Print Inspection: KHJO

The findings of the re-licensure survey, conducted 01/03/22 through 01/04/22 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

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 revisit to the re-licensure survey of 01/04/22, conducted 04/04/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause and document the injuries were not the result of abuse or report the injury to the local SPD office as suspected abuse, for 1 of 1 sampled resident (# 3) with an injury of unknown cause. Findings include, but are not limited to:

Resident 3 was admitted to the Memory Care Community in 10/2021.

Progress notes, dated 12/27/21 identified a bruise to the resident's right side of his/her body measuring approximately two inches long by one inch wide.

There was no documented evidence the facility either investigated the injury and documented it was not the result of abuse or that the facility reported the injury to the local SPD office as suspected abuse.

During an interview on 1/03/22, Staff 1 (Administrator) stated she was not aware of the injury and no incident report had been completed. She acknowledged the facility did not conduct an investigation of the injury nor report the injury to the local SPD office.

On 01/03/22, Staff 1 was asked to report the injury of unknown cause to the local SPD office. On 01/04/22, the facility provided documentation to the surveyor that the incident had been reported.

1) Both incidents have been reported to APS and investigated to rule out abuse or neglect.

2) Staff will be inserviced regarding the importance of filling out incident reports. All injuries of unknown origin will be reported to APS and investigated.

3) Chart notes will be reviewed weekly by IDT team to identify potential issues.

4) Administrator or designee will responsible to monitor ongoing compliance.

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

Resident 3 was admitted to the facility in 10/2021 with diagnoses including dementia and traumatic brain injury.

A review of Resident 3's move-in evaluation, dated 10/08/21, revealed the following required elements were not addressed:

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

* Environmental factors that impact the resident's behavior, including, but not limited to, noise, lighting and room temperature.

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator) on 01/04/22. She acknowledged the findings.

1) Missing elements of the Move-In evaluation will be added to Resident 3's service plan.

2) Move-In evaluation form will be updated to include required elements.

3) Prior to future move in's, evaluation wil be reviewed for accuracy.

4) Administrator or designee will be responsible to ensure ongoing compliance.

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

Residents 1's service plan, dated 11/10/21, was not reflective of the resident's current status and lacked clear direction to staff in the following areas:

* Bed mobility-two person assist;

* Ambulation limited to wheelchair with assistance;

* Bathing-two person assist;

* Dressing-two person assist;

* Grooming- two person assist;

* Hygiene- two person assist;

* Full assist for food and fluid intake; and

* Skin conditions.

The need to ensure residents service plans were reflective and provided directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 01/04/22. They acknowledged the findings.

1) Resident 1's service plan will be updated to reflect current status.

2) Service Planning Team will review each update to ensure service plans are reflective of current resident status. Staff will be inserviced regarding use of the ISP process to capture ongoing changes.

3) Audits will be conducted weekly for 3 months and reviewed with quarterly QAPI.

4) Administrator, RN, or designee will be responsible to ensure ongoing compliance.

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

1.  Resident 2 was admitted to the facility in February 2017 with diagnoses including stroke.

Observations of the resident, interviews with staff and review of the resident's 10/09/21 service plan, 09/01/21 through 01/02/22 progress notes, incident investigations and physician communications were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Witnessed and unwitnessed falls;

* Wound with drainage on the left foot;

* Scratches and irritation to the knee and ankle; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 01/04/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 08/2011 with diagnoses including dementia.

Clinical Records dated 10/03/21 through 01/03/22 which included progress notes, service plans, temporary service plans (TSP) and the resident's 12/01/21 through 01/03/22 MARs/TARs were reviewed.

The progress notes revealed the resident experienced the following short-term changes of condition:

* On 12/13/21, facility staff documented, "Resident appears to have a new bump on back of the neck. Will have RN advise." A carestaff noted the bump on the back of the resident's neck had grown larger and changed color.

* On 12/25/21, progress notes identified a skin condition to the right buttocks, "looks like the beginning stages of skin breakdown."

There was no documented evidence the facility completed an evaluation of the skin conditions, determined what actions or interventions were needed, communicated needs to staff, or monitored the condition at least weekly to resolution.

