Print Inspection: V7PS

The findings of the re-licensure survey, conducted 04/17/23 through 04/19/23, 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 re-visit to the re-licensure survey of 04/19/23, conducted 07/26/23 through 07/27/23, 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 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 04/19/23, conducted on 10/04/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

1. A review of House Meeting minutes dated 01/23/23 through 04/07/23 revealed the following resident concerns:

* 01/23/23 - "lights in resident room 2 D are broken";

* 02/03/23 -  "Cleaning crew missing last two weeks, we need one more caregiver, 2 F fan not working and water in 2 F, 3 E and 2 E needs repair, a loud fan outside 3 E. Improve lighting outside. Multiple requests for these repairs";

* 03/03/23 - "2 F fan doesn't work, want more staff in house, more outside lighting, food menu is too repetitive and maintenance requests never get fixed"; and

* 04/07/23 - "2 F bathroom [fan] needs fixed, [outside] lighting around campus; lighting outside resident units 2 A, 2 B, 3 B and 3 E, food menu is repetitive, and staff has improved however, could be better."

2. Observations of the environment on 04/18/23 identified multiple resident concerns from the house meeting minutes, including water temperatures, lighting, and staffing had not been addressed or resolved.

3. During an individual resident interview and a group interview conducted during the survey with six un-sampled residents, the following complaints or concerns were brought up:

* Upper management had poor customer service and don't show up for scheduled meetings with residents; and

* Wi-fi Internet is often not working and we can't watch our TV or use the Internet.

The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 (Ashland Administrator) on 04/19/23. He acknowledged the ongoing concerns.

OAR 411-054-0025 (7) - Facility Administration: Policy & Procedure:

The following resident concerns were noted in the recent survey: 1. lights in resident room 2 D

are broken, 2. Cleaning crew missing last

two weeks, we need one more caregiver,

2 F fan not working and water in 2 F, 3 E

and 2 E needs repair, a loud fan outside

3 E. Improve lighting outside. Multiple

requests for these repairs, 3. 2 F fan doesn't work, want more staff in house, more outside

lighting, food menu is too repetitive and

maintenance requests never get fixed, 4. 2 F bathroom [fan] needs fixed, [outside] lighting around campus;

lighting outside resident units 2 A, 2 B, 3

B and 3 E, food menu is repetitive, and

staff has improved however, could be

better."

1.Actions to be taken to correct the rule violation include:

a.Facility has re-structured the resident grievance process, ensuring that grievance forms are available in conspicuous areas, easily accessible to residents and family members. Facility will take items 1-4 above and create grievance forms for each area of concern. Facility will follow the grievance process policy for all items listed above, until each area is resolved.

2.To ensure the system will be corrected so this violation does not happen again;  

a. Facility has provided training to all staff on the grievance process,

b.Facility has moved grievance forms in common areas that are easily accessible,  

c. Facility is sending out a memo via email to all residents' family members explaining how the grievance process works, & where to find grievance forms,

d.Facility is putting the grievance process instructions on each resident's door to ensure they are aware of this process,

e. Facility has removed the barrier of having to get a grievance form from a staff member, and instead leaving them out in the common area, to ensure that each resident feels comfortable expressing concerns.

3. Facility Administrator will review grievance binder daily during morning stand-up and ensure follow-up action happens timely.

4. Facility Administrator or designee will be responsible to ensure the system has been corrected and that the system is monitored.

Based on interview and record review, it was determined the facility failed to report an incident to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 1 of 1 sampled resident (#2) with a documented physical altercation with another resident. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 11/2021 with diagnoses including unspecified dementia, psychotic disturbance and mood disturbance.

Review of the resident's record, including progress notes, incident reports and alert charting records identified the following:

On 04/02/23, Resident 2 pushed another resident back down into his/her seat. This represented an incident where the facility failed to protect a resident, was considered neglect/abuse and needed to be reported to the local SPD office immediately.

There was no documented evidence the facility reported the incident to the local SPD office as required.

The facility was asked to report the resident to resident altercation to the local SPD office on 04/17/23. On 04/17/23 at 1:38 pm, Staff 12 (Consultant) provided confirmation of the self report.

