse.

During an interview with Staff 2 (RN) on 03/24/23, she referred to her assessment, entered in the progress notes on 02/17/23, and stated the resident did not have a skin issue on his/her right outer buttocks and thigh when she assessed his/her skin. She acknowledged the documentation staff entered related to the resident's skin from 02/14/23 through 02/26/23.

The need to ensure physical injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/24/23. They acknowledged the findings. The facility was instructed to report the injury to the local SPD and did so that day.

1. The injury of unkown cause was immediately reported to APS

2. Ongoing training upon hire and at least quarterly as a group. Individual trainins as needed.

3. Quarterly review  of documentation as well as random reviews for at least 12 months.

4. RN, RCC and Admin will work together to ensure that all injuries are properly documented, reported and followed.

Based on observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the facility's kitchen, food storage areas, food preparation, and food service on 03/21/23 and 03/22/23 revealed the following:

03/21/23:

* Dirty dishes, dirty sponges, and a face mask were observed on the edges of the hand-washing sink and a turkey breast was thawing in the basin;

* Bags of apples, potatoes, rice and containers with sugar and flour were stored in front of, and adjacent to, the mop storage sink and posed a risk for cross-contamination;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              

* Staff 12 (CG) and Staff 10 (CG) were not wearing aprons;

* Staff 12 was observed to make a sandwich with bare hands; and

* Staff 10 and 12 reported they used a spray bottle of bleach solution to sanitize kitchen surfaces. Staff reported they did not use a sanitation bucket and did not have test strips.

3/22/23:

* Staff  9 (Cook) failed to change gloves and wash hands between touching multiple kitchen surfaces and handling food; and

* Staff 9 failed to use a probe thermometer to ensure the proper temperature had been reached when cooking scrambled eggs.

The need to ensure food was stored and prepared in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 2 (RN), Staff 10, and Staff 12 on 03/21/23 and with Staff  9 and Staff 1 (Administrator) on 3/22/23. They acknowledged the findings.

Facility is developing more detailed policy and proceedure specifically for the kitchen regarding food sanitation rules. Staff has presently been trained on keeping handwash sinks free of everything not required to wash hands.

Building maintenance has build a door and shelves for the food storage area that is adjacent to the mop storage sink.

Care staff that prepare food have been trained on the purpose and need for wearing aprons while preparing food. Policy and procedures will be developed to address this and ongoing training at least quarterly and as needed.

Care staff has been trained in the importance of hand sanitation and the proper use of gloves while preparing food. Policy and procedure will be devoloped to address this with on going training at least quarterly and as needed.

Facility has purchase Steramine tabs and test strips to use for sanitizing kitchen surfaces. Staff has been trained in the proper use of the tabs and the test strips and policy and procedure will be developed to address this with on going training at least quarterly and as needed.

Staff has been trained in the safe practice  for defrosting meat. Policy will be developed with on going training at least quarterly and as needed.

Staff has been trained in proper use of the probe thermometer as well as safe temps for foods. Training will be reviewed quarterly and as needed.

Responsible staff will include RCM and Administrator.

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

Resident 1 was admitted to the facility in 11/2022 with diagnoses including traumatic brain injury.

During the acuity interview, the resident was identified to require a mechanical lift for transfers and to have a pressure ulcer on his/her right ankle.

Review of Resident 1's current service plan, 12/28/22 and 03/03/23 service plans, 12/21/22 through 03/21/23 progress notes and temporary service plans, and interviews with staff and the resident revealed the following:

a. Resident 1's 03/03/23 service plan provided conflicting instructions to staff related to how to assist Resident 1 with transfers, which included both mechanical lift transfers and physical assistance from staff.

b. Resident 1 had a documented pressure ulcer on his/her right ankle. Multiple progress notes from 02/15/23 through 03/21/23, interviews with multiple staff during survey indicated the resident experienced ankle pain. Resident 1 stated during an interview on 03/23/23 s/he had pain in right leg. There was no information related to the resident's pain in the service plan.

The need to ensure the service plan provided clear instruction to staff and was reflective of the resident's status and care needs was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/24/23. They acknowledged the findings.

1. a. Service plan was corrected to reflect when the individuals mentation required 2 person mechanical lift vs independent or stand by assist with transfers.

b. The service plan was updated to reflect the residents chronic and temporarty pain.

2. Ongoing training will be provided to the service planning team to address all areas of care in the service plan.

3. Evaluation will be performed quarterly and at random review by management for at least 12 months.

4. RCM, RN and management will ensure that the service plans are an accurate representation of the resident and that the rule is being met.