During an interview on 01/03/22, Staff 1 (Administrator) indicated there were no TSPs for the above changes of condition.

The need to evaluate and monitor short-term changes of condition at least weekly to resolution with clear direction to staff was discussed with Staff 1 and Staff 2 (RN) on 01/04/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 10/2021 with diagnoses including dementia.

Clinical Records dated 10/08/21 through 01/03/22 which included progress notes, service plans, temporary service plans (TSP) and the resident's 12/01/21 through 01/03/22 MARs/TARs were reviewed.

The progress notes identified the resident experienced the following short-term change of condition:

* On 11/20/21, the resident was found to have "redness/irritation to the buttocks."

There was no documented evidence the facility evaluated the skin condition and monitored it at least weekly to resolution.

During an interview on 01/03/22, Staff 1 (Administrator) indicated there were no TSPs for the above change of condition.

The need to evaluate and monitor short-term changes of condition at least weekly to resolution with clear direction to staff was discussed with Staff 1 and Staff 2 (RN) on 01/04/22. They acknowledged the findings.

1) Residents 1, 2, and 3 have been assessed for short term change of condition.

2) RN will be informed of all skin issues and monitor weekly until resolved. RN will provide clear, resident specific direction to staff as short or long term change of condition occurs.

3) Weekly audits will be done for three months and brought to quarterly QAPI.

4) RN or designee will be responsible to ensure ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment which documented findings, resident status, determined interventions and updated the service plan for 1 of 1 sampled resident (#3) who experienced a significant weight change. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 10/2021 with diagnoses including dementia and traumatic brain injury.   

Weight records dated 10/10/21 to 01/01/22, progress and RN notes dated 10/08/21 through 01/03/22 were reviewed and revealed the resident experienced the following:

A 15.2 pound weight gain from 10/10/21 to 11/01/21. This constituted a 10.62% severe weight gain in one month. The resident's weights were monitored monthly and remained stable at between 158 pounds and 161 pounds from 11/2021 to 01/2022.

On 01/03/22 and 01/04/22, the resident transported him/herself to the dining room for meals and consumed 100% or his/her breakfast and two lunch meals.

The facility failed to ensure an RN assessment was completed for the severe weight gain with documented findings, interventions as indicated, and the service plan was updated to reflect the severe weight gain.

The need to ensure an RN assessment was completed related to significant changes in condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 01/04/22. The staff acknowledged the findings.

1) RN will assess Resident 3 for weight gain. Service plan will be updated to include weight gain.

2) All residents will be weighed no less than monthly, reweighed for gain or loss of 3 pounds, and reported to RN for assessment.

3) All resident weights will be reviewed at least monthly.

4) Administrator, RN, or designee will be responsible to ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits were maintained in the residents' records, and that recommendations were implemented for 1 of 1 sampled resident (#2) who were receiving home health services from outside providers. Findings include, but are not limited to:

Resident 2 was admitted to the facility in February 2017 with diagnoses including stroke.  

During the acuity interview on 01/03/22, Resident 2 was identified as receiving outside provider services related to skilled nursing for wound care.   

Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 10/04/21 through 01/03/22 were completed.

The resident was re-admitted to skilled nursing services on 10/04/21 for wound care to the left foot on a chronic wound which reopened. Skilled nursing was providing dressing changes and wound checks twice per week.  

Skilled nursing wound care visit notes were not consistently documented and/or recommendations were not implemented as follows:

* Home health wound care notes were documented only once per week on six occasions;

* No home health wound care notes were documented for the week of 11/29/21, 12/6/21 and 12/27/21; and

* A skilled nursing recommendation on 12/20/21 instructed staff to remind the resident to elevate his/her legs.

There was no evidence the recommendations were implemented and/or communicated to staff.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 01/04/22. They acknowledged the findings.

1) Resident 1's Home Health Visit notes have been reviewed. Identified recommendation has been added to the resident's service plan.

2) Home Health Providers have been instructed to leave visit documentation at every visit. Staff will be inserviced regarding using the ISP process to communicate outside providers recommendations and instructions.

