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The findings of the re-licensure survey, conducted 11/06/23 through 11/08/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 11/08/23, conducted 06/11/24 through 06/12/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 11/08/23, conducted on 08/15/24, 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, 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 investigate incidents and/or injuries of unknown cause to rule out abuse, document all required areas of an investigation, and report to the local SPD office if abuse or neglect could not be ruled out for 1 of 1 sampled resident (#2) with incidents and/or injuries of unknown cause. Findings include, but are not limited to:

Resident 2 moved into the facility in 11/2022 with diagnoses including cerebral infarction. Resident 2 required a wheelchair for mobility.

Observations of the resident and staff interviews on 11/06/23 and 11/07/23 revealed the resident required physical assistance with transfers and bathroom use.

Review of the resident's 07/28/23 service plan, temporary service plans, facility progress notes, and incident investigations was completed and revealed the following:

A progress note dated 11/01/23 noted the resident had a "dark discoloration under both eyes and what looks like an open sore on upper lip, from unknown origin."

In an interview with Staff 3 (LPN) on 11/07/23 at 12:30 pm, she stated there was no documented evidence the incidents had been investigated at the time of the occurrence including all required components, nor was there evidence the occurrence had been reported to the local SPD office if abuse and/or neglect was not ruled out.  

At the request of the survey team, the above incident was reported to the local SPD office and confirmation was received.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out, and, if not, the injuries were reported to the local SPD office, was discussed with Staff 1 (ED) and Staff 3 on 11/07/23 and 11/08/23. They acknowledged the findings.

Nurse, ED or designee to review 24-hour progress notes, Tuesday-Friday, and report findings with health services team.  

Nurse, ED or designee to print and review 72-hour progress note Report each Monday with health services team.

Health service team to receive additional training on injuries of unknown origion and abuse reporting.

Abuse reporting line to be poosted in all medication rooms and employee lounge.

All new hires to be educated on location of hotline during general facility orientation.

Executive Director, Nurse or designee will monitor.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 moved into the facility in 05/2023 with diagnoses including diabetes.

The resident's new move-in evaluation was reviewed and there was no documented evidence the following elements were addressed:

* Customary routines including sleeping, eating and bathing;

* Physical health status including list of medications and PRN use and vital signs of indicated by diagnosis, health problems or medications;

* Mental health issues including presence of depression, thought disorders or behavioral or mood problems, history of treatment and effective non-drug interventions;

* Personality including how the person copes with change or challenging situations;

* Fall risk or history;

* History of dehydration or unexplained weight loss or gain;

* Elopement risk or history; and

* Environmental factors that impact the resident's behavior including noise, lighting, room temperature.

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED) on 11/08/23. She acknowledged the findings.

Health service team to be trained/retrained on correct use of service planning tool, which includes addressing residents' customary routines and preferences.

ED, Nurse or designee to monitor and review all new service plans weekly to ensure that evaluations are personalized and completed within specified timeline.

Designee to report any concerns to Executive Director

Will review resident 3 service plan for corrections.   

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 resident (# 6) who recently moved into the facility. This is a repeat citation. Findings include, but are not limited to:

Resident 6 moved into the facility in 05/2024 with diagnoses including dementia. The resident's move-in evaluation documentation dated 04/30/24 and 05/01/24 was reviewed and showed the following elements were not addressed:

* Customary routines, including sleeping, eating, and bathing;

* Personality, including how the person copes with change or challenging situations;

* Dental status;

* How the resident expresses pain or discomfort;

* History of dehydration or unexplained weight loss or gain; and

* Environmental factors that impact the resident's behavior including noise, lighting, room temperature.

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED), Staff 15 (Regional RN), Staff 2 (Assistant Health Services Director/LPN), and Staff 16 (Health Services Director/RN) on 06/12/24. They acknowledged the findings.

1.) The resident's assessment was updated and signed at time of re-survey

2.) The health service team to be trained on the UDA (user defined assessment) in the Point Click Care system, to ensure that all areas are captured.

3.) The Excutive Director or designee will review each new assessment and ensure that all sections are being completed.

4.) The Executive Director or designee will discuss any new assessments with the Health Service team once a week.   

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of the resident's current needs, provided clear direction to staff regarding the delivery of services, were reviewed quarterly, and were implemented for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2018 with diagnoses including multiple sclerosis.

On 11/06/23, the quarterly service plan provided by staff to the surveyor was dated 06/02/23. There was no evidence the service plan had been reviewed quarterly.

In an interview on 11/08/23 at 10:30 am, Staff 2 (RN) and Staff 3 (LPN) acknowledged the service plan had not been reviewed quarterly.

The need to ensure service plans were reviewed quarterly was reviewed with Staff 1 (ED) on 10/08/23. She acknowledged the findings.

2. Resident 4 was admitted to the facility in 2022 with diagnoses including dementia, hypertension, and congestive heart failure.

Review of the resident's current service plan, dated 04/04/23, revealed it had not been reviewed quarterly.

In an interview on 11/08/23 at 10:30 am, Staff 2 (RN) and Staff 3 (LPN) reviewed the record and acknowledged the service plan had not been reviewed quarterly.

