Print Inspection: 94DZ

The findings of the re-licensure survey, conducted 08/02/23 through 08/04/23, 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.

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 08/04/23, conducted 12/26/23 through 12/28/23, 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.

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 second re-visit to the re-licensure survey of 08/04/23, conducted on 03/18/24, are documented in this report.

It was determined the facility was in 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 observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:

A tour of the facility conducted on 08/02/23 at 9:52 am identified the following was not accessible and in a conspicuous location:

* The name of the administrator or designee in charge. The designee in charge was not posted by shift or whenever the Memory Care Coordinator was out of the facility; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.

The need to ensure all required postings were in an accessible and conspicuous place was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 4 (Memory Care Coordinator), and Staff 6 (Director of Plant Operations) on 08/04/2 at 10:12 am. They acknowledged the findings.

C152 - Facility Administration: Required Postings

oThere is already a "Manager on Duty" sign in the unit, however the facility did not have a name or position designated in this sign. The Administrator is ordering "Med Tech" and "Memory Care Coordinator (MCC)" name plates that will be used at the appropriate times throughout the day and night to designate whether the MCC or the med tech is the current manager on duty. The Administrator and/or designee will train all memory care med techs and the MCC on this new procedure.

oThe Administrator posted a sign in front of the main memory care entrance that says where the latest state survey is located. The most recent re-licensure survey is located in the designated location as specified on the posting next to the memory care entrance.

oFor the monitoring plan the Administrator and/or designee will do a daily walk through to check for the following postings: (1) to ensure that staff are putting the appropriate position name plate in the "Manager on Duty" sign; (2) that the signage indicating the location of the most recent re-licensure survey is posted next to the memory care doors; and (3) that the copy of the most recent re-licensure survey is available in the designated location.

Based on interview and record review, it was determined the facility failed to conduct investigations for injuries of unknown cause to rule out abuse, or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (# 1) whose record was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behavioral disturbance and anxiety.

Progress notes dated from 05/05/23 through 08/02/23 and incident reports were reviewed and revealed the following:

a. A progress note dated 05/15/23 reflected a bruise to the resident's left breast had been resolved. There was no documented evidence the facility investigated the injury of unknown cause to rule out abuse or neglect.

b. On 05/31/23, Staff 5 (LPN) noted an abrasion to the resident's left eye. The progress note verified Resident 1 was "unable to recall how it happened" and Staff 5 documented "seems to be resident tried to scratch [his/her] eye." Staff 5 was unable to provide the details of why he thought Resident 1 was trying to scratch his/her eye. There was no documented evidence the facility investigated the injury of unknown cause to reasonably rule out abuse or neglect.

The need to ensure injuries of unknown cause were investigated within 24 hours to reasonably rule out abuse and/or neglect, and to report them to the local SPD office when abuse and/or neglect could not be ruled out was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 on 08/04/23. They acknowledged the findings.

C231 - Reporting & Investigating Abuse-Other Action

oThe Administrator and/or designee will ensure an incident report and subsequent investigation to rule out abuse or neglect are completed for the issues brought up in the 5/15/2023 progress note in Resident 1's chart. The facility will self-report any injuries of unknown origin to APS.

oThe Administrator and/or designee will ensure an incident report and subsequent investigation to rule out abuse and neglect are completed for the issues brought up in the 5/31/2023 progress note in Resident 1's chart. The facility will self-report any injuries of unknown origin to APS.

oThe Administrator will conduct a training for the nurses on when skin issues with residents require an incident report and subsequent investigation.   

oThe Administrator of designee will conduct a training for all med techs on the need to put in an incident report for every skin issue.

oFor the monitoring plan the Administrator or designee will check all skins logs from memory care once per week to ensure issues are closed out or that a weekly progress note has been written by one of the nurses.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behavioral disturbance, anxiety, and having a pacemaker.

The resident's 05/12/23 service plan and service plan updates dated from 05/30/23 through 07/25/23 were reviewed, and care giving staff were interviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Cell phone use and assisting in keeping it charged;

* What to expect when family visits the resident;

* Specific requests of how to leave the resident's room (e.g. blinds closed, door shut);

* The resident's interests in television, music, and reading the newspaper;

* Person centered behavior interventions relating to anxiety, depression, and refusing care;

* Topical pain medication;

* Ability to use the call system;

* Who provides bathing assistance and the bathing schedule;

* Instructions relating to a pacemaker;  

* Person centered discussion topics;

* How the resident takes his/her water;

* Barrier cream application with each incontinent change; and

* Transportation assistance needed.

