Print Inspection: 2W7S

The findings of the re-licensure survey, conducted 10/10/22 through 10/12/22, 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 re-visit to the re-licensure survey of 10/12/22, conducted on 01/26/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include but are not limited to:

On 10/11/22 the survey team conducted a group interview with facility residents. During the interview multiple residents expressed complaints about the facility including, experiencing call light response time of over 30 minutes and lack of resolution from administration.

In an interview on 10/12/22, Staff 1 (ED) confirmed knowledge of resident complaints regarding long call light response times and was interviewed about the facility's grievance resolution policy. Staff 1 provided the survey team with overage reports used by the facility daily to identify any call lights not taken within 20 minutes. According to Staff 1, the process was to include follow up to each resident who experienced call light response times of over 20 minutes. On each of the forms provided, the area that included follow up to the resident was left blank.

The facility lacked documented evidence of thorough investigation and resolution of resident's complaints of long call light response times.

Staff 1 acknowledged the need to improve the facility's method for responding to and resolving resident complaints.

The need to ensure the facility implemented effective methods of responding to and resolving all resident complaints was discussed with Staff 1, Staff 2 (Regional RN Consultant) and Staff 3 (Regional Director of Operation) on 10/12/22. They acknowledged the findings.

1. Call light exeption report form was updated to accurately capture call lights exceeding 20 min threshold and provide administrative follow up with resident on form

2. All residents and Staff will be educated on the grievance process by 11/7 and reminded where to locate the grievance forms in the community. Call light exception logs will be reviewed daily with IDT and overages addressed with resident and staff involved within 3 days.  

3. The call light exception forms will be reviewed daily at stand up. The grievance process will be reviewed weekly with IDT for the next 8 weeks and monthly thereafter.

4. Social Services Director, Executive Director  

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident care needs, were followed and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2018 with diagnoses including difficulty in walking and muscle weakness.

Observations and interview with Resident 4 during the survey revealed the resident required a walker or a wheelchair for mobility.

Observations of the resident, interviews with the resident and staff, review of the current 09/06/22 service plan and clinical records during the survey, revealed Resident 4's service plan was not reflective of the resident's status in the following areas:

* Use of a power wheelchair; and

* Use of a seatbelt while in the power wheelchair.

The need to ensure the service plan was reflective of the resident's needs was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant) and Staff 3 (Regional Director of Operations) on 10/12/22. Staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 11/2018 with diagnoses including multiple sclerosis and paraplegia.

Observations of Resident 5 during the survey revealed the resident was dependent on staff for most ADLs and used an air mattress while in bed.

Observations of the resident, interviews with the resident and staff, review of the current 09/13/22 service plan and clinical records during the survey, revealed Resident 5's service plan was not reflective of the resident's status and did not provide clear instruction to staff  in the following areas:

* Use of seatbelt while in power wheelchair;

* Use of wedge to support leg while in bed; and

* Use of bilateral heel protectors at night.

The need to ensure the service plan was reflective of the resident's needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant) and Staff 3 (Regional Director of Operation) on 10/12/22. Staff acknowledged the findings.

3. Resident 1 was admitted to the MCC in 04/2022 with diagnoses including alcohol dependence with alcohol-induced persisting dementia, cerebral infarction (stroke) and dysphagia (swallowing problems).

Observations were made, interviews with the resident, the resident's family and staff were conducted and the resident's current service plan, dated 09/30/22, was reviewed. The service plan was not reflective, did not provide clear direction to staff and/or was not adhered to in the following areas:

* Behavioral interventions and what could trigger behaviors;

* Communication strategies including the use of gestures and clarifying questions by the staff to improve the resident's comprehension;

* Ability to self direct medications;

* Toileting assistance including when the resident was independent and when s/he required assistance;

* Urinal use;

* Shower preferences; and

* Swallow strategies including cueing and assistance required.

The need to ensure service plans were reflective of the current needs of the resident, provided clear caregiving instruction to staff and were followed was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3 (Regional Director of Operations), Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings.

