Print Inspection: T2EQ

The findings of the re-licensure survey, conducted 8/30/21 through 9/1/21, 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 for 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

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 9/1/2021, conducted on 12/29/21, 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, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.

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 second revisit to the re-licensure survey of 9/1/2021, conducted on 3/1/2022, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

2.  Resident 5 was admitted to the facility in May 2021 with diagnoses including dementia with behavioral disturbance.

Review of the resident's progress notes from 6/11/21 through 8/30/21 noted on 6/14/21, Resident 5 was involved in a physical altercation with a non sampled resident. The incident was not thoroughly investigated and there was no documentation the incident was reported to the local SPD office.

In an interview with Staff 1 (ED) on 8/31/21, she acknowledged the altercation was not investigated thoroughly or reported to the local SPD office. On 9/1/21, Staff 1 provided documentation that she self reported the altercation to local SPD office.

The need to report resident to resident altercations to the local SPD office as suspected abuse was discussed with Staff 1, Staff 2 (RN) and Staff 3 (LPN) on 9/1/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure investigations of all incidents were thorough and complete and all incidents of suspected abuse were immediately reported to the local SPD office for 2 of 5 sampled residents (#s 4 and 5) reviewed with resident to resident altercations. Findings include, but are not limited to:

1.  Resident 4 was admitted to the facility in March 2021 with diagnoses including dementia with behavioral disturbance.

Review of the resident's progress notes from 6/7/21 through 8/30/21 noted on 6/27/21, Resident 4 had an altercation with a non sampled resident. The incident was investigated and the facility determined they were not able to rule out abuse and neglect. There was no documentation the incident was reported to the local SPD office.

In an interview with Staff 1 (ED) on 8/30/21, she acknowledged the altercation was not reported to the local SPD office. On 8/31/21, Staff 1 provided documentation that she self reported the altercation to local SPD office.

The need to report resident to resident altercations to the local SPD office as suspected abuse was discussed with Staff 1, Staff 2 (RN) and Staff 3 (LPN) on 9/1/21. They acknowledged the findings.

1. Executive Director will follow Rose Linn Vintage Place Policy on Reportable Events. The Executive Director or RN or designee will review all progress notes for the last 24 to 48 hours at daily Clinical Meeting and investigate anything that is charted that should have been an A/Incident report.

2. Incident reports will be reviewed within required time frame. APS/protective services offices will notified of any incident of abuse or suspected abuse that  occurs per state regulation.

3. The Executive Director or designee will report within 24 hours to APS. This includes resident to resident altercations, skin issues and wounds of unknown cause, any injuries of unknown cause.

4. Executive or designee are responsible for compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (#4) who experienced a significant change of condition related to weight loss. Findings include, but are not limited to:

Resident 4 was admitted to the facility in March 2021 with diagnoses including dementia with behavioral disturbance.

Weight records, dated 3/11/21 - 8/28/21, indicated Resident 4 experienced a 32 pound weight loss. This constituted a 14.54% total body weight loss in six months and represented a significant change of condition.

Review of Resident 4's physician orders indicated an order for supplemental shakes three times daily between meals was prescribed on 3/28/21 and a subsequent order for supplemental shakes was written on 8/16/21.

The most recent service plan, dated 7/28/21, indicated Resident 4 required escorts to the dining room for all meals and cueing throughout the meal. The service plan lacked instruction to staff regarding weight loss and instructions for supplemental shakes.   

During observations on 8/30/21,  Resident 4,  attended lunch meal with staff escort to the dining room and had occasional cueing throughout the meal.

During an interview on 9/1/21, Staff 2 (RN) confirmed she was aware of the weight loss however, there was no RN assessment completed and no further weight loss interventions were implemented related to Resident 4's weight loss.

The need to ensure an RN assessment was completed and included documented findings, resident status, interventions made as a result of the assessment and an update to the service plan for Resident 4's significant weight loss was discussed with Staff 1 (ED), Staff 2 and Staff 3 (LPN) on 9/1/21. They acknowledged the findings.

