Print Inspection: 5LQT

The findings of the re-licensure survey conducted 01/30/24 through 02/01/24 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

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 re-visit to the re-licensure survey of 02/02/24, conducted on 06/12/24 are documented in this report. It was determined the facility was in compliance with 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

During the acuity interview on 01/30/24, Staff 10 (MT) confirmed the resident service plans were kept in each resident's binder in the medication room. Upon observation on 01/30/24, Resident 1 and Resident 2's service plans were not located in their respective binders. The survey team requested the most recent service plans from Staff 2 (Memory Care Director), which were printed and distributed to the survey team.

The need to ensure service plans were readily available to staff was discussed with Staff 1 (Administrator) on 02/01/24. She acknowledged the findings.

C 260:  OAR 411-054-0036 (1-4) Service Plan: General

1.DHS, ALD, CFLD and RN  will complete all service plans to reflect any changes through TSPs, orders, diagnosis, and incident reports.  All service plans will be printed, signed and placed within access to all care staff.

Resident 1: Service plan has been printed and placed in binder for care sataff to readily access

Resident 2: Service plan has been printed and placed in  binder for care staff to readily access.

2.MBK to provide training to direct care staff on location of service plans.

3.Quarterly and as significant changes occur

4.ED, DHS, ALD, CFLD, CFLC and designee

Based on interview and record review, it was determined the facility failed to ensure they had a designated "Infection Control Specialist" and failed to maintain proof of vaccination status or documentation of a medical or religious exemption as required in OAR 333-019-1010(4). Findings include, but are not limited to:

1. In an interview on 02/01/24, Staff 1 (Administrator) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist," responsible for carrying out the infection prevention and control protocols, qualified by education, training, and experience or certification, and who had completed specialized training in infection prevention and control protocols.

2. Upon entrance to the facility on 01/30/24, the facility's documentation of monthly COVID-19 reporting on vaccination status to the Oregon Health Authority (OHA) for staff was requested.

In an interview with Staff 1 on 02/01/24 at 9:45 am documentation of COVID-19 vaccination status reporting was provided which revealed reporting was not completed for the months of 11/2023 and 12/2023.

The need to ensure the facility has a designated "Infection Control Specialist" and reported monthly on COVID-19 vaccination status was reviewed with Staff 1 on 02/01/24. The findings were acknowledged.

C 295:  OAR 411-054-0050(1-5):  Infection Prevention & Control

1.Community will designate an "Infection Control Specialist" who has completed specialized training in infection prevention and control protocols. Community will maintain proof of vaccination status in personnel file.

2.ED, AED, Administrator, and/or designee will ensure Infection Control Specialist is assigned and will review assignment need quarterly or as needed.

3.Quarterly or as needed

4.ED and designee

Based on observation, interview, and record review, it was determined the facility failed to ensure MARs included specific instructions for PRN medications, for 2 of 2 sampled residents (#s 1 and 2) and contained reasons for use for 1 of 2 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2023 with diagnoses including dementia. Resident 2's MAR was reviewed from 01/01/24 through 01/30/24 and the following was noted:

a. Resident 2 had a physician's order for PRN risperidone (a psychotropic medication) 0.25 mg one tablet as needed for "agitation". There were no resident specific parameters for the use of the PRN as to how the resident demonstrates "agitation".

In an interview with Staff 10 (MT), it was confirmed that the electronic MAR did not contain any additional information for staff as to how Resident 2 displays "agitation".  

b. Multiple medications on the MAR lacked a reason for use.

On 01/31/24 at 11:20 am, the surveyor and Staff 10 reviewed the electronic MAR and confirmed the electronic MAR contained no additional information vs. the printed MAR.

The need to ensure all medications on the MAR included resident specific instructions for PRN medications and included reasons for use was discussed with Staff 1 (Administrator) on 02/01/24. The findings were acknowledged.  

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease. A review of the resident's 01/01/24 to 01/30/24 MAR revealed the following:

Resident 1 had a physician's order for risperidone (a psychotropic medication) 0.5 mg one tablet to use every six hours as needed for "agitation". There were no resident specific parameters for the use of the PRN as to how the resident demonstrated "agitation".  

During an interview on 01/31/24, Staff 10 (MT) confirmed the electronic MAR did not contain any additional information for staff as to how Resident 1 displays "agitation."  