The need to ensure service plans were reflective of residents' current needs, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including unspecified dementia and having a pacemaker.

The resident's 06/29/23 service plan and Care Plan Updates dated 07/25/23 through 08/02/23 were reviewed. Staff were interviewed and the resident was observed. The following lacked clear instruction to care giving staff relating to the provision of care for the resident:

* Instructions relating to a pacemaker;

* The personality of the resident and how to approach him/her;

* Cueing and supervision during meal times;

* Resident 2's spouse and him/her going to the Assisted Living Facility's dining room for lunch at least once a week;

* Ability to shave self when handed the electric razor;

* Ability to brush own teeth when handed a toothbrush; and

* Mattress flipping.

The need to ensure service plans were reflective of residents' current needs, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

C260 - Service Plan: General

oThe MCC and/or designee will update Resident 1 and Resident 2's service plans to ensure they are reflective of the residents' current needs, include a written description of who shall provide the services and what, when, how and how often the services shall be provided.

oThe Administrator has created a new form to be used by the Resident Service Coordinators (RSCs) and the Memory Care Coordinator (MCC) each time they create or update a resident service plan. The RSCs and MCC will give the new form to the CGs in advance of the service plan being due to help capture more resident-specific details and help ensure we capture all details for our service plans. The Administrator will train the RSCs and MCC on the new form and how to incorporate it into each service plan.

oThe Administrator and/or designee will review all service plans in memory care to ensure they include the necessary resident-specific details.

oFor a monitoring plan, the Administrator will require that the MCC turn in the completed forms to the Administrator after each service plan is created or updated. The Administrator will review each created or updated service plan to ensure all resident-specific details have been included. Service plans will be updated upon move-in, within 30 days of move-in, after any significant change of condition, and on a quarterly basis thereafter. The Administrator or designee will pull a weekly report from the EMR and review all upcoming service plans to ensure the MCC is completing all service plans on time and turning the new form into the Administrator in a timely manner.   

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and interventions determined, documented, and monitored until resolution for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behavioral disturbance and muscle contracture.

Progress notes dated from 05/05/23 through 08/02/23 and outside provider notes dated from 06/08/23 through 08/01/23 were reviewed. The following short term changes of condition were identified:

* 05/05/23 - assisted fall to the floor;

* 07/11/23 - "redness under both armpits"; and

* 07/13/23 - a wound to the right foot.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift, and monitored the conditions with progress noted at least weekly through resolution for each of the resident's changes of condition.

The need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including unspecified dementia and was identified as having a catheter.

Progress notes dated from 06/29/23 through 08/02/23, and MARs dated from 07/01/23 through 08/02/23 were reviewed. The following short term changes of condition were identified:  

* 06/29/23 - admitted to the facility; and

* 07/24/23 - a urinary tract infection (UTI) and an antibiotic was started on the same day.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift, and monitored the conditions with progress noted at least weekly through resolution for each of the resident's changes of condition.

The need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

C270 - Change of Condition and Monitoring

oThe Director of Health Services (DHS) and/or designee will address the short term changes of condition for Resident 1 from 5/5/23, 7/11/23, and 7/13/23, and the short term changes of condition for Resident 2 from 6/29/23 and 7/24/24, to ensure these changes of condition are evaluated to determine what

actions or interventions are needed, that actions or interventions are communicated to staff on each shift, and that these conditions were monitored with progress

noted at least weekly through resolution.

oThe Administrator will train the nurses on the correct process for reporting and charting on short-term changes of condition.

oThe Administrator and/or nurses will train all med techs on the proper protocol for reporting and charting on short-term changes of condition.

oFor the monitoring plan the Administrator and/or designee will review the alert charting binder in memory care on a weekly basis to ensure the established procedure is being followed by the nurses and med techs.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and had signed physician orders for all medications the facility was responsible to administer for 2 of 2 residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behavioral disturbance, hypertension, and depression.

The resident's 07/01/23 through 08/02/23 MARs and physician's orders were reviewed. The following medications were not administered as prescribed due to the medication not being available at the facility:

* Losartan (for hypertension) on 07/28/23, 08/01/23, and 08/02/23;

* Sertraline (for depression) on 07/01/23;

* Vitamin B12 (for supplement) from 07/22/23 through 07/25/23; and

* Povidone-Iodine (for wound care) on 07/01/23 and 07/07/23.  

The need to ensure the facility administered all medications per physician's order was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including unspecified dementia and uncontrolled type 2 diabetes.