1. Resident 4s service plan updated with recent weight loss and interventions.

2. Change of condition training was completed with all staff meeting on 9/20/21 and reviewed with RN, RCM, RCC and ED in RLVP policy and procedure.

3. This will be reviewed daily at clinical meeting with progess notes, alert charting, TSP, "wisdom to act" notification on ipod from care staff and MTof any residents that are needing a short term change of condition to be discussed by RN, RCM, RCC, and ED to ensure that all resident Change of Condition is monitored to reflect care changes. RN or RCM will determine based on the information and observation of the resident if it is a Short-Term Change of Condition or a Long-Term Change of Condition. RN or RCM will record the resident's name on the self-audit form for either change of condition (Either Short Term or Long Term form) and begin following the items on the checklist for that particular change of condition.

4. Executive Director, RN or designee will be responsible for compliance.      

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed staff. Findings include, but are not limited to:

Delegation records for Resident 5, reviewed with Staff 2 (RN) on 8/31/21, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 7 (MT), Staff 8 (MT) and Staff 10 (MT) to include:

* Nursing assessment and condition of the client to determine if the client's condition was stable and predictable;

* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; and

* Frequency the client should be reassessed, including rationale.

The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 5 (Corporate RN) on 9/1/21. They acknowledged the findings.

1. Resident 5s RN failed to document all required componets of delegation in accordance with the OSBN. If the resident is stable or predictable before delegating the MT.

2. RN will assess whether the condition of the diabetic  resident is stable or predictable upon move in to the community and prior to delegating the Med tech.

Documentation of the assessment will be recorded in the resident chart.

2. RN to complete a diabetic assessment for all residents requiring delegation services prior to performing any delegation services. RN to determine if the resident is stable and predictable for the purpose of iniital delegation and continued to delegation.

3. The facility RN will complete a diabetic assessment upon admission, 30 days following admission, 90 fays following admission, then quarterly and if a significant change of condition should occur.

4. RN and ED responsbile for compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 5 sampled residents (# 5) whose medication records were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in May 2021 with diagnoses including diabetes and received insulin injections daily.

Resident 5 had physician's orders directing staff to administer:

* Humalog insulin 15 units subcutaneous three times a day with meals; and

* Lantus Solosar insulin 30 units subcutaneous twice a day.

Residents 5's 8/1 through 8/30/21 MAR and delegation records were reviewed.

On 8/1/21 and 8/2/21, Staff 13 (MT), initialed administration of  Humalog insulin at 5:00 pm and Lantus Solosar insulin at 5:30 pm.

On 8/7/21, Staff 11 (MT) initialed administration of the Humalog insulin at 5:00 pm and Lantus Solosar insulin at 5:30 pm.

There was no documented delegation for Staff 11 and 13 to administer insulin.

During an interview on 8/31/21, Staff 2 (RN) stated a MT that had been delegated administered insulin to Resident 5 when Staff 11 and 13 were working.  Staff 2 verified Staff 11 and 13 initialed administration of insulin that they had not administered.  

The need to ensure MARs were accurate was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN) and Staff 5 (Corporate RN). They acknowledged the findings.

1. Resident 5s RN delegations were held back for staff #11 and #13.

2. On September 15th, 2021 In-service Med Tech training was completed and discuss the survey findings. The Med Tech who administers the insulin will sign into the system under their user name when they are assisting other Med Tech with Insulin administration when the Med Tech completing the pass is not yet delegated to ensure MARs is accurate. RN will complete a RN delegation course with OSBN.

3. RN, RCM/RCC will provide MAR audits weekly to assure accuracy. Ongoing based quartely once the MAR's accurace is stable. RN delegations to be reviewed per RN delegatins based on what he/she decideds after residents is stable and able to delegate.