The need to ensure PRN medications included resident specific parameters and instructions was discussed with Staff 1 (Administrator) on 02/01/24. The findings were acknowledged.

C 310:  OAR 411-054-0055 (2) Systems: Medication Administration

1.All MARs will be reviewed for resident specific parameters.  The community will obtain signed order clarifications for every resident.

Resident 2: Resident specific parameters for medication and reason for use are updated in MAR.

Resident 1: Resident specific parameters and instructions for medication use are updated in MAR.

2.Med staff will receive training in required MD order components and policy on requesting order clarifications.

3.Daily and as needed

4.DHS, ED, CFLD, CFLC, or designee

Based on interview and record review, it was determined the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing. Findings include, but are not limited to:

During a review of staff training records on 01/31/24, Staff 1 (Administrator) was unable to provide documented evidence the sampled newly hired staff had completed all pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned. There was no written documentation of initial and annual training completed by each employee.

The need to maintain written documentation of training completed by each employee and to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 1 on 02/01/24. She acknowledged the findings.

Refer to Z 155 and C 372.

C 365:  OAR 411-054-0070 (2):  Staffing Rqmt and Training:  Training Rqmts

1.Audit of staff training records will be completed for training, including competencies of direct care staff through evaluation, observation, or written testing requirements.  Missing training items and documentation to be completed. COVID-19 reporting vaccination requirement met and process in place for required reporting.

2.Training to be provided to BOM, DHS, CFLD, ALD on proper onboarding processes and training requirements.

3.Weekly

4.BOM/ED/AED

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 14, 10, and 11) were trained in the use of the abdominal thrust and First Aid within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 01/31/24 and identified the following:

Staff 14 (CG), hired 10/23/23, Staff 10 (MT), hired 11/10/23, and Staff 11 (MT), hired 11/27/23, lacked documentation of demonstrated competency in First Aid/Abdominal Thrust.

During an interview on 01/31/24, Staff 2 (Memory Care Director) confirmed the lack of documented evidence the above sampled staff completed first aid and abdominal thrust training.

The need to ensure staff demonstrated competency in the use of abdominal thrust and First Aid within 30 days of hire was discussed with Staff 1 on 02/01/24. She acknowledged the findings.

C 372:  OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1.Audit of staff training records will be completed for training, first aid and abdominal thrust requirements.  Missing training items and documentation to be completed.

Staff 14: Staff training for CPR, abdmoninal thrust, first aid scheduled and will be documented as complete.

Staff 10: Staff training for CPR, abdominal thrust,first aid scheduled and will be documented as complete.

Staff 11: Staff training for CPR, abdmominal thrust, first aid scheduled and will be documented as complete.  

2.Training to be provided to BOM, DHS, CFLD, CFLC on proper onboarding processes and training requirements.

3.Weekly

4.BOM/ED/AED

Based on observation and interview, it was determined the facility failed to ensure all doors that exited the memory care community to the outdoor courtyard were equipped with operational alarming devices or other acceptable systems to alert staff when residents exited into the courtyard. Findings include, but are not limited to:

A tour of the facility on 01/30/24, revealed the following:

* There were no exit door alarms for either of the two doors to the outdoor courtyard from the dining room and the adjacent hallway.

During a walk through of the environment on 01/31/24, Staff 1 (Administrator) verified the lack of exit door alarms.

C 555:  OAR 411-054-0200 (11-13):  Call Sys, Exit Dr Alarm, Phones, TV, or Cable

1.Community will have exit door alarms installed for the two doors leading into the outdoor courtyard from the dining room and adjacent hallway.

2.ED or designee is contracting services to have appropriate installation of door alarms that meet the requirement of alerting staff when doors are operated.

3.ED or designee will follow-up weekly to ensure appropriate installation is completed timely.

4.ED, Environmental Services Director and designee are responsible to see that corrections are completed.

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 295, C 365, C 372 and C 555.

Z 142:  OAR 411-057-0140(2) Administration Compliance

1.A licensed administrator is in place at the community.

2.Administrator will receive training and will follow licensing rules in community Infection Prevention and control policies, staff training requirements, exit door alarm maintenance.

