Print Inspection: UWPK

The findings of the re-licensure survey conducted 04/03/23 through 04/07/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004.

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 04/07/23, conducted 01/22/24 to 01/24/24, 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

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 04/07/23, conducted on 06/06/24, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure residents' right to a safe and homelike environment and to be treated with dignity and respect. Findings include, but are not limited to:

In individual interviews conducted between 01/22/24 and 01/24/24, facility residents made the following statements:

* "We have to be careful what we say in the hallways because [Staff 17 (ED)] is listening to us on the cameras. No one hangs out anymore. They all just stay in their rooms because they're afraid she's listening.";

* "I wouldn't feel comfortable talking with [Staff 17] about concerns.";

* "[Staff 17] made me so anxious I had to take an anxiety pill.";

* "Everyone's walking on pins and needles since [Staff 17] started. We used to be a community and now we're all afraid she's going to shut the place down.";

* "[Staff 17] put her face in my face, nose to nose and talked down to me as if I was her pet dog.";

* "[Staff 17] told me to shut up and let her speak.";

* "[Staff 17] is unprofessional.";

* "It's unacceptable to spread fear amongst the entire population.";

* "My mental well-being and spiritual well-being has [sic] been harmed.";

* "[Staff 17] basically didn't listen to me ....I don't appreciate being talked to like a child."; and

* "[Staff 17] yelled at me for 45 minutes. I'm afraid she's going to kick me out."

During a 01/23/24 interview, a non-sampled resident was observed to cry when speaking about a recent interaction with Staff 17.

During a 01/24/24 interview, Staff 17 stated, "I've had some people working against me since I started here ...I feel I've made some enemies here."

The need to ensure residents' right to a safe and homelike environment and to be treated with dignity and respect was discussed with Staff 17 on 01/24/24. She acknowledged the findings.

# C200- Based on observation and interview, it was determined the facility failed to ensure residents' right to a safe and homelike environment and to be treated with dignity and respect.

1-The facility will ensure that the residents are treated with dignity and respect.  Specifically, staff member #17 will build individual relationships with each of the residents so that they feel they are treated with dignity and respect.

2- To ensure that the facility knows how the residents are feeling, a manger will check in at least monthly with each resident and document that they are feeling safe in their home.

3-This area will be evaluated monthly for 6 months or longer if the issue is not resolved

4-The RN, the ED, the Assistant HSD and the RCC will be responsible for monitoring to ensure the corrections are completed

2. Resident 1 was admitted to the facility in 10/2017 with diagnoses including dementia and diabetes.

The resident's progress notes, dated 01/04/23 through 04/02/23, Service Plan Addendums (SPAs), RN assessments, and incident reports and investigations were reviewed, and staff were interviewed. The following changes of condition were identified:

* 01/01/23 - Weight loss;

* 03/09/23 - Weight loss and non-injury fall in the dining room;

* 03/17/23 - Fall with skin tears in bedroom;

* 03/27/23 - Non-injury fall on facility front porch; and

* 04/01/23 - Non-injury fall in his/her closet.

There was no documented evidence the facility evaluated the resident for a change of condition, monitored the resident until resolution, or referred to the RN to determine if further actions or interventions were needed.

The need to ensure residents were evaluated, monitored and referred to the RN for changes of condition was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (Assistant Health Services Director) on 04/06/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, significant changes of condition were referred to the RN, resident-specific instructions or interventions were developed and reviewed for effectiveness, and the condition was monitored to resolution at least weekly for 2 of 2 sampled residents (#s 1 and 2) who were reviewed for changes of condition. Resident 2 experienced ongoing falls resulting in falls with injuries. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including dementia.

Resident 2's service plan, dated 01/28/23, described the resident as being at risk for falls and to remind the resident to use his/her call device for assistance as needed. The service plan indicated staff will provide physical assistance with all ambulatory needs such as in/out of bed, to/from meals, and activities.

Record review indicated Resident 2 experienced multiple falls as follows:

*On 02/05/23, the resident experienced a fall without injury before breakfast. Resident 2 reported tenderness on the back of the head, left shoulder, and buttocks. The resident reported they did not know how s/he fell. There were no documented resident specific interventions to minimize the further occurrence of falls.

*On 02/05/23, the resident was found on the floor of their apartment shortly before dinner. Resident 2 reported s/he was not hurting anywhere. There were no documented resident specific interventions to minimize the further occurrence of falls.    

*On 02/10/23, the resident was found on the floor of his/her bathroom. Resident 2 had complaints of right hip pain. There were no documented resident specific interventions to minimize the further occurrence of falls.    

*On 02/14/23, the resident was found on floor of their apartment and was unable to report to staff how s/he got on the floor. There were no documented resident specific interventions to minimize the further occurrence of falls.