The need to ensure service plans were reviewed quarterly was discussed with Staff 1 (ED) on 10/08/23. She acknowledged the findings.

3. Resident 2 moved into the facility in 11/2022 with diagnoses including cerebral infarction.

a. The resident's current quarterly evaluation was completed on 11/02/23 and there was no updated service plan based on the resident evaluation performed.

b. Resident 2's service plan, updated 07/28/23, temporary service plans and facility progress notes dated 08/02/23 through 11/07/23 were reviewed, interviews with care staff were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Personal hygiene assistance;

* Dressing assistance;

* Grooming assistance;

* Transfer assistance;

* Toileting assistance; and

* Pet care status.

The need to ensure service plans were reflective of the resident's care needs, provided clear caregiving instructions, were implemented, and were updated quarterly as required was discussed with Staff 1 (ED) on 11/08/23. She acknowledged the findings.

4. Resident 3 moved into the facility in 05/2023 with diagnoses including diabetes.

a. The resident's current quarterly evaluation was completed on 10/25/23, and there was no updated service plan based on the resident evaluation performed.

b. Resident 3's service plan, updated 05/22/23, temporary service plans and facility progress notes dated 08/01/23 through 11/08/23 were reviewed, interviews with the resident were conducted and observations were made.

The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Self-administered medications status; and

* Insulin management status.

The need to ensure service plans were reflective of the resident's care needs, provided clear caregiving instructions, and were updated quarterly as required was discussed with Staff 1 (ED) on 11/08/23. She acknowledged the findings.

All service plans will be updated quarterly and provide clear instructions to staff which identify residents' personal choices and needs for ADLs.

Nurse or designee will create and implement the use of an up-to-date service planning binder, accessible to all health service team members.

Health service team will read updated service plans and review any changes at daily shift-change meetings.

Nurse or designee to be responsible for monitoring and updating service plan binder weekly.

Nurse and ED to complete service planning training through Oregon Care Partners by Dec 15th :

"Service Plans for Assisted Living Facilities" and

"The Role of Service Plans"

Health Service team to discuss service plans due, at daily stand-up meeting (Monday-Friday).  

Residents 1,2, 3, and 4 service plans will be updated quarterly and reflect all componets of care, including diagnosises.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

Resident 1, 2 and 3's current service plans were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 11/08/23. They acknowledged the findings.

Resident 1, 2, and 3 will be reviewed by service planning team and resident-chosen representatives

All residents and any resident-chosen representatives will be invited to a coordination of care meeting with the ED, health services team and, if applicable, case managers, for any comprehnesive service plan reviews.

The Nurse or designee will monitor and schedule all meetings with care partners.

Service plan meetings will be reviewed at daily stand-up meetings (Monday-Friday)

Based on interview and record review, it was determined the facility failed to ensure 4 of  4 newly-hired staff (#s 7, 8, 9 and 10) completed all required pre-service orientation and 3 of 3 newly-hired direct care staff (#s 7, 8 and 9) completed dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records, reviewed with Staff 14 (Receptionist) on 11/07/23, revealed the following:

a. Staff 7 (MT), hired 11/04/23, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Infectious disease prevention training;

* Fire safety and emergency procedures; and

* Food handler's certificate.

In addition, Staff 7 lacked documented evidence of completing the following required pre-service dementia training prior to beginning job duties:

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms, including, but not limited to, reducing use of antipsychotics;

* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and

* Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach.

b. Staff 8 (PCA), hired 03/12/23, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Resident rights and values of CBC care;

* Fire safety and emergency procedures; and

* Food handler's certificate.

In addition, Staff 8 lacked documented evidence of completing the following required pre-service dementia training prior to beginning job duties:

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms, including, but not limited to, reducing use of antipsychotics;

* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and

* Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach.

c. Staff 9 (MT), hired 09/05/23, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Infectious disease prevention training;

* Fire safety and emergency protocols; and

* Food certificate.

In addition, Staff 9 lacked documented evidence of completing the following required pre-service dementia training prior to beginning job duties:

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms, including, but not limited to, reducing use of antipsychotics;

* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and

* Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach.

d. Staff 10 (Activity), hired 09/19/23, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Resident rights and values of CBC care;

* Infectious disease prevention training; and

* Fire safety and emergency protocols.

The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning job responsibilities was reviewed with Staff 1 (ED) and Staff 14 on 11/07/23 and 11/08/23. They acknowledged the findings.

Prior to providing care, staff will receive an orientation to residents and service plans.

Identified staff will complete training.

Prior to working with residents all staff will complete their Pre-service Dementia Training and Pre-service Infection Control training on Oregon Care Partners.

All staff will also attend a General Orientation with the Prestige Leadership Team which covers Resident Rights, the Value of community-based care, first aid, abdominal thrusts, Fire safety and Emergency protocols.

All staff will complete their Oregon Food Handlers card prior to handling food.

The Administrative Assistant or designee will oversee employee files and update Executive Director weekly on any missing or incomplete trainings.