4. ED and RN will be responsible to ensure corrections are implemented and monitored.

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months of fire drills and fire drill records lacked documentation of all required components. Findings include, but are not limited to:

Fire and life safety records, reviewed between 3/24/21 and 8/30/21 revealed the following deficiencies:

1. Fire and life safety instruction was not provided to staff on alternating months of the fire drills; and

2. Fire drill records lacked the following components:

* Escape route used;

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

* Evacuation time period needed.

The need to provide fire and life safety instruction for staff on alternating months of fire drills and ensure all required components are documented on fire drill records was discussed with Staff 1 (ED) on 8/30/21. She acknowledged the findings.

1. Community need to provide fire and life safety instruction for staff on alternating months of fire drills and ensure all required components are documented on fire drill records.

2. Community will continue to conduct monthly fire, life and saftey training per Rose Linn Vintage Place Policy which is approved by the State to meet OARs. Staff will be trained at new hired and the following topics every other month. Elopement drill, Evacuation methods, Fire, smoke, bomb threat and explosion, Chemical sprill or leak, Pandemic, structual damage, prolonged power failure, water and sewer loss, Hurricane, tornado, tsunami, volcanic eruption, floor and earthquate. Staff will be interviewed and questioned outside of monthly training to ensure that all know and are aware of the safety escape route that is outline in our Fire Life and Safety plans.

3. This system will continue to be done monthly to ensure compliance and safety plan was being by staff. This will be monitored monthly.

4. This will be monitored monthly Maintenance Director and ED responsible for compliance.

Based on interview and record review, it was determined that the facility failed to

ensure fire drills were conducted according to Oregon Fire Code, and fire drill records contained all the required components. This is a repeat citation.  Findings include, but are not limited to:

Fire and safety records between 11-01-2021 and 12-28-2021 were provided by the facility. The following deficiencies were identified:

Fire drill records lacked documentation of following components:

* Escape route used;

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

Staff 1 (ED) was interviewed on 12/29/2021, she stated the facility had conducted a full evacuation drill and documented detailed information however, the facility was unable to locate the documentation and it was not provided.

The need to ensure all the required components were documented for all fire drills was discussed with Staff 1 (ED) and Staff 16 (RCF Maintenance) on 12/29/2021. They acknowledged the findings. No further information was provided.

C-420 1. Community need to provide fire and life safety instruction for staff on alternating months of fire drills and ensure all required components are documented on fire drill records.

2. Community will continue to conduct monthly fire, life and saftey training per Rose Linn Vintage Place Policy which is approved by the State to meet OARs. Staff will be trained at new hired and the following topics every other month. Elopement drill, Evacuation methods, Fire, smoke, bomb threat and explosion, Chemical sprill or leak, Pandemic, structual damage, prolonged power failure, water and sewer loss, Hurricane, tornado, tsunami, volcanic eruption, floor and earthquate. Staff will be interviewed and questioned outside of monthly training to ensure that all know and are aware of the safety escape route that is outline in our Fire Life and Safety plans.

3. This system will continue to be done monthly to ensure compliance and safety plan was being by staff. This will be monitored monthly.

4. This will be monitored monthly Maintenance Director and ED responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records, dated 3/2021-8/2021, were reviewed during the survey. The facility lacked documented evidence of the following:

* Alternating escape routes were used during fire drills;

* Evidence residents were being instructed on fire and life safety procedures within 24 hours of admission;

* Fire and life safety training for residents was held at least annually and included all required training topics: general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building;

* A written record of fire safety training, including content of the training sessions and the residents attending; and

* Documented evidence immediate changes were made to ensure the evacuation standards were met when the facility had identified residents who were unwilling to participate in the fire drills.

The requirements regarding general fire and life safety instruction for residents was reviewed with Staff 1 (ED) on 8/30/21. She acknowledged the findings.

1. Fire and life safety records, dated 3/21 - 8/21 lacked documentation required regardng the fire and life safety instructions in residents file was reviewd.  