Based on observation, interview and record review, it was determined the facility failed to determine, document and communicate what resident specific actions or interventions were needed when a resident experienced short-term changes of condition, failed to monitor the changes with weekly progress noted until the condition resolved, and failed to evaluate and refer significant changes in the resident's health to the RN for assessment for 1 of 1 sampled resident (#1) who experienced changes of condition. Resident 1 experienced multiple falls with injury and ongoing pain to the right ankle. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2022 with diagnoses including a traumatic brain injury, low back pain, osteoarthritis of the knee, and a history of falls.  

Review of the resident's 12/28/22 and 03/03/23 service plans, 12/21/22 through 03/21/23 progress notes, temporary service plans, RN assessments, incident investigations, and interviews with staff revealed the following:

During the acuity interview, Staff 2 (RN) stated the resident had fallen multiple times in recent months when s/he attempted to transfer without staff assistance and also had a pressure ulcer on his/her right ankle.

a. Between 12/21/22 and 03/21/23, facility staff documented Resident 1 experienced 16 falls, the following included complaints of pain or injury:

* 01/02/23: Scratch on right abdomen;

* 01/08/23: Complaints of pain in low back and knees;

* 01/09/23: Bruise on the left rib cage and complaints of knee and back pain;

* 01/24/23: Complaints of back pain;

* 01/30/22: Complaints of pain in knees and low back;

* 02/06/22 Complaints of pain in left arm and shoulder;

* 02/12/23: Complaints of "whole body pain"; and

* 02/15/23: Wound to scalp, hip pain, and right ankle sprain.

A 01/06/23 temporary service plan instructed staff to remind the resident to use his/her call light.

Resident 1 was identified to be at risk for falls, experienced 16 falls in three months, eight falls with complaints of pain and/or injury and there was no documented evidence the facility determined what actions and interventions were needed to minimize future falls and the resident continued to fall.

Resident 1 was observed during the survey to ambulate with a wheelchair.  

b. Resident 1's current service plan dated 12/28/22, noted the resident was dependent on staff for lower body dressing and required staff assist for transfers.

On 02/14/23, Resident 1 had a ground level fall and was diagnosed at the emergency department of the local hospital with a right ankle sprain. The following was documented in Resident 1's progress notes:

* 02/16/23: "Woke at 3 am stating [his/her] ankle hurt";

* 02/17/23: "Wound to the top of [his/her] head, hip and sprain [sic] ankle. [S/he] said [s/he] was in a lot of pain when you touch it";

* 02/18/23: "Wound to the top of [his/her] head, hip and sprain [sic] ankle. [S/he] said [s/he] was in a lot of pain when you touch it";

* 02/18/23: "Alert for wound to scalp, hip pain, sprained ankle when touched [s/he] screams out in pain";

* 02/19/23: "Alert for wound to scalp, hip pain and sprained ankle [s/he] yells out in pain just touching [him/her]";

* 02/19/23: "Wound to the top of [his/her] head, hip and sprain [sic] ankle. [S/he] said [s/he] was in a lot of pain when you touch it"; and

* 02/24/23: "Screams when you barely touch [his/her] ankle."

On 02/24/23, Staff 2 RN completed an assessment, nine days after the resident complained of  significant ongoing pain in the ankle, and stated Resident 1 "had complained of ankle pain after a GLF [ground level fall] and at this time there appears to be a pressure ulcer on his R [sic] lateral ankle ... The wound measures 1.5 cm x 1.0 cm x unk [sic], area of necrotic tissue measures 1cm x 1 cm with 1.5 cm redness noted around the wound."

During an observation and interview with the resident on 03/23/23, the resident stated he had pain in his right leg and was observed leaving the facility for wound care.  

During an interview with Staff 2 (RN) on 03/24/23, she indicated staff had not apprised her of  the resident's ankle pain or open wound until 02/24/23, by which time the wound had progressed to have necrotic tissue.  

Resident 1 experienced a fall with injury and was noted to have significant ongoing pain and a wound which required an RN assessment. There was no documented evidence the facility evaluated the resident's ankle upon his/her return from the emergency department, determined what actions and interventions were needed, and referred him/her to the RN.

c. Documentation in progress notes and a temporary service plan on 02/14/23 indicated Resident 1 had an area on his/her right outer buttocks and thigh which was red with "broken skin". There was no documented evidence the condition was monitored at least weekly through resolution.

The need to determine, document and communicate what resident specific actions or interventions were needed when a resident experienced short-term changes of condition, monitor the changes with weekly progress noted until the condition resolved, and evaluate and refer significant changes in the resident's health to the RN for assessment was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/24/23. They acknowledged the lack of documentation in Resident 1's clinical record.

1. a. Service plan was updated with specific fall prevention instructions.

b. RN completed an assessment and a referral was made to wound care to treat and follow.

c. Staff instructed that if RN is unavailable for weekly checks other management will evalute and chart  on short term change of conditions.