3.Weekly

4.ED

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 10, 11, 13, and 14) had required memory care specific pre-service orientation completed prior to beginning job duties and failed to ensure 3 of 3 newly hired direct care staff demonstrated competency in all areas prior to providing resident care independently and administering medications unsupervised; and that annual training was completed and documented for 4 of 4 long term staff (#s 5, 7, 8 and 9). Findings include, but are not limited to:

1. Staff 11 (MT), hired 11/27/23 lacked documented evidence an observation and evaluation had been completed which determined their ability to perform safe medication and treatment administration unsupervised. Staff received competency training prior to administering additional medications.

2.  Staff 10 (MT), hired 11/10/23, Staff 11 (MT), hired 11/27/23 and Staff 13 (Activities Assistant), hired 01/02/24, and Staff 14 (CG), hired 10/23/23 lacked documented evidence of pre-service orientation training topics in the following areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures; and

* Written job description.

3. There was no documented evidence Staff 10, 11, 13, and 14 completed the following pre-service dementia training:

* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to behaviors;

* Strategies for addressing social needs and engaging them in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.

4. There was no documented evidence Staff 10, 11, and 14 completed the following additional pre-service training required of direct care staff prior to providing personal care:

* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);

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

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.

5. There was no documented evidence Staff 10, 11 and 14 completed the following pre-service training required of direct care staff prior to independently providing care and services:

* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan, as required in OAR 411-054-0070(4); and

* The use of supportive devices with restraining qualities in memory care communities.

6. There was no documented evidence Staff 10, 11, and 14 had demonstrated competency within 30 days of hire in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

7. Review of the facility training records revealed Staff 5 (CG), Staff 7 (MT), Staff 8 (CG) and Staff 9 (Director of Wellness Programming) did not complete 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care.

The need to ensure all newly hired staff completed pre-service orientation and competency, and all veteran staff completed 16 hours of annual training was discussed with Staff 1 (Administrator), on 2/1/24. She acknowledged the findings.

Z 155:  OAR 411-057-0155(1-6) Staff Training Requirements

1.Audit of staff training records will be completed for training and skills requirements.  Missing training items to be completed.  Skills demonstration checklists to be completed with oversight of Administrator, ED, DHS, and designee.  

Staff 10: Training and competency assessment is completed and documented.

Staff 11, 13, 14: Pre-service orientation and training completed and documented for resident rights, abuse reporting, infectiouse disease prevention, fire safety and emergencies, written job description.

Staff 10, 11, 13, 14 pre-service dimentia training completed and documented for disease, communication and responding to behaviors, social needs and engagement, aspects of dimentia as noted in SOD.

Staff 10, 11, 14: Completed and documented pre-service training for personal care environmental facors, family support, recognizing behaviors.

Staff 10, 11, 14 completed and documented pre-service training for personal care for supportive devices and restraints.

Staff 10, 11, 14: Completed demonstrated competencies for role of service plans in providing individualized care.

Staff 5, 7, 8, 9 completed and documented 16 hours of annual trainingrelated to provisions of care in CBC, including six hours related to dimentia care.

2.Training to be provided to BOM, DHS, CFLD, ALD on proper onboarding processes and training requirements.

3.Weekly

4.BOM, ED, AED, DHS, or designee

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 260 and C 310.

Z 162:  OAR 411-057-0160(2b) Compliance with Rules Health Care

1.A licensed administrator is in place to provide campus oversight.  

2.Administrator, RN, CFLD, CFLC to be involved in service planning, daily clinical meetings and weekly high-risk meetings.  

3.Daily and weekly

4.ED, AED, CFLD, DHS or designee

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:

During the survey, the doors to the interior courtyard were observed to be locked on 01/30/24, 01/31/24 and 02/01/24.

During a tour of the building on 01/30/24 with Staff 2 (Memory Care Director), Staff 2 reported the courtyard doors were locked at all times and residents could access the interior courtyard by asking care staff to unlock the door.

The need to ensure the facility has a written policy which described under what circumstances the doors to the courtyard would be locked was reviewed with Staff 1 (Administrator) on 02/01/24.  She acknowledged the findings.

Z 173:  OAR 411-057-01706 Secure Outdoor Recreation Area

1.Community has a written policy in place for the use of the Ourtdoor Recreation Space which describes the circimstances of when recreation area doors will be unlocked/locked.

2.CFLD, CFLC has provided training to staff regarding recreation area policy - access parameters and the use of alert system when residents enter/exit recreation area.

3.ED, CFLD, CFLC or designee will audit doors monthly to ensure access to recreation area aligns with policy.

4.ED, CFLD, Environmental Services Director and designee are responsible to see that corrections are completed.