2. Residents will be interviewed and questioned outisde of monthly training to ensure that all know and are aware of the safety escape route that is outlined in our Fire, Life and Safety plans. Map of the building with a evacuation route will be place on the back of the residents door.

3. The community will conduct two complete annual building evacuations identifing alternate escape routes. Document of problems encountered and comments relating to residents who resisted or failed to participate in the drill as well as the evacuation time period needed will be completed. Maintenance Director will discuss this process with new residents moving into the community within 24 hours and annually documention will be submit to the Executive Director for residents file.

This system will be reviewed monthly

4. Maintenance Director and Executive Director responsible for compliance.

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

Refer to C420 and C510.

C-455 Refer C420 and C510

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair and courtyard pathway edges did not contain drop offs to prevent tripping hazards for residents. Findings include, but are not limited to:

The facility's outdoor courtyard/patio area was toured on 8/30/21. Drop off's, up to three inches in depth, were observed along both sides of the cement pathway edges creating a possible trip hazard to residents.

The need to ensure all exterior pathways were maintained in good repair was discussed with Staff 1 (ED) on 8/31/21. She acknowledged the findings.

1. The facility's outdoor courtyard/patio area was toured on 8/30/21. Drop off's, up to three inches in depth, were observed along both sides of the cement pathway edges creating a possible trip hazard to residents.

2. On September 19, 2021, the courtyard was filled with dirt in the areas that were not level for a walker or wheelchair.  

Maintenance Director will utilize the Inspection Checklist to review twice a year with evacuation drills for compliance.

3. The Maintenance Director,  will check the courtyard grounds monthly and annually to make sure the ground level is within the required regulations and adjusted the courtyard as needed.

4. It will be evaluated Monthly at Dept. Head Meeting

The Executive Director, Maintenance Director or designee is responsible for compliance.

Based on interview and record review, it was determined that the facility failed to ensure all exterior pathways areas were maintained and in good repair. This is a repeat citation. Findings include, but are not limited to:

* The edge of the concrete pathway along the side of the facility had several drop-off areas that were 1 and ½ inches in depth; and

* In one area, the drop- off was 2 and ½ inches in depth.

The need to ensure all exterior pathways were in good condition and free from drop-offs was discussed with staff 1 (ED) and staff 16 (RCF Maintenance) on 12/29/2021. They stated that they planned to mitigate the drop-offs by installing gravel, but acknowledged they had yet to complete the correction.

1. The facility's outdoor courtyard/patio was tour on December 29th, 2021.

2. The courtyard will be filled with gravel by the end of January 31st, 2022 in areas that were not level for a walker or wheelchair, by the outside landscaper provider.  

Maintenance Director will utilize the Inspection Checklist to review twice a year with evacuation drills for compliance.

3. The Maintenance Director,  will check the courtyard grounds monthly and annually to make sure the ground level is within the required regulations and adjusted the courtyard as needed.

4. It will be evaluated Monthly at Dept. Head Meeting

The Executive Director, Maintenance Director or designee is responsible for compliance.

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 C231, C420, C422, C510.

1. Refer to C231, C420, C422, C510

3. This system will be review monthly.

4. RN and ED or designee will be responsible for compliance.  

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C420 and C510.

Z-142 Refer to C420 and C455 and C510

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 C252, C280, C282, C310.

1. Refer to C252, C280, C282, C310

3. This system will be review monthly.

4. RN and ED or designee will be responsible for compliance.  

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed, followed and included in the service plan for 1 of 3 sampled memory care residents (#4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in March 2021 with diagnoses including Alzheimer's disease and dementia with behavioral disturbance.

Resident 4's service plan, dated 7/28/21, and weight records were reviewed.

Resident 4 experienced a 32 pound or 14.54% total body weight loss in six months.

There was no individualized hydration and nutrition plan identified for the resident and weight loss interventions were not reviewed for effectiveness and no new interventions were implemented based on the resident's weight loss.