3) Weekly audits will be conducted for 3 months and intermittently thereafter and brought to quarterly QAPI.

4) RN, Administrator or designee will be responsible to ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure signed physicians orders were in place for all treatments administered to a resident for 1 of 3 sampled residents (#2) whose MARs/TARs were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in February 2017 with diagnoses including stroke.

Review of the resident's 09/01/21 through 01/03/22 progress notes, 11/10/21 physician orders and the 11/01/21 through 01/03/22 MARs/TARs showed the following:

* A progress note dated 12/30/21 indicated the wound on the left foot was oozing out of the dressing with a foul smell. Home health was unreachable so medication technician staff "cleaned the wound and the wound dressing was changed." There was no other information regarding the specific dressing change that was completed.

There were no signed physician orders for any dressing changes or treatments for the resident's foot. Home health notes provided no specific dressing change and treatment instructions for the facility's use.

In an interview on 01/4/22, Staff 2 (RN) indicated no orders were obtained for the treatment of the wound if home health was unavailable and the dressing became soiled or loose. Staff 2 stated she was not notified of the wound draining or the need for a dressing change prior to the treatment being completed.

The need to ensure the facility had orders for all treatments administered was discussed with Staff 1 (Administrator) and Staff 2 on 01/04/22. They acknowledged the findings.

1) Dressing change and treatment orders including instructions should the dressing become soiled or loose have been obtained.

2) All residents will be reviewed to ensure signed treatment orders are in place.

3) Intermittent audits will be conducted for existing treatments, and all treatments will be monitored on acuity board.

4) RN/Administrator will be responsible to ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire drill records for July 2021 through December 2021 were reviewed during survey.

The following required components were not documented in the fire drill records:

* The escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

The need to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC) was discussed with Staff 1 (Administrator) on 01/03/22. She acknowledged the findings.

1) Staff conducting fire drills will be inserviced regarding the required elements and documentation for a fire drill.

2) Fire drill form has been updated to include missing required elements.

3) Each fire drill will be reviewed by Administrator for accuracy and completeness.

4) Administrator will be responsible to ensure ongoing compliance.

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

Observations of the facility on 01/03/22 revealed the following areas in need of cleaning or repair:

* Chipped paint on cabinets in the kitchen;

* Numerous dining room chairs had large tears with dangling pieces of vinyl along the armrests, backs and seats, with exposed fabric and/or stuffing;

* Multiple closed floor vents in the halls and near the common area had dirt and debris;

* Chairs in the entry way and common area had rips, debris and/or spillage along the sides and seats;

* Large scrapes, dings and black marks were observed on walls in the dining room and living room;

* Resident Rooms 5, 6, 9, 10, 12, 15 and 16 had dark carpet stains of varying sizes near the doorways and beds; and

* Resident 1's wheelchair armrest was severely torn with exposed foam.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 01/03/22. She acknowledged the findings.

1) Identified environmental issues will be remedied by Environmental Services Director.

2) Staff will be inserviced on timely and proper use of Maintenance Request System. Maintenance team will add identified areas to monthly maintence rounds.

3) Environmental rounds will be conducted with Maintenance team and Administrator weekly.

4) Environmental Services Director/Administrator will be responsible to ensure ongoing compliance.

Based on 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 231, C 420 and C 513.

Refer to C231, C240, C420 and C513

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 252, C 260, C 270, C 280, C 290 and C 303.

Refer to C252, C260, C270, C280, C290, AND C303

Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height. Findings include, but are not limited to:

A tour of the facility courtyard on 01/03/22 showed multiple sections of fencing around the perimeter of the secured outdoor area were less than six feet in height. The shortest sections were approximately 68 inches.

The fencing sections that were less than six feet in height were discussed with Staff 1 (Administrator) on 01/03/22. She acknowledged the findings.

1) All sections on exterior fence found to be less than six feet will be raised to a minimum of six feet.

2) Intermittent measuring of fence will occur to ensure fence stays at least six feet high.

3) Semi-Annual measuring of the fence will be added to routine maintenance rounds.

4) Environmental Services Director or designee will be responsible to ensure ongoing compliance.