*On 02/22/23, the resident was found on the floor of their apartment. The resident was unable to report to staff how s/he fell and reported his/her buttocks was hurt. There were no documented resident specific interventions to minimize the further occurrence of falls.

*On 02/23/23, the resident was found on the floor of their apartment. The resident reported s/he had slid down the wall next to the toilet after coming off the toilet and had reports of pain to the top of his/her scalp. There were no documented resident specific interventions to minimize the further occurrence of falls.

*On 03/14/23, the resident was found on the floor of their apartment. The resident reported s/he was in the wheelchair when they fell but could not fully remember. The resident expressed pain in his/her left wrist and left side hurt. There were no documented resident specific interventions to minimize the further occurrence of falls.

*On 03/22/23, the resident experienced a fall in their apartment and had hit his/her head. There were no documented resident specific interventions to minimize the further occurrence of falls.

In an interview on 04/04/23, the resident was unable to report or remember experiencing any falls while living at the facility.

In an interview on 04/05/23, Staff 1 (Executive Director) reported there was no further documentation of resident specific interventions to minimize further occurrences of Resident 2's falls

There was no documentation to show ongoing evaluation of existing interventions, determination and implementation of any new interventions, and monitoring of those interventions for effectiveness.

Resident 2 had repeated falls with and without injury without resident specific interventions by the facility to minimize the further occurrence of injuries and falls.

On 04/05/23, the need to ensure changes of condition had resident-specific interventions was discussed with Staff 1, Staff 2 (Health Services Director), and Staff 2 (Assistant Health Services Director). They acknowledged the findings.

OAR 411-054-0040 Change of Condition and Monitoring - Residents 1 and 2 have had change of condition assessments by the RN and service plans have been updated.  

We have reviewed our system for identification of changes and our RN's role for ensuring assessments for significant change of condition. Changes in residents' condition will be evaluated, assessed and monitored according to the community "Change of Resident Condition" policy and procedure and OAR 411-054-0040.  Incident reports for falls will be investigated within 48 hours with interventions in place and communicated to staff to prevent re-occurrence.  Weights to be obtained and reviewed at least monthly to evaluate if weight changes have occurred. Interventions will be monitored weekly to determine efficacy until weight is considered stable.  Care staff are being educated on the system and their responsibilities prior to compliance date.

Changes in condition will have documentation of resident's status until the issue is resolved.

The Executive Director and RN are responsible for ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 1 of 1 sampled resident (#1) reviewed for significant changes of condition. Resident 1 experienced severe on-going weight loss. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/2017, with diagnoses including dementia and diabetes.

During the entrance conference on 04/03/23, staff reported that the resident had a recent significant weight loss.

Review of facility progress notes and weight records from 01/05/23 through 04/03/23, revealed the following:  

* The resident weighed 142 pounds on 01/05/23. On 02/11/23, the resident's weight had dropped to 131.4 pounds. This was a severe weight loss of 11 pounds or 7.75% loss in total body weight in one month; and

* The next weight on 02/21/23 was 131 pounds and 03/09/23 the resident was 126 pounds, an additional five pounds or 3.82 % loss in total body weight.

During the survey on 04/04/23, the surveyor requested the resident be weighed. Resident 1's weight was 122 pounds. A loss of another four pounds or 3.17% weight loss for a total of 20 pounds or 14.08% in three months.

Between 01/2023 and 02/2023 Resident 1 lost a severe amount of weight. There was no documented evidence the RN completed an assessment including the resident status, findings and interventions made as a result.  Resident 1 continued to have documented weight loss.

Observations of the resident between 04/03/23 and 04/07/23 showed the resident was able to feed himself/herself once provided food and had occasional cueing. The resident did not seek out or ask for food items during the survey observations but would usually accept items when staff offered.

The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/RN) and Staff 3 (Assistant Health and Wellness Director) on 04/06/23. They acknowledged the findings.

OAR 411-054-0045 (1) (a-f) (A) (C-F) Resident Health Service

Resident 1 has had a change of condition assessment and service plan has been updated.

The RN will follow-up on staff reported resident changes according to the community "Change of Resident Condition" policy and procedure.  The RN will assess any resident identified to have a significant change of condition and document findings per policy.  Care staff are being educated on their responsibility and the system prior to compliance date.  RN will attend "The Role of the RN in Community Based Care" May 9-11, 2023.

Updates to service notes, evaluations and service plans will be made as indicated.  Short-term health monitoring and staff direction will be implemented as indicated by the RN assessment. Progress notes will be audited for changes routinely at our clinical meeting by Executive Director and RN.

The Executive Director and RN are responsible for ongoing compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 6 moved to the facility in 07/2021 with diagnoses including major depressive disorder and coronary artery disease, and was identified during the acuity interview as having weight loss and a new diagnosis of dementia.