The resident's 07/01/23 through 08/02/23 MARs and physician's orders were reviewed. The following issues were identified:

* Atrovastatin (for high cholesterol) was not administered on 07/11/23 and ciprofloxacin (antibiotic) was not administered on 07/24/23 at 8:00 am as the medication was not available at the facility;

* It was unclear if the resident's capillary blood glucose (CBG) reading was done or if s/he received sliding scale Novolog on 07/01/23 at 1:00 pm as the MAR was blank for that entry;

* The physician ordered parameters for Resident 2's CBGs were, " below 70, staff to give 8 oz glass of juice, or a small mini candy bar, followed by a glass of milk or half of sandwich." On 07/01/23, staff documented the resident's CBGs were 71, but they followed the parameters as if the CBGs were below 70; and

* There was no documented evidence of a signed physician's order for Desitin cream.

The need to ensure the facility administered all medications per physician's order and had signed physician orders for all medications the facility was responsible to administer was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

C303 - Systems: Treatment Orders

oThe Director of Health Services (DHS) and/or designee will ensure all medications are administered per physician's order and that all medications the facility is responsible for administering have signed physician's orders for Resident 1 and Resident 2.

oThe Administrator and/or designee will conduct a training for all med techs on the correct procedure for any missed medications and a training on following all physician orders as prescribed. The training will focus on reordering medications in a timely manner by observing the blue strip on medication cards, which alerts med techs about when to order more medications in time. The training will also focus on ensuring there are no blanks in the MARs.

oFor a monitoring plan the Administrator and/or designee will check the missed medication report and medication unavailable report on a weekly basis. The Administrator and/or designee will follow up with med techs on any missed medications by leaving a weekly report for all memory care med techs that shows if there were any blanks in the MAR. Med techs will be required to follow up and correct any blanks in the MAR.  

Based on interview and record review, it was determined the facility failed to ensure the accuracy of MARs which included completed documentation, the reason for use for each medication, resident specific parameters and instructions for PRN medications, and initials of the person administering the medication for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behavioral disturbance and anxiety.

The resident's 07/01/23 through 08/02/23 MARs were reviewed and the following inaccuracies were identified:

a. Povidone-Iodine lacked a reason for use and clear direction to staff on where to administer the medication.

b. The following PRN medications to treat for the same reason lacked resident specific parameters and instructions relating to the order of administration:

* Bisacodyl suppository (for constipation);

* Polyethylene glycol (for constipation);

* Haloperidol (for hallucinations and agitation);

* Quetiapine (for hallucinations and agitation);

* Gabapentin (for pain); and

* Morphine (for pain).

The need to ensure residents' MARs were accurate, included reasons for use, and had clear resident specific parameters and instruction to staff was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including unspecified dementia and uncontrolled type 2 diabetes.

The resident's 07/01/23 through 08/02/23 MARs were reviewed and the following inaccuracies were identified:

a. Preservision Areds lacked a reason for use.

b. On 07/19/23 the staff member that administered the sliding scale Novolog was not the same staff member who signed the MAR.

c. There were five PRN bowel medications to treat constipation, but there were no resident specific parameters listed for polyethylene glycol or Senna.

d. The facility's RN had added the following directions to staff on the MAR:

- Check resident's catheter bag for blood in urine three times a day. There were blanks on 07/03/23, 07/04/23, and 07/08/23 for the 11:00 pm check. Staff noted the resident was sleeping at the 11:00 pm check on 07/01/23, 07/02/23, 07/06/23, 07/10/23 through 07/12/23, 7/15/23, 07/16/23, 07/19/23 through 07/26/23 so there was no information documented.

- Give Resident 2 a night time snack in order to help maintain blood sugars at 8:30 pm or at 9:30 pm. Staff documented the snacks were not given on 07/02/23, 07/03/23, 07/05/23 through 07/10/23, 07/12/23 through 07/14/23, and 07/17/23 through 07/22/23.

- Staff were directed to obtain a urine sample every two weeks. It was not completed on 07/12/23 and there was no documented evidence it was tried again until 07/26/23.

- Staff were directed to give eight ounces of water to the resident if s/he had capillary blood glucose (CBG) readings of 300 to 349. Eight ounces of water was not documented as given on 07/02/23, 07/06/23, 07/11/23 (two separate times), 07/14/23, 07/18/23, 07/19/23, 07/24/23, and 07/25/23.

- Staff were also directed to give the resident 16 ounces of water if his/her CBG readings were 350 and above. There was no documentation the water had been given on 07/08/23 (two separate times), 07/14/23, 07/17/23, 07/18/23, and 07/24/23.

The need to ensure MARs were accurate, included completed documentation, reasons for use for each medication, resident specific parameters and instructions for PRN medications, and initials of the person administering the medication was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.   