The need for individualized nutrition and hydration plans was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 9/1/21. They acknowledged the findings.

Refer to C280.

1. Resident 4s was admitted to the community in March 2021 with diagnoses including Alzheimer's disease and dementia with behavioral disturbance.

2. Care Plan was upated 9/22/21 individual plan recent weight loss, likes and dislikes of snacks. Staff offer snacks 3 times per day and offer him additional snacks thu the day.

3. RN, RCM, and RCC will be implementing and monitoring the effectiveiness, change of condition in weight loss and snack perferance in the resident care plans. Interventions shall be implemented and communicated on the service plan. On-going monitoring shall be developed to ensure interventions are in place and have been effective.

4. RN, RCM, RCC and ED are responsible for this compliance.  

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 1 of 3 sampled residents (#4) whose records were reviewed. Findings include, but are not limited to:

Resident 4 admitted to the facility in March 2021 with a diagnosis of dementia with behavioral disturbance.

The evaluation to determine Resident 4's activities lacked the following requirements and were not included on the resident's service plan dated 7/28/21:

* 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;

* Identification of activities for behavioral interventions;

* Resident preferences for activities;

* Occupation or chore related tasks;

* Scheduled and planned events (e.g. entertainment, outings);

* One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music);

* Spiritual, creative, and intellectual activities;

* Sensory stimulation activities;

* Physical activities that enhance or maintain a resident 's ability to ambulate or move; and

* Outdoor activities.

On 8/30/21 interviews with Staff 16 (Activities Director), Staff 10 (MT) and Staff 14 (CG) identified Resident 4 loved to walk outside in the courtyard, played dominos, had good turn taking and matching skills with 1:1 games and disliked group activities. The resident specific information was not available in the resident's service plan.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities.  

The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 9/1/21. They acknowledged the findings.

1. Resident 4 admitted to the facility in March 2021 with a diagnosis of dementia with behavioral disturbance. The evaluation to determine Resident 4's activities lacked the following requirements and were not included on the resident's service plan dated 7/28/21.

2. Care plan was updated on 8/31/21 with recent behaviors and individualized plan with activities and interventations. On Sept. 17, 2021 in-service with Corp RN with ED, RN, RCM, RCC and activity director on the individualized care plans with a focus on activities to ensure all areas pertaining to activities are individualized and reflective of the residents current needs.

3. This will be done with each new care plan, every 90 days and upon a change of condition.

4. RN, RCM, RCC, Activities Director, Executive Director responsible for compliance.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#4) with documented behaviors. Findings include, but are not limited to:

Resident 4 was admitted to the facility in March 2021 with diagnoses including dementia with behavioral disturbance.

Resident 4's record documented behaviors including aggression towards staff and residents, wandering into other resident's rooms, and resident to resident altercations on 6/27/21 and 8/22/21.

There were temporary service plans (TSP's) written after each resident to resident altercation however, after a few days of alert charting the TSP's were removed and no longer available to staff. the The resident's service plan, dated 7/28/21, did not address the behaviors, resident to resident altercations and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.

On 9/1/21 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN). They acknowledged the findings.

1. Resident 4's record documented behaviors including aggression towards staff and residents, wandering into other resident's rooms, and resident to resident altercations on 6/27/21 and 8/22/21.

2. Resident 4 care plan was updated and provided to the survey team on August 31, 2021. But going forward: RN, RCM, RCC and Activity Director would assess the residents for any changes of condition and update service plan coordinating and implementing specific interventions pertaining to a resident to assist staff in minimizing behaviors. RN, RCM, RCC and ED  would have care conference to discuss behaviors and change of condition with family and update OPTUM NP with plan of care when needed and/or physician.

3. Interventions shall be implemented and communicated on the service plan. On-going monitoring shall be developed to ensure interventions are in place and have been effective.

4. RN/ RCM and Executive Director or designee will monitor for compliance weekly.