2. RN and RCM will develop a spreadsheet to track, monitor and resolve change of conditions.

3. Quarterly for 12 months and at random intervals.

4. RN, RCM and Admin.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was conducted when the resident experienced a significant change of condition for 1 of 1 sampled resident (#1). Resident 1 experienced significant pain and was noted to have a pressure ulcer on his/her right ankle. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2022 with diagnoses including a traumatic brain injury and a history of falls.

Review of the resident's facility record revealed the resident fell on 02/14/23, was sent to the emergency department of the local hospital and was diagnosed with a right ankle sprain.

Between 02/15/23 and 02/24/23, there were multiple progress notes indicating the resident had experienced pain in his/her right ankle. The RN completed an assessment on 02/24/23, nine days after the incident and reports of pain began, and documented the resident had a pressure wound on his/her right ankle which measured 1 cm x 1.5 cm with unknown depth and necrotic tissue.

The need to ensure the RN completed a timely assessment when Resident 1 experienced a significant change of condition related to pain was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/23/23. They acknowledged the documentation in the resident's facility record.

Refer to C270, example b.

1. RN re-educated on the importance of completing timely assessments when residents experience a significant change of condition.

Staff re-educated on the importance of bringing significant changes to the immediate attention of ithe RN.

2. Ongoing training with management and staff on proper reporting and ongoing documentation of problems with quarterly reviews and as needed by management.

3. Quarterly and as needed for at least 12 months

4. RN, RCM and Administrator.

Based on interview and record review, it was determined the facility failed to coordinate care with outside service providers for 1 of 1 sampled resident (#1) reviewed for coordination of care. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2022 with diagnoses including a traumatic brain injury.

During the acuity interview, facility staff indicated the resident received outpatient PT and SLP (Speech therapy).

Resident 1's current service plan, 12/21/22 through 03/21/23 progress notes, temporary service plans, and outside provider visit notes were reviewed. Staff were interviewed.

The following was documented by facility staff in the progress notes related to PT and SLP visits:

* 01/19/23 PT: Resident 1 "has a print out for daily exercises and will be going to PT 2x per week. Some options for assisting [Resident 1] that were discussed were transfer pole, trapeze and sit to stand";  

* 01/24/23: SLP stated that [Resident 1] "Needs to work on using more pauses between each word when [s/he] is speaking. The facility needs to provide an outline on paper of [Resident 1's] schedule so that  [SLP] can laminate it. [SLP] wants [Resident 1] to check off the tasks [s/he] does";

* 01/31/23: SLP gave the resident "Homework...printed out a list of questions for [Resident 1] to ask [his/her] parents...emphasis on [Resident 1] placing a pause in between each word to help slow [him/her] down to make it better for others to understand"; and

* 02/20/22: SLP "Wants [Resident 1] to practice saying questions for his/her mom and dad with a pause between each word to help with clarity of speech."

There was no documented evidence the facility followed up on the recommendations made by the SLP and PT providers or updated the service plan.

During an interview with Staff 1 (Administrator) and Staff 2 (RN) on 03/24/23, they stated a facility staff member accompanied the resident to outside provider visits and indicated the outside PT/SLP providers rarely sent visit notes back to the facility. The need to coordinate care with outside service providers for continuity of care was discussed with Staff 1 and Staff 2 at that time. They acknowledged the findings.

1. Staff has been and will continue to be trained on the importance and need to have documentation in place for the purpose of coordination of care for residents. Staff has been trained to bring documentation from each appointment back with the resident from each appointment and document it same day in the appropriate place in the chart.

2. Policy and procedure will be devolped with on going training at least quarterly and as needed.

3. Evaluation will be completed quarterly for at least 12 months and as needed.

4. Responsible staff will include RCM, Admin and Nursing.  Recommendations from appropriate providers such as wound care, PT, ST, or OT will be reflected in resident TAR and service plan.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2022 with diagnoses including a traumatic brain injury, low back pain, osteoarthritis of the knee, and a history of falls.

During the acuity interview, facility staff reported that the resident had a pressure sore on his/her right ankle and received wound care treatment from a physician in the community.

Review of  Resident 1's current service plan,  12/21/22 through 03/21/23 progress notes, temporary service plans, physician orders, the 03/01/23 - 03/21/23 MAR, and interviews with staff revealed the following:

A pressure ulcer on the resident's right ankle was assessed by the RN on 02/24/23. In a temporary service plan on that date, she instructed the staff to contact the RN for dressing changes if needed.

Staff documented in progress notes dated 03/03/23, 03/11/23, and 03/19/23 that wound care was provided to the resident's ankle.

A review of the 12/21/22 through 03/21/23 physician orders revealed no documented evidence the facility staff had orders to treat the wound.

The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility administered was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/24/23. They acknowledged the findings.