C310 - Systems: Medication Administration

oThe Director of Health Services (DHS) and/or designee will ensure Resident 1's MAR is accurate, includes reasons for use, and has clear resident specific parameters and instruction to staff.

oThe Director of Health Services (DHS) and/or designee will ensure Resident 2's MAR is accurate, includes completed documentation, reasons for use for each medication, resident specific parameters and instructions for PRN medications, and that the initials of the person administering the medications are accurate, includes reasons for use, and has clear resident specific parameters and instruction to staff.

oThe Director of Health Services (DHS) and/or the Assistant Director of Health Services (ADHS) will audit all of the physician orders for all memory care residents to ensure each one has a reason for use. The DHS and/or ADHS will audit all PRN orders to ensure they clearly indicate which medication is to be used in which order when the reasons for use are for the same issue.

oThe Director of Health Services (DHS) and/or designee will conduct a training for all memory care med techs on the proper procedure for signing off on medications they administer and the importance of never signing off on a medication they did not administer themselves. This training will also focus on the proper procedure for accurate and complete documentation in all residents' MARs, with a special emphasis on the types of directions missed in Resident 2's MAR.

oFor the monitoring plan the Administrator and/or designee will audit the physician orders on the MARs on a quarterly basis when the service plan is due to be update or upon move-in when a new service plan is created.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had written, resident-specific parameters and non-pharmacological interventions for staff to attempt prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (# 1) who was prescribed a PRN medication to address anxiety. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behavioral disturbance and anxiety.

The resident's 07/01/23 through 08/02/23 MARs and physician's orders were reviewed.

On 07/11/23 staff administered a PRN Lorazepam (for anxiety). There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medication.

The need to ensure residents' MARs included resident specific non-pharmacological interventions for staff to try prior to the administration of a PRN psychotropic which included documentation of the interventions tried with ineffective results was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.  

C330 - Systems: Psychotropic Medication

oThe Director of Health Services (DHS) and/or designee will ensure Resident 1's MAR includes resident-specific non-pharmacological interventions for staff to try prior to the administration of a PRN psychotropic, which includes documentation of the interventions tried with ineffective results.

oThe Administrator and/or designee will audit to ensure all psychotropic meds have at least 3 non-pharmacological interventions listed that can be used before the medication is administered.

oThe Administrator and/or designee will retrain all med techs on how to use and document all non-pharmacological interventions prior to administering a medication.

oFor the monitoring plan the Administrator and/or designee will monitor each psychotropic medication order to ensure that we have 3 non-pharmacological interventions.

Based on interview and record review, it was determined the facility failed to implement an acuity based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

A review of the facility's ABST revealed there was no documented evidence the following required eight elements were addressed:  

* Dressing and undressing;

* Medication administration, passing out medications;

* Providing non-drug interventions for pain management;

* Providing treatments (e.g., skin care, wound care, antibiotic treatment);

* Cueing or redirecting due to cognitive impairment or dementia;

* Monitoring physical conditions or symptoms;

* Monitoring behavioral conditions or symptoms; and

* Responding to call lights.

The facility's ABST was reviewed and discussed with Staff 1 (ED) and Staff 2 (Administrator) on 08/04/23. No additional information was received.

C361 - Acuity-Based Staffing Tool

oThe Administrator and/or designee will switch to using the State of Oregon acuity-based staffing tool.  

oThe Administrator, Resident Service Coordinators, and/or Memory Care Coordinator will enter all residents into the state tool. In the future all new residents will be added into the state tool upon move-in and all existing residents will have their profiles updated on a quarterly basis or when a change of condition occurs.

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

Fire drill and fire and life safety training records from 02/01/23 through 08/02/23 were requested. Review of the records provided identified the following deficiencies:

a. Fire Drills:

* One fire drill was conducted on 05/12/23 at 9:00 pm, not every other month as required.

* The facility was not relocating residents from the simulated fire area. Therefore, there was no documentation of:

- Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

- Evacuation time-period needed; and

- Number of occupants evacuated.

b. Fire and life safety training for staff:

* The facility was not providing fire and life safety training for staff on alternate months as required.

Although there was documentation of fire and life safety training provided on 07/11/23 and 04/25/23 campus wide, per reviewing the staff sign in sheets, only two of the 17 identified memory care staff were present during these trainings.

On 08/04/23 at 10:30 am, Staff 1 (ED) confirmed there was no system in place to ensure all memory care staff were trained in fire and life safety if they had not attended the all-staff trainings.