All staff will be reviewed for compliance with Dementia Training and Infection control annually, through Oregon Care Partners.

Based on interview and record review, it was determined the facility failed to ensure newly-hired direct care staff demonstrated satisfactory performance in all required areas within the first 30 days of hire for 3 of 3 direct care staff (#s 8, 9 and 12). Findings include, but are not limited to:

Facility training records were reviewed with Staff 14 (Receptionist) on 11/07/23. The following was noted:

1. Staff 8 (PCA), hired 03/12/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation; and

* First aid, abdominal thrust.

2. Staff 9 (MT), hired 09/05/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation;

* First aid, abdominal thrust; and

* The ability to perform safe medication and treatment administration unsupervised.

The surveyor requested Staff 9 to be removed from the schedule as an MT until she had documentation of demonstrated satisfactory performance in all assigned job duties.

3. Staff 12 (MT), hired 08/11/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* The role of service plans in providing individualized resident care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* First aid, abdominal thrust;

* General food safety, serving and sanitation; and

* The ability to perform safe medication and treatment administration unsupervised.

The surveyor requested Staff 12 to be removed from the schedule as an MT until she had documentation of demonstrated satisfactory performance in all assigned job duties.

The need to ensure newly-hired direct care staff demonstrated satisfactory performance in all required areas within the first 30 days of hire was discussed with Staff 1 (ED) and Staff 14 on 11/07/23 and 11/08/23. They acknowledged the findings.

All current staff will complete competency checklist.

Direct Care staff will demonstrate competency in providing care duties within the first 30-days of hire. This will be made evidence by completion of Orientation and Competency Checklist.

Nurse or designee will oversee and sign-off completed checklists as well as provide additional training as needed.  

Based on interview and record review, it was determined the facility failed to ensure the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 3 long-term staff (#4) whose training records were reviewed. Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 14 (Receptionist) on 11/07/23. The following was noted:

Staff 4 (MT), hired on 11/05/03, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on hire date, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, of which at least six hours were related to dementia care.

The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training, was discussed with Staff 1 (ED) and Staff 14 on 11/07/23 and 11/08/23. They acknowledged the findings.

Will review all staff for annual Oregon Care partners training in Dementia and Infection control.

Nurse to review progress monthly with Executive Director.

Will use Healthcare Acadamy for monthly continuing education

Based on interview and record review, it was determined the facility failed to include required components on fire drill records, and failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records dated 05/2023 through 10/2023 were reviewed and revealed the following:

* Fire drill records lacked the following components:

- Location of simulated fire;

- Escape route used; and

- Problems encountered and comments related to residents who resisted or failed to participate in the drills.

* Fire and life safety instruction was not consistently provided to staff on alternate months.

The requirements regarding fire drills and fire/life safety instruction for staff were reviewed with Staff 6 (Maintenance) on 11/07/23 and Staff 1 (ED) on 11/08/23. The findings were acknowledged. No further information was provided.

All fire drills will be conducted by the Maintenance team or designee, as outlined in Oregon Fire Codes.

On alternating months, the Maintenance team or designee will include fire and life safety training.

Maintenance team will report findings and completed trainings to ED monthly.  

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed during the survey. The following was lacking from the records:

* Documentation of fire and life safety training provided to residents within 24 hours of move-in; and

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed, at least annually, was reviewed with Staff 6 (Maintenance) on 11/07/23 and Staff 1 (ED) on 11/08/23. The findings were acknowledged. No further information was provided.

All new residents will receive Fire and Life Saftey Training as outlined in the Oregon Fire Codes.

All residents will be offered the opportunity to participate in annual Fire and Life Saftey Training.

Trainings will be conducted by the Mainteneance team or designee.

A Fire and Life saftey training schedule will be implemented by the Maintenance team and reviewed by the ED or designee bi-monthly.   

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 C252.

See 252

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

Observations of the facility from 11/06/23 through 11/08/23 revealed the following:

First Floor:

* Carpet in Room 106 entrance had brown stains; and

* Handrails near the nursing station and near mechanical room were gouged and splintered.

Second floor:

* Carpet in the hallway, near Rooms 201, 203, 204, 254, 256, 260, 261, elevator area and staff lounge had black and brown stains;

* Handrails throughout the second floor were splintered; and

* Windows were covered with spider webs and dead insects.

Third floor:

* Rooms 358 and 361 entrance doors and doorframes were gouged, splintered and had peeling paint;

* Handrails throughout the third floor were splintered;

* Carpet near the elevator and Rooms 301 and 305 had dark brown stains;

* The laundry room had a layer of dust behind of the dryers; and

* Windows were covered with spider webs and dead insects.

On 11/08/23, the surveyor toured the facility with Staff 6 (Maintenance) and reviewed the above findings with Staff 1 (ED). They acknowledged the above areas needed to be cleaned and/or repaired.

All interior and exterior surfaces will be kept clean and in good repair.

All alreas of concern will be addressed and on-going will be kept clean and in good repair.

Maintenance team or designee will walk the community weekly and report any areas of concern to ED.

The Maintenance team or designee will monitor weekly and report any deficiences or areas of concern to the ED.