Print Inspection: J4OL

The findings of the re-licensure survey conducted 08/01/22 through 08/03/22 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 C refer to the Residential Care and Assisted Living Facilities 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 revisit to the re-licensure survey of 08/03/22, conducted 05/02/23 through 05/04/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 resident service plans were accurate, reflective of the resident's needs and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2019 with a history of falls and a diagnosis of dementia.

Observations of the resident, interviews with staff on 08/01/22 through 08/03/22, and a review of the current service plan dated 07/11/22 indicated the service plan was not reflective of the resident's care needs and lacked clear instructions to staff in the following areas:

* Mental health status, including effective non-drug interventions;

* Level of assistance needed with ADLs;

* Assistance with transfers;

* Decrease in mobility and use of wheelchair;

* Eating status and interventions;

* Pain areas and non-pharmaceutical interventions; and

* Recent falls and interventions.

The need to ensure service plans were reflective of residents' current needs and provided specific instruction to staff was discussed with Staff 1 (Executive Director) and Staff 3 (Memory Care Director) on 08/03/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 05/2022 with diagnoses including congestive heart failure, Alzheimer's/dementia, depression and chronic pain.

Review of Resident 3's service plan, dated 07/11/22, 07/2022 MAR, progress notes dated 05/01/22 through 08/01/22, and interviews with staff identified inaccuracies in the following areas:

* The service plan stated the resident had "no active depression," yet depression was listed under his/her diagnoses, and he/she takes prescribed medication for depression;

* During the acuity interview, Staff 5 (RN) stated the resident often refused bathing and daily weights; however, the resident's current service plan indicated the resident was "not resistant to care";

* The service plan stated Resident 3 "did not require frequent PRN medications" and "had no pain issues that were managed by medications." However, the resident's MAR listed numerous PRN pain medication doses administered; and

* The service plan stated Resident 3 had "no wound or skin issues." In the acuity interview, Staff 5 stated the resident had a current skin rash which was being monitored and progress notes showed "alert charting" for the rash.

On 08/03/22 the need to ensure service plans were updated as needed to accurately reflect residents' current status and to provide clear instructions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Regional Director of Operations) and Staff 3 (Memory Care Director). They acknowledged the findings.

Care needs for sampled residents #1 & #3 have been reviewed and service plans updated for any noted missing information.  A review of the remaining residents service plans will be completed to verify accuracy.

Training on the service planning process and use of Temporary Care Plans has been provided to the new Memory Care Director to assure understanding of purpose and process for use.  Development if the initial and ongoing service plans will include a review of resident current care needs as well as any behavior patterns such as refusals of care to assure information is present for staff reference. MCD will conduct reviews daily on days worked of progress notes and occurrence related documents to identify for needed TCP's or service plan updates.

Daily review of progress notes & SP routine of initial, 30 day and 90 day or with a significant change of condition

Memory Care Director with oversight from Executive Director

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition monitored, for 2 of 3 sampled residents who experienced short-term changes of condition (#s 1 and 2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2022 with a diagnosis of dementia and fall risk.

Review of Resident 2's service plan, dated 07/27/22, and progress notes, dated 07/07/22 through 08/01/22, revealed the resident experienced short-term changes without documented monitoring at least weekly until resolution in the following areas:

* Multiple falls;

* Skin tear;

* New medications; and

* Fracture of right clavicle.

The need to ensure changes of condition were evaluated, had documentation to reflect monitoring to resolution at least weekly and clear, resident-specific directions were provided to staff was discussed with Staff 1 (Executive Director), Staff 2 (Regional Director of Operations), Staff 3 (Memory Care Director) and Staff 5 (RN). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2019 with diagnoses including dementia.  

Observations of the resident, interviews with staff, review of the resident's 07/11/22 service plan, 05/10/22 through 08/01/22 charting notes, and incident reports were completed. The resident experienced multiple short-term changes of condition in the following areas:

* Injury and non-injury falls;

* Bruises and skin conditions;

* Emergency room visits; and

* Increased emotional stress.

There was no documented evidence the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored and documented on the progress of the condition at least weekly until resolved.

On 08/03/22, the above information and compliance guidelines for changes of condition and monitoring were discussed with and provided to Staff 1 (Executive Director) and Staff 3 (Memory Care Director).

1) Resident #2 has since passed away. Resident # 1 has been reassessed and change of condition assesment notes placed in progress notes as of 8/3/22.  A review of resident progress notes for the last 14 days was completed to verify completion of change of condition assessment and monitoring as applicable.