The need to ensure fire drills and fire and life safety training was conducted per the rules was reviewed with Staff 1 on 08/04/23. She acknowledged the findings.

C420 - Fire and Life Safety: Safety

oThe Director of Plant Operations and/or designee will run fire drills in memory care every other month to ensure the facility is meeting the requirements set form in the relevant OARs.

oThe Director of Plant Operations and/or designee will run fire and life safety trainings every other month for all memory care employees (alternating on month's where the fire drills didn't happen). Employee attendance will be tracked and logged. The Administrator and/or designee will ensure all memory care staff attend these trainings or are trained later to make up for any missed group trainings.

oThe Director of Plant Operations or designee in collaboration with the Administrator or designee will do a monthly audit to ensure all memory care employees have attended a fire drill and/or attended a fire and life safety training each month.

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months. This is a repeat citation. Findings include, but are not limited to:

Fire drill and fire and life safety training records from 10/03/23 through 12/26/23 were requested. Review of the records provided identified the following:

In interview on 12/28/23 Staff 2 (Administrator) stated the system for providing life safety instruction was to have MCC staff attend a meeting on the ALF side of the building.

Review of the life safety instruction records showed on 11/02/23 and 11/03/23 an employee town hall meeting was conducted and included information about fire drills. Review of the sign in sheet revealed no staff from MCC had attended the meeting.

In interview on 12/28/23 with Staff 2 (Administrator) and Staff 4 (Memory Care Administrator) they acknowledged there was no system in place to ensure memory care staff were trained in fire and life safety if they did not attend the employee town hall meeting.

The need to ensure fire and life safety training was conducted and documented per Oregon Administrative Rules for all MCC staff was reviewed with Staff 2 (Administrator) and Staff 4 (Memory Care Administrator) on 12/28/23. They acknowledged the findings.

C 420 - Fire and Life Safety -

The Director of Plant Operations and/or designee will run fire drills in memory care every month (even months) to ensure the facility is meeting the requirements set forth in the relevant OARs. Our online maintenace system will trigger these drills on the appropriate months.

The Director of Plant Operations and/or designee will run fire and life safety trainings every other month (odd months) for all memory care employees. Employee attendance will be tracked and logged. Our on-line maintenance system will trigger these drills on the appropriate months.

The Memory Care Administrator (MCA) and/or designee will ensure all memory care staff attend these trainings. If an employee is unable to attend the training, the MCA and/or designee will meet with that employee to go over the training and have them sign that they received the training and understand the content.The MCA or designee will ensure that all memory care staff have attended a fire and life safety training every other month.

As a monitoring plan, the MCA and Administrator have created a Teams channel to upload a calendar for training topics for the respective months that fire drills do not take place and to upload the staff sign in sheet. This will be updated after each training session, so that MCA and/or designee can update in real time.

Based on interview and record review, it was determined the facility failed 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. Findings include, but are not limited to:

On 08/04/23, Staff 1 (ED) was asked to explain the facility's process for providing fire safety training to residents upon admission and annually. Staff 1 stated that although there was a resident binder the facility provided campus wide to new admissions that included fire and life safety information, she did not know what the facility's process was to ensure residents who moved in to the memory care unit received the information. Staff 1 confirmed the facility was not providing annual training as required.

The need to ensure residents were trained in fire safety procedures upon admission and at least annually was reviewed with Staff 1 on 08/04/23. She acknowledged the findings.

C422 - Fire and Life Safety: Training for Residents

oThe Administrator and/or designee will immediately conduct and document a fire and life safety training for all current memory care residents and their family member/s to ensure everyone is up to date on their trainings. This will be documented on a new form and put in the resident medical record.

oUpon move in the Director of Community Relations and/or designee will provide a fire and life safety training for the new resident and their family member/s. This will be documented on a new form and put in the resident medical record.

oAnnually the Memory Care Coordinator and/or designee will provide all memory care residents and their family member/s with a fire and life safety trainnig. This will be documented on a form and put in each resident's medical record for documentation.

oFor a monitoring plan the Administrator and/or designee will conduct an annual audit to ensure that all annual trainings have been completed. Additionally, the Administrator and/or designee will audit each new move in to the memory care unit through the Move-In Checklist to ensure the fire and life safety training form has been filled out for all new residents.

Based on interview and record review, it was determined the facility failed 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. This is a repeat citation. Findings include, but are not limited to:

On 12/28/23, Staff 2 (Administrator) and Staff 4 (Memory Care Administrator) were asked to explain the facility's process for providing fire safety training to residents in the MCC upon admission and annually. They confirmed the facility was not yet providing and documenting annual instruction for residents as required.