1.Facility has contacted providers of all patients with any wound care and obtained orders for any potential wound care that may be needed in facility on an as needed or emergency basis.  These changes have been added to residents care plan and TAR.

2. Develop and implement a policy to follow up weekly with outside providers to ensure that medical visit reports and other such documentation is reflected on the MAR, Care Plan and treatment plan

3. Quarterly for at least 12 months and as needed.

4. RN, RCM and Admin

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and documentation completed in accordance with the Oregon Fire Code (OFC), and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records dated 09/17/22 through 03/21/23 were reviewed.

There was no documented evidence the facility conducted fire drills every other month and provided fire and life safety training instruction to staff on alternating months from fire drills.

Documentation for fire drills conducted on 09/17/22 and 12/20/22 lacked one or more of the following required elements:

* Location of the simulated fire;

* Problems encountered, comments relating to residents who resident or failed to participated in the drills; and

* Evidence alternate routes were used during the drills.

During an interview with Staff 1 (Administrator) on 03/23/23, she stated the facility had not provided fire and life safety training to staff on months alternating between fire drills. The need to ensure fire drills were conducted every other month with all required components addressed and fire and life safety instruction provided to staff on alternate months was discussed with Staff 1 at that time.

1. Admin has devoloped a flow sheet to track each reportable area concerning the fire drills.

2. Admin and RCM will prepare the fire drill forms and review the point of origion, escape route how to assist those residents who refuse to participate in the drills.

3. Admin and RCM will ensure that every other month staff is trained in Fire AND life safety.

4. Admin and RCM

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed in fire and life safety topics at least annually, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 03/22/23.

During an interview with Staff 1 (Administrator) on 03/23/23, she stated annual instruction in fire and life safety topics had not been conducted with residents. The need to ensure fire and life safety instruction was provided to residents annually as required by the OFC was discussed with Staff 1 at that time. She acknowledged the requirements as required by the OFC.

1.Admin will ensure that every resident receives Fire and life safety training upon entering the facility as well as every year at the resident council meeting the begining of April. Those who do not attend the resident council meeting will have individual training on Fire and life safety the first week in April every year.

2. Policy will be develpoed for yearly training fro all residents.

3. Upon new admision of residents and yearly in April at the resident counsil meeting.

4. Admin, RCM, and Activity director (responsible for running Residnet counsil meetings)

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in good repair and free of tripping hazards. Findings include, but are not limited to:

A tour of the environment was conducted on 03/21/23. The following was noted:

1. There were drop-offs between 3-5 inches from the concrete pathways in the front of the building to the adjacent surface.

2. The anti-slip tape on the two wooden wheelchair ramps in the back of the building had areas where the tape had peeled off.

The environment was toured with Staff 2 (RN) on 03/21/23. The need to ensure the environment was maintained in good repair and free of tripping hazards was discussed at that time. She acknowledged the findings.

1. A maintenance log has been created for staff to report problems throughout the facility. All drop offs have been repaired as well as the anti slip on the wheel chair ramps.

2. Policy and procedure will be developed for staff to ensure they are properly reporting maintenance issue and the maintenance crew is reviewing the log on a regular basis.

3. Quarterly for 12 months and as needed.

4. Admin and RCM

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair and free from unpleasant odors. Findings include, but are not limited to:  

During a tour of the environment on 03/21/23, a large red stain was noted on the carpet of the elevator. A strong, pervasive odor of excrement, which emanated from Room 11, was noted in the hallway outside the door. The odor grew increasingly stronger from 03/21/23 to 03/23/23 and could be smelled throughout the entire second floor.

In an interview with Staff 1 (Administrator) and Staff 2 (RN) on 03/22/23, they indicated the resident in Room 11 defecated on the floor and in a basin at the end of his/her bed and only allowed staff into his/her room once a week on Thursday afternoon to clean.

During an interview with Staff 13 (Housekeeper) on 03/23/22, she indicated the resident allowed her to come in and clean the floors once a week. She stated the resident's excrement was thickly encrusted on the floor and that she needed to use a tool to scrape it off the floor.

The need to maintain the environment clean and in good repair, and free from unpleasant odors was discussed with Staff 1 and 2 on 03/22/23 and 03/23/23. They acknowledged the findings.

1.The floor in the elevator is being replaced by a non porous cleanable material. Admin and RCM will ensure that house keeping cleans the floor daily and as needed.

The odor has been addressed with the resident whose room is the cause. The individual has agreed to allow housekeeping to increase room cleaning from 1x weekly to 2x weekly. Staff will continue to work with the individual to allow then to clean more often as needed.

2. A maintenance log has been devoloped to address facility maintenance issues including odors.

3. Quarterly for 12 months and as needed.

4. Administrator and RCM