2)  Re-education will be provided to MT staff on the alert charting process.  New MCD has received training on the community's alert charting process to asure understanding and role driven oversight.  Progress notes and resident occurrent related documentation will be reviewed routinely to assure assessments notes are present as applicable and staff monitoring notes are present while resident is on active alert.

3)  Progress notes and occurrence related documentation will be reviewed daily.  ED will verify completion of noted audits during weekly meetings with MCD and nurse.

4)  MCD, Nurse and ED  

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 2 of 2 sampled residents (#s 1, and 2) reviewed for significant changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia and fall risk.

Review of progress notes dated 07/07/22 through 08/01/22 revealed the following:

Resident 2 fell on 07/19/22 and was sent to the ER for complaint of pain in his/her right arm. Resident 2 was diagnosed with a fracture of his/her right clavicle.

In an interview with Staff 5 (RN) on 08/02/22, she revealed she was unaware Resident 2 experienced a fall with a fracture, and she had not completed an RN assessment for a significant change of condition.

The need to ensure the facility RN conducted an RN assessment after a significant change of condition was discussed with Staff 1 (Executive Director), Staff 2 (Regional Director of Operations), Staff 3 (Memory Care Director and Staff 5. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2019 with diagnoses including dementia and depression.

Review of the resident's clinical records identified that on 07/12/22, Resident 1 experienced a fall which resulted in a head injury which required staples. The record indicated after the fall, the resident had experienced a steady decline in his/her health and an increased need for assistance with all ADLs.

Observations of the resident from 08/01/22 to 08/03/22 revealed the resident was in a wheelchair and staff provided assistance for all transfers and wheelchair mobility.

During the survey, Staff 9 (CG) reported that prior to the fall, the resident did not use a wheelchair and was able to walk independently with his/her cane. Since the fall, Staff 9 stated the resident was no longer walking and required additional staff assistance for toileting and transfers.

Resident 1's changes represented a significant change of condition, for which an RN assessment was required. There was no documented evidence the RN assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

On 08/02/22, Staff 5 (RN) confirmed she had not completed an RN assessment for the resident's overall decline in ADLs and mobility.

The need to complete an RN assessment when residents' experienced a significant change of condition was discussed with Staff 1 (Executive Director) and Staff 3 (Memory Care Director)  on 08/03/22. They acknowledged the findings.

Resident #2 has since passed away.  Resident #1 has been reassessed by the nurse and assessment notes are present in the chart as of 8/3/22.

A review of resident progress notes for the last 14 days was completed to identify residents with significant changes in condition and verify completion of an RN assessment.

2)  New MCD has received training on current regulations and associated community policy regarding change of condition and monitoring to asure understanding and role driven oversight.  Progress notes and resident occurrent related documentation will be reviewed routinely to assure RN assessments notes are present as applicable.

3)  Progress notes and occurrence related documentation will be reviewed daily.  ED will verify completion of noted audits during weekly meetings with MCD and Nurse.

4)  MCD, Nurse and ED   

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

Review of facility records on 08/02/22 identified the following deficiencies:

* There was no documented evidence fire drills were conducted every other month as required; and

* There was no documented evidence fire and life safety instruction was provided to staff on alternating months.

On 08/03/22 the need to conduct regular fire drills, and to provide fire and life safety instruction to staff in accordance with the OFC, was discussed with Staff 1 (Executive Director), Staff 2 (Regional Director of Operations) and Staff 3 (Memory Care Director). They acknowledged the findings.

Next fire drill is scheduled for:_8/24/22__________________

ED and Maintenance Director have reinstituted a rotating calendar to follow to assure drills and trainings are provided consistently and on a rotating schedule.

Fire Drill andTrainings will be audited monthly to assure compliance.  

ED and Maintenance Director   

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to residents at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 08/02/22 identified the following deficiency:

* There was no documented evidence annual training on fire safety was provided to residents.

On 08/03/22 the need to provide and document fire and life safety instruction for residents at least annually, in accordance with the OFC, was discussed with Staff 1 (Executive Director), Staff 2 (Regional Director of Operations) and Staff 3 (Memory Care Director). They acknowledged the findings.

Training scheduled for residents on _8/25/22______________

ED and Maintenance Director have added the annual resident training to the Fire Drill/Training calendar for tracking.