The need to ensure residents were given instruction in fire safety procedures upon admission and annually, or evaluated and documented as unable to follow instructions, was reviewed with Staff 2 (Administrator) and Staff 4 (Memory Care Administrator) on 12/28/23. They acknowledged the findings.

C 422 - Fire and Life Safety; Training for Residents

MCA will provide training to residents, within 24 hours of admissopn and at least annually on general safety procedures, evacuation methods, responsibilities during fire drill and designated meeting places outside the building or within the fire safe area in the event of an actual fire. The MCA will assess all the memory care residents, including the two residents who were reviewed during the survey, to determine who can cognitively benefit from this training and who can follow direction. If a resident cannot follow direction and would not benefit from a fire and safety training, this will be documented in that resident's service plan. The MCA will  update each residents' service plan with this training if they are assessed as able to follow direction.

To monitor this annually, the date of these trainings will be listed on each resident's service plan so that annual trainings can be updated.

As a monitoring plan, the fire and life safety has been included in the move-in checklist so that each resident who moves into memory care can receive this training. The move-in checklists for all new memory care residents are reviewed daily in the Leadership Jump meetings. The Administrator and/or Executive Director or a designee attend the daily Jump meetings and will ensure the move-in checklists for all memory care residents are reviewed daily.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C420, C422, Z155, and Z164.

C 455 - Inspections and Investigation: Insp Interval

Refer to the corrective action plans for the following citations: C 420, C 422, Z155, and Z 164.

Based on observation and interview, it was determined the facility failed to ensure all exterior Residential Care Facility's (RCF) grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:

Observations of the outside secured courtyard on 08/02/23 and 08/04/23 revealed the following:

* A folding table was being stored in the courtyard;  

* Two dining room chairs, one in disrepair, were located in the courtyard; and

* Refuse from the raised gardening beds was laying beside a pathway.  

The secured courtyard was toured with Staff 1 (ED), Staff 2 (Administrator), Staff 4 (Memory Care Coordinator), and Staff 6 (Director of Plant Operations) on 08/04/2 at 10:12 am. They acknowledged the findings.

C510 - General Building Exterior

oThe Director of Plant Operations and/or designee  cleaned up all refuse in the outdoor courtyard immediately.

oThe Director of Plant Operations and/or designee placed a refuse container in the memory care garden for yard waste.

oAdministrator and/or designee will do a staff training in memory care with a sign in sheet to ensure the employees know they cannot put refuse or broken items out in the courtyards.

oThe Administrator, Porter, and/or Memory Care Coordinator will do daily rounds to ensure no refuse is put in the courtyards.

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exited the Residential Care Facility (RCF). Findings include, but are not limited to:

The facility was toured on 08/02/23. It was observed the door leading out to the secured courtyard did not have an operating system that would alert staff when a resident exited the building.

The need to ensure the facility provided an exit door alarm or other acceptable system to alert staff when residents exited the RCF was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 4 (Memory Care Coordinator), and Staff 6 (Director of Plant Operations) on 08/04/2 at 10:12 am. They acknowledged the findings.

C555 - Call Sys, Exit Dr Alarm, Phones, TV, or Cable

oThe Administrator installed functioning door alarms on both courtyard door and the front door of memory care.

oThe Administrator has ensured that our alarm monitoring software, CISCOR, is up and running on the computer in the memory care chart room. Additionally the Administrator has ensured that a functioning walkie talkie has been placed in the memory care kitchen so that care staff can hear the door alarms if anyone is going through either of these doors.

oThe Administrator or designee will train all memory care staff on the door alarm system and expectations on walkie talkie use.

oThe Administrator or designee will do a weekly check on all door alarms in memory care to ensure they are functioning properly.  

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 152, C 231, C 361, C 420, C 422, C 510, and C 555.

Z142 - Administration Compliance

oRefer to the corrective action plans for the following citations: C 152, C 231, C 361, C 420, C 422, C 510, and C 555.

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  C420 and C422.

Z 142 - Administration Compliance

Refer to the corrective action plans for the following citations:  C 420 and C 422.     

Based on interview and record review, it was determined the facility failed to have documented evidence of required demonstrated competency in assigned duties within 30 days of hire for 3 of 3 newly hired direct care staff (#s 8, 12, and 13), annual training including six hours related to dementia care topics for 1 of 2 long-term direct care staff (#7), and annual infection control training for 1 of 2 non-direct care staff (#15). Finding include, but are not limited to:

Staff training records were reviewed with Staff 1 (ED) on 08/04/23 and the following deficiencies were identified:

a. Staff 8 (MT), hired 06/08/23, Staff 12 (CG), hired 01/26/23, and Staff 13 (CG), hired 01/31/23, lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in the following required areas:

* Providing assistance with ADLs; and

* Conditions that required assessment, treatment, observation and reporting.

b. Staff 7 (MT), hired 07/07/14, 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.

c. Staff 15 (Life Enrichment Assistant), hired 09/21/16, lacked documented evidence of annual infection control training.  