1) Resident 4 service plan was reviewed and updated on 10/13/2022

Resident 5 service plan was reviewed and updated on 10/13/2022

Resident 1 service plan was reviewed and updated on 10/13/2022

2) Provide an in-service with the service planning team to review the OAR's as they pertain to service planning to address updates, that they are reflective of the residents needs, give clear direction to staff and staff to follow those directions

3) IDT will audit 2 random service plans weekly for accuracy and current person centered care needs for 8 weeks then quarterly thereafter

4) RCC, RN DHS, and Executive Director is responsible

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly (exposing their nose, or nose and mouth) while providing care to residents, while directing activities in a common area and while preparing food.

1. On 10/12/22 at 2:31 pm, Staff 3 (Regional Director of Operations) and a member of the survey team observed a staff member providing ADL care to a resident with his/her mask exposing both the nose and mouth.  

2. On 10/11/22 at 10:50 am, Staff 4 (Cook) was observed without wearing a face mask while in the facility kitchen preparing lunch for the residents.

3. On 10/12/22 at 2:15 pm, Staff 4 and Staff 10 (Cook) were observed without wearing face masks while in the facility kitchen, in close proximity to one another and standing over a food prep table with uncovered food.

The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3, Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings.

1) Staff members were in-serviced on proper PPE usage on 10/12/2022 with return demonstration and understanding

2) Provide an in-service to All Staff pertaining to infection prevention and control policy related to proper PPE usage. Any staff struggling to wear a standard mask properly will use an adhesive mask.  

3) IDT will perform 5 PPE audits per day for 6 weeks, auditing mask useage, then weekly thereafter

4) RCC, RN DHS, Executive Director responsible

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific instructions and parameters for 1 of 3 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the MCC in 04/2022 with diagnoses including alcohol dependence with alcohol-induced persisting dementia, cerebral infarction (stroke) and other symptoms and signs involving cognitive function and awareness.

The resident's 10/01/22 through 10/10/22 MAR and most current service plan, dated 09/30/22, were reviewed and revealed the following:

* The resident had PRN orders for Benzocaine Gel 20% and Ibuprofen 400 mg to manage tooth pain;

* The resident had PRN orders for Acetaminophen 500 mg and Lidocaine Cream 4% for pain; and

* The resident's service plan and MAR indicated that s/he was able to self-direct PRN medications.

An interview, with Resident 1 and Staff 3 (Regional Director of Operations) on 10/12/22 at 2:31 pm, confirmed the resident was unable to recall and/or verbalize his/her PRN pain medications independently, s/he was unable to verbalize which medication s/he would prefer when given a choice, and s/he was unable to recall if staff had offered him/her a choice between these medications in the past.

Following the interview, Staff 3 verbally confirmed Resident 1 was unable to self-direct his/her PRN medications and the MAR would be changed immediately.

The need to ensure MARs were accurate and included resident specific instructions and parameters was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3, Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings.

1) Resident 1's MAR was updated to reflect PRN pain medication non-verbal indicators on 10/13/22.

2) All MCU residents will have non-verbal indicators for all PRN pain medications by 11/1/2022. Med Techs will be in-serviced on identifying non-verbal pain indicators and how to determine PRN use by 11/1/22

3) New or updated PRN pain medication orders will be reviewed daily at standup meeting to ensure non-verbal indicators are listed on the order and MAR.

4) RCC and RN DHS responsible

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, C295 and C310.

See POC for Z165.

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

Resident 1 was admitted to the MCC in 04/2022 with diagnoses including alcohol dependence with alcohol-induced persisting dementia and restlessness and agitation.

Resident 1's record documented behaviors including agitation and verbal and/or physical aggression toward residents and staff.

The resident's most current service plan, dated 09/30/22, lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 10/12/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3 (Regional Director of Operations), Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings, and no additional documentation was provided.

1) Resident 1's service plan was reviewed and updated on 10/12/2022.

2) An in-service will be provided with the service planning team to review the OAR's as they pertain to service planning to address updates, that they are reflective of the residents needs, give clear direction with approach and person-centered behavior interventions

3) IDT will audit 2 random service plans weekly for accuracy and current resident person-centered care needs for 8 weeks then quarterly thereafter

4) RCC, RN DHS, Milieu Counselor, Executive Director responsible