The resident's current service plan dated 01/21/24, 01/01/24 through 01/22/24 MARs, progress notes dated 10/30/23 to 01/19/24, and weight records dated 06/02/21 to 01/18/24 were reviewed, observations were made, and interviews were conducted.

Review of the resident's monthly weight records from 12/04/23 through 01/18/24 showed the following:

12/04/23 - 125.8 pounds;

01/05/23 - 118.8 pounds;

01/17/24 - 115 pounds;

01/18/24 - 115.8 pounds; and

01/23/24 - 115 pounds (obtained during survey).

From 12/04/23 to 01/05/24, the resident lost seven pounds which constituted a severe weight loss of 5.6% in one month. This weight loss represented a significant change of condition and required an RN assessment.

On 01/23/24 the resident was observed eating 25% of his/her lunch and dinner.

During a 01/23/24 interview, Staff 2 (Health Services Director) reported the significant weight loss on 01/05/24 had not been identified, and an RN assessment was not completed for the significant weight loss. She acknowledged the need for an RN assessment and a completed one was received by survey on 01/24/24.

On 01/24/24 the need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 17 (Executive Director), Staff 2, and Staff 18 (Health Support Services). They acknowledged the findings.

# 280 -As evidenced by observation and record it was detemined that the facility failed to ensure an RN assessmnet was completed for a resident who experienced a significant change of condition.

1-The facility will ensure that an RN assessment is completed for each resident who experiences a significant change of condition.

2-Training has been provided to staff on reporting change of condition, and training has been provided to the RN on when a change of condition assessment must be completed.

3- The area needing correction will be evaluated daily at a Health Services meeting

4-The ED will ensure that the corrections are completed and monitored

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 4 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 07/2022 with diagnoses including diabetes.

Current physician orders and the 03/01/23 through 03/31/23 MARs identified the resident to have an order for CBGs to be taken three times a day and to notify the physician for CBGs under 70 or over 250.

During the month of March, the resident's CBGs were documented to be over 250 on 21 occasions.

There was no documented evidence the facility notified the physician of any of the CBGs.

Staff 16 (MT) confirmed in interview on 04/06/23 at 10:00 am that the physician was not notified of the CBGs.

The need to follow physician orders was shared with Staff 1 (ED) and Staff 2 (Health Services Director) on 04/06/23. They acknowledged the findings.

OAR 411-054-0055 (1) (f-h) Systems: Treatment Orders

An audit of resident 3 has been reviewed to ensure CBG orders match EMAR. Physician will be notified of CBG's out of parameters.

Health Services Team will train staff to follow current policy and procedures on physician communication. All treatments will have a signed order by an authorized medical provider. Health Services Team and staff will follow physician's orders for resident's treatments.  Med Techs will be in-serviced on medication room policy and procedures and treatment assistance procedures.

Administrator and RN are responsible for training of Med Techs and ensuring all physician orders are being followed.

The Executive Director and RN are responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner if a resident refused consent to an order for 1 of 1 sampled resident (#1) with refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/2017 with diagnoses including dementia.

Resident 1's physicians orders and 03/2023 MARs were reviewed.

Staff documented Resident 1 refused the following:

* Cholecalciferol (vitamin D) three times;

* AM CBGs six times;

* Multivitamin three times; and

* Lantus (insulin) two times.

There was no documented evidence the facility notified Resident 1's physician of the refusals.

On 04/07/23, the need to ensure the facility notified physicians or practitioners of refusals was reviewed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (Assist. Health Services Director). They acknowledged there was no documented evidence the facility had notified the physician of the refusals.

OAR 411-054-0055 (1) (f-h) Systems: Resident Right to Refuse

Resident 1's MAR was audited and physician has been notified of resident refusals.

Providers will be notified of all medication refusals within 24 hours of the refusal.  Health Services Team will train staff on policy and procedures concerning medication refusals.

The Executive Director and RN are responisble for training of Med Techs and ensuring all policies are being followed.  

The Executive Director and RN are responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 long-term staff (#14) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 04/06/23.

There was no documented evidence Staff 14 (MT), hired 10/05/20, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care.

On 04/06/23, the need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (ED) and Staff 4 (Office Manager). They acknowledged the findings.

OAR 411-054-0070 (5-7) Annual Training and Other Requirements

Annual In-Service Training - All trainings have been completed.  Dementia training is up to date for all employees.

Records of annual staff training are kept in the Office Manager's office.  Prestige maintains a schedule of monthly training assigned automatically to appropriate staff by Learning Management System (LMS). This listed is updated annually and as needed.

All staff are required to take assigned trainings. Health Services Team will ensure training is complete. 6 hour dementia training requirement will be added via electronically through department approved online learning courses.