The need to ensure all required training was completed was reviewed with Staff 1 and Staff 2 (Administrator) on 08/04/23. They acknowledged the findings.

Z155 - Staff Training Requirements

oThe Administrator or designee will ensure that Staff #8, #12, and #13, complete their competency checklists.

oThe Administrator or designee will ensure that Staff #7 completes all of their annual training, including six hours of dementia care topics.

oThe Director of Life Enrichment or designee will ensure that Staff #15 completes their annual infection control training.

oThe Administrator or designee will ensure our med tech and caregiver competency checklists include the following items:

o* Providing assistance with ADLs; and

o* Conditions that required assessment, treatment, observation and reporting.

oThe Administrator or designee will ensure all new memory care employees have a completed competency checklist within 30 days of hire.

oThe Administrator or designee will conduct a weekly audit and utilize the Pulse Report to report out compliance with this OAR on a weekly basis at the Jump Meeting.

oThe Administrator or designee will ensure all memory care staff complete all required monthly CEU trainings and meet their annual training hours requirement.

oThe Executive Director or designee will ensure all direct care and non-direct care employees complete their annual infection control training.

oThe Administrator or designee will conduct an audit each month by the 25th to ensure all memory care employees have completed their monthly CEU trainings. The audit results will be reported in the Jump Meeting via the Pulse Report. By completing this audit by the 25th of the month the Administrator or designee can catch anyone who hasn't completed their CEUs and ensure they complete them by the end of each month.

Based on interview and record review, it was determined the facility failed to complete required pre-service orientation prior to beginning their job responsibilities, for 1 of 3 newly hired staff (#19), have documented evidence of required pre-service dementia training completed for 2 of 3 newly hired staff (#s 18 and 19) and demonstrated competency in assigned duties within 30 days of hire for 2 of 3 newly hired direct care staff (#s 17 and 19). This is a repeat citation. Findings include, but are not limited to:

On 12/27/23, training records were reviewed with Staff 2 (Administrator) and Staff  20 (Business Office Manager). The following deficiencies were identified.

1. Staff 19 (CG), hired on 11/03/23, failed to complete required infectious disease prevention prior to beginning her job responsibilities.

2. Staff 18 (CG) and Staff 19 (CG), hired on 10/31/23 and 11/03/23, identified the following.

a. Staff 18 lacked documentation in the following areas:

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

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

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

b. Staff 19 failed to complete the following required areas prior to beginning her job responsibilities:

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

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

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food and fluids, preventing wandering, and use of person-centered approach;

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

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

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

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

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

3. Staff 17 (MT) and Staff 19 (CG), hired on 11/21/23 and 11/03/23, lacked documented evidence of competency demonstration within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care;

* 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.

Additionally, Staff 19 lacked documentation the following:

* Providing assistance with ADLs.

The need to ensure newly-hired staff completed all required training prior to beginning their job duties and documented methods to determine competency of direct care staff were reviewed with Staff 2 and Staff 20 on 12/27/23. They acknowledged the findings.

Z 155 - Staff Training Requirements

The Assistant Resident Service Coordinator (ARSC) and/or designee is actively working with direct care staff  to complete required pre-service trainings.

The Administrator confirmed that Staff #19 completed their pre-service orientation, including, but not limited to, their infectious disease prevention training on 11/1/2023.

The Administrator confirmed that Staff #s 18 and 19 have their pre-service dementa training completed as of 10/28/2023 and 11/1/2023, respectively. The ARSC and/or designee will ensure Staff #19 complete their competency checklist.

Staff #17 has already completed all trainings and their competency checklist.

As a monitoring plan, the ARSC and Administrator will meet weekly to discuss current training deficiencies.

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, C 270, C 303, C 310, and C 330.

Z162 - Compliance with Rules Health Care

oRefer to the corrective action plans for the following citations: C 260, C 270, C 303, C 310, and C 330.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans and provide a meaningful activity program for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behavioral disturbance, anxiety, depression, and muscle contracture. The resident was identified as being bed bound and not wanting to leave his/her room.   