Resident annual training will be audited monthly to oversee ongoing compliance.

ED and Maintenance Director  

Based on observation, interview and record review, it was determined the facility failed to ensure compliance with non-health care related Residential Care and Assisted Living regulations. Findings include, but are not limited to:

Refer to C420 and C422.

Please see individual POCs for C420 & C422

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly-hired direct care staff (#s 8 and 10) completed all required pre-service training prior to providing direct care to residents, 3 of 3 staff (#s 8, 10 and 11) had demonstrated competency in all required areas within 30 days of hire, and 2 of 2 sampled long-term direct care staff (#s 7 and 12) completed a total of 16 hours of in-service training annually, including six hours of dementia care training. Findings include, but are not limited to:

Training records were reviewed on 08/03/22. The following deficiencies were identified:

1. There was no documented evidence Staff 8 (CG), hired on 04/21/22, and Staff 10 (CG), hired on 05/24/22, completed the following pre-service training requirements within 30 days of hire:

* 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 persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia, including addressing pain, providing food/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 in the resident's condition and report behaviors that required 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.

2. Staff 11 (Med Aide) was hired on 06/16/22. There was no documented evidence that Staff 8, Staff 10 and Staff 11 demonstrated competency in their job duties within 30 days of hire in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

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

There was no documented evidence that Staff 11 demonstrated competency in medication and treatment administration. In addition, there was no documented evidence five remaining Med Aides had demonstrated competency in medication and treatment administration. Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations) were requested to ensure training of Med Aides prior to their next scheduled shifts.

3. Staff 7 (CG) was hired on 10/18/20, and Staff 12 (Med Aide) was hired on 03/04/20. Training records lacked documented evidence 16 hours of annual training related to provision of care, which included six hours of dementia care, was completed.

The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 and Staff 2 on 08/03/22. They acknowledged the findings.

Staff #8 & #10 have completed the Pre-Service Dementia training and documentation is housed in the Orientation and Training Binder.

Required pre-service training topics required in the initial 30 days post hire has been provided to Staff #8, #10 & #11 as of ____9/15/22________.  Memory Care Training skills check list is present in Orientation and Training binder.

Annual inservice hours for Staff #7 & #12 will completed by 9/3/22.  

An audit of all remaining staff providing care to residents with dementia have had their training files audited to verify complaince.  

Audits will continue upon completion of the initial training process and at least twice monthly thereafter to oversee ongoing complaince.

ED or Designee

Based on observation, interview and record review, it was determined the facility failed to provide healthcare services in accordance with OARs 411 Division 54 for Assisted Living and Residential Care Facilities. Findings include, but are not limited to:

Refer to C260, C270 and C280.

Refer to individual POC for C260, C270 & C280

Based on interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 1 of 3 sampled residents (#1) residing in the MCC. Findings include, but are not limited to:

Residents 1's current service plan was reviewed during survey. The service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Executive Director) and Staff 3 (Memory Care Director) on 08/03/22. They acknowledged the findings.

Service plan for Resident #1 has been updated with an individualized nutrition and hydration plan.  An audit of remaining resident service plans will be conducted to verify presence of individualized nutrition and hydration plans.

New MCD has received training on the service planning process to assure understanding of content for this area.  

Service plans will be reviewed/updated initially, every 90 days or with a change in condition to assure service plans remain an accurate reflection of trends/needs.

Resident progress note documentation will be reviewed routinely (daily) to identify any changes in between formal SP review/updates.

MCD, Nurse and ED  

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 1 of 3 sampled residents (# 1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1's service plan offered some information relating to the resident's past interests; however, the facility had not thoroughly evaluated the resident's:

* 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.

Observations of the resident from 08/01/22 through 08/03/22 revealed the resident sitting in his/her wheelchair alone for extended periods, without consistent interaction or engagement from staff.

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.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Executive Director) and Staff 3 (Memory Care Director) on 08/03/22. They acknowledged the findings.

Service plan for Resident #1 has been updated with an individualized activity plan.  An audit of remaining resident service plans will be conducted to verify presence of individualized activity plans.

New MCD has received training on the service planning process to assure understanding of expected content in this area.  

Service plans will be reviewed/updated initially, every 90 days or with a change in condition to assure service plans remain an accurate reflection of trends/needs. Resident progress note documentation will be reviewed routinely (daily) to identify any changes in between formal SP review/updates.

MCD, Nurse and ED