The Executive Director and Office Manager are responsible to ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to provide documentation that fire and life safety trainings were conducted on alternate months of fire drills and all required components of fire drills were documented. Findings include, but are not limited to:

Review of fire drill records on 04/04/23, for October 2022 through March 2023, showed the facility failed to conduct fire and life safety training's on alternate months of fire drills.

Fire drills failed to consistently document the following required fire drill components:

*Escape routes used;

*Problems encountered;

*Evacuation time-period needed; and

*Number of occupants evacuated.

On 04/04/23, the need to ensure documentation that fire and life safety trainings were being conducted on alternating months of fire drills and all required fire drills components were documented was discussed with Staff 1 (ED) and Staff 6 (Maintenance Director). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire Life and Safety: Safety

Prestige Fire Life and Safety policy and procedure reviewed with maintenance director.

Training for correct utilization of Prestige form, containing all state required documentation provided to maintenance director. Fire drills are in TELs as a task with a reminder to be completed every other month. Alternate months will include a fire and life safety in-service. These will include evacuation and evacuation routes, use of fire extinguishers, point of safety, communicating with fire department, radio communications with coworkers and additional as needed.

Maintenance director is responsible for all training with Executive Director oversight in accordance with OAR

Based on interview and record review, it was determined the facility failed to provide documentation that all required components of fire drills were documented. This is a repeat citation. Findings include, but are not limited to:

Review of fire drill records dated 11/10/23, 12/19/23, and 01/16/24 revealed a lack of documentation of one or all of the following required fire drill components:

*Escape routes used;

*Problems encountered;

*Evacuation time-period needed; and

*Number of occupants evacuated.

On 01/22/24, the need to ensure all required fire drill components were documented was discussed with Staff 17 (ED) and Staff 6 (Maintenance Director). They acknowledged the findings.

#420- Based on interview and record review, it was determined that the facility failed to provide documentation that all components of fire drills were completed.

1-The facility will create a tool to track all components of the fire drills

2-The facility will use this tool to track fire drills moving forward

3-The area will be reviewed monthly at the time of the firedrill

4- This will be reviewed by the Maintenance Director and the Executive Director

Based on observation, 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 C280 and C420.

455-The facility failed to ensure that their re-licensure survey paln of correction was implemented.

1-A new plan of correction has been created for citations of C280 and C420

2-The correction for C280 is through additional training off the staff and the facility RN.  The violation for C420 will be corrected through changes to a form to meet the regulation.

3- The corrections for C280 will be monitored daily.

The corrections for C420 will be monitored monthly

4- The ED will be responsible for monitoring the corrections

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:

The exterior of the facility was toured on 04/03/23 and 04/04/23. The following deficiencies were identified:

*Exterior pathways around the perimeter of the building contained drop-offs up to four inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents; and

*The exterior of the facility had an excess of cobwebs throughout.  

On 04/04/23, the building's exterior was toured with Staff 1 (ED). She acknowledged the findings.

OAR 411-054-0300 General Building Exterior

Facility has ordered bark to be refilled along the pathways to ensure equal height of hard and soft ground. Refilling will be added to TELs as an annual task to be done at the end of winter.  Handrail system will be placed to ensure resident safety during exit and/or evacuation from building.  Building will be powerwashed and sprayed for bug control.

Daily walk throughs will occur to ensure ongoing safety issues are addressed.  Exterior building cleaning will be added to monthly tasks in TELs.

Maintenance Director is responsible for ongoing compliance with Executive Director oversight.

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

Observations of the facility from 04/03/23 through 04/06/23 identified the following areas in need of cleaning and repair:

*The elevator carpet had multiple stains;

*Multiple handrails throughout the facility were worn down exposing bare wood with sharp rough surfaces;

*Exit doors to the outside courtyard were worn down to exposed wood and had multiple scuffs and a buildup of black matter;

*Walls were observed with holes, scuffs, and missing paint near the exit doors to the outside courtyard;

*Flooring tiles with cracks was observed near the exit doors to the outside courtyard;

*A chair in a hallway was observed with a tear on the armrest;

*The dining room ceiling was observed with paint peeling away from the ceiling; and

*A popcorn machine in the theater was observed with a buildup of grease and debris.

On 04/06/23, the areas in need of cleaning and repair was discussed with Staff 1 (ED). She acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

All areas in need of cleaning and repair have been addressed.  Furnishings that are tatted or torn have been removed.  Bids for floor replacement have been attained and will be scheduled.  

Carpet cleaning will be put in TELS for all carpeted areas to be cleaned on a rotating basis.  Touch-up painting will be done on a prn basis.  Handrails will be inspected and fixed as needed.  Kick plates for all exit doors have been ordered and painting complete.

Maintenance Director will maintain a walk through on a daily basis, both inside and outside per Prestige Policy. All tasks will be added to TELs for weekly and monthly scheduling.

Maintenance Director will review routinely and Executive Director will review weekly to ensure ongoing compliance.