Although there was some information related to activities Resident 1 may want to participate in, the documentation lacked the following components:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

Resident 1's 05/12/23 service plan identified cooking, exercise, music, reading the newspaper, watching television, and walking for his/her preferred hobbies and interests.

Per interview with Staff 11 (CG) on 08/04/23 at 9:52 am, the resident did not have a television in his/her room, had no interest in leaving their room, preferred the "blinds down," and would tell staff, "don't leave the door open."

There were no observations made of staff inviting Resident 1 to any of the facility's activities or going in to the resident's room to visit.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including unspecified dementia.

Although there was some information related to Resident 2's current interests, the documentation lacked the following components:  

* Past interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

On 08/04/23 at 10:58 am, Staff 10 (CG) confirmed Resident 2's current interests as well as his/her ability to let staff know which television channel s/he prefers.

Observations of the resident during the survey were of him/her in a recliner watching television in his/her room with daily visits from family.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Memory Care Coordinator), and Staff 5 (LPN) on 08/04/23. They acknowledged the findings.   

Z164 - Activities

oThe Director of Life Enrichment has a new activities assessment form that will be used for all memory care residents. This form will also be used for all new residents who move into memory care moving forward.

oThe Director of Life Enrichment or designee will complete an activities assessment for all memory care residents immediately and share the completed assessments with the care staff in memory care. A hard copy of the assessment will be placed in the medical record for each memory resident.

oFor a monitoring plan the Director of Life Enrichment and/or designee will ensure that an activities assessments are completed for all new memory care residents by adding a new item to the facility's "Move-In Checklist", which is reviewed daily in the Jump Meeting.

Based on observation, interview, and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 2 sampled residents (#s 2 and 3) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Residents 2 was admitted to the facility in 06/2023 with diagnoses including unspecified dementia.

Review of the service plan dated 11/22/23 showed information related to Resident 2's past interests, however, the documentation lacked the following components:  

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

On 12/27/23, Staff 21 and 22 (Life Enrichment) were interviewed and confirmed there were no individual activity evaluations or plans.

Observations of Resident 2 during the survey were of him/her in a recliner watching television in his/her room.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 2 (Administrator) and Staff 4 (Memory Care Coordinator) on 12/28/23. They acknowledged the findings.

2. Resident 3 was admitted in 11/2021 with diagnoses including dementia.

Review of Resident 3's service plan showed it lacked the following components:  

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

On 12/27/23, Staff 21 and 22 were interviewed and confirmed there were no individual activity evaluations or plans.  

In interview on 12/28/23, Staff 23 (Life Enrichment Director) confirmed individual evaluations had not been completed for the residents in the MCC.

Observations of Resident 3 during the survey were of him/her seated in their room or the dining room, not engaged in activities.

The lack of an activity evaluation and individualized activity plan was discussed with  Staff 2 (Administrator) and Staff 4 (Memory Care Coordinator) on 12/28/23. They acknowledged the findings.

Z 164 - Life Enrichment

The Administrator will work with the Director of Life enrichment to enhance the current activities assessment for to be used for all memory care residents. This form will also be used for all new memory care residents who move into memory care moving forward.

The Director of Life Enrichment and/or designee will complete an activities assessment for resident #2 and #3 and all existing memory care resident using the enhanced form and share the completed assessments with the care staff in memory care. A hard copy of the assessment will be placed in the medical record for each memory care resident.

For a monitoring plan, the Director of Life Enrichment and Administrator or designee will ensure that an activities assessment is completed for all new memory care residents by adding a new item to the facility's "New Move-In Checklist", which is reviewed daily in the Leadership Jump Meetings.

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The outdoor secured courtyard was toured on 08/02/23 at 9:52 am and the following was observed:

* A wicker couch;

* A wicker love seat;

* A bench; and

* Four chairs.

Residents had free access to the secured courtyard. The above mentioned outdoor furniture  was easily movable, thus not of sufficient weight to prevent injury or elopement.

The secured courtyard was toured on 08/04/23 at 10:12 am with Staff 1 (ED), Staff 2 (Administrator), Staff 4 (Memory Care Coordinator), and Staff 6 (Director of Plant Operations) on 08/04/2 at 10:12 am. They acknowledged the findings.

Z173 - Secure Outdoor Recreation Area

oThe Director of Plant Operations and/or designee will ensure that all furniture and/or climbable objects that are within six feet of the fence have been removed.

o        The Director of Plant Operations or designee will ensure that all furniture is secured in place and at least six feet from the fence.

oThe Director of Plant Operations and/or designee will do daily rounds in the memory care courtyard to ensure that all furniture is at least six feet from the fence and secured in place.