The need to immediately report incidents of abuse or suspected abuse to the local SPD office and take measures necessary to protect residents and prevent the reoccurrence of abuse was discussed with Staff 1 (Ashland Administrator) on 04/19/23 at 10:50 am. He acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action:

1. Actions to be taken to correct the rule violation include:

a.Resident to resident altercations involving                resident #2 was reported to the local SPD office on 4/17/23 during survey.

2.To ensure the system will be corrected so this violation will not happen again:

a.All staff will be provided training on the following topics: Incident report requirements, investigating incident reports, how to appropriately r/o abuse & neglect, implementing new interventions via TSPs, ensuring previous interventions & applicable service planning care were being followed to showcase rule out abuse & neglect secondary to 'as evidenced by' & when to report to local APS.

b.Facility will review incident reports each morning (during working days) to ensure that all incident reports are completed thoroughly, investigations including ruling out abuse and neglect are done timesly, that incidents are reported to APS if needed and that the facility administrator has reviewed and signed all incident reports and investigations.

3. Reporting & investigating abuse & neglect system(s) will be monitored as follows:

a.Facility Administrator & Facility LN will coordinate with HR Manager daily at stand up  to ensure that all staff have completed the required pre-service & on-going training - 'Abuse & Reporting Requirements.'

b.Facility Administrator & Clinical Team will review all incident reports at least 5 days per week during morning stand-up.

4. Facility Administrator, Licensed Nurse or Designee will be responsible for overseeing all systems related to Reporting & Investigating Abuse/Neglect.

Based on interview and record review, it was determined the facility failed to ensure evaluations were completed at least quarterly for 2 of 2 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted in 09/2021 with diagnoses including dementia.

The most recent quarterly evaluation for Resident 3 was completed on 09/02/22. There were no updated quarterly evaluations.

The need to ensure evaluations were reviewed quarterly was discussed with Staff 1 (Ashland Administrator) and Staff 6 (Jefferson Administrator) during interviews on 04/17/23 and 04/19/23. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to facility in 01/2022 with diagnoses including Alzheimer's disease early onset, unspecified dementia and unspecified severity with behavioral disturbance and depression.

The most recent quarterly evaluation for Resident 1 was completed in 08/2022. The facility provided documentation that a quarterly evaluation was started on 04/16/23 but had not been completed at survey exit.

The need to ensure quarterly evaluations were completed timely was discussed with Staff 1 (Ashland Administrator) on 04/19/23. He acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation

1.  Actions to be taken to correct the rule violation include:

a.Residents #1 and #3's  evaluations have been updated to reflect the residents' current status per Oregon State Rule.

2.  To ensure the system will be corrected so this violation will not happen again; a complete audit of 100% of current evaluations will be conducted. Additionally,going forward all evaluations including all required factors will be completed per company policy and Oregon Administrative Rule prior to move-in, updated within 30 days, quarterly thereafter and with any significant change of condition. The document should be signed to indicate who completed the evaluation.

3. To ensure the system will be corrected so this violation does not happen again; evaluations will be reviewed and updated with any acute or significant change of condition, as well as with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the residents' current status per Oregon State Rule. Clinical services and Facility Administrator participate with this process to ensure accuracy

4. The Facility Administrator, Licensed Nurse or designee will be responsible to ensure the system has been corrected and that the system is monitored.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed quarterly, were reflective of residents' needs and provided a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 1 of 3 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to facility in 01/2022 with diagnoses including Alzheimer's disease, early onset.

a. The current service plan dated 09/05/22 had not been updated quarterly.

b. The current service plan dated 09/05/2022 and Temporary Service Plans (TSP's) from 01/24/23 to 04/07/23 were reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Level of assistance required for eating;

* Ability to use dining utensils; and

* Fall interventions.

The need to ensure service plans were completed quarterly, were reflective of residents' current needs and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Ashland Administrator) on 04/19/23 at 10:50 am. He acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

1. Actions to be taken to correct the rule violation include:

a.Resident #1 care plan will be updated to reflect the evaluation, person centered with individual preferences and care needs. To address all changes including but not limited to; Level of assistance required for eating; ability to use dining utensils; and fall interventions.

2. To ensure the system will be corrected so this violation does not happen again; service plans will be reviewed and updated with any acute or significant change of condition, as well as with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the residents' current status per Oregon State Rule. Clinical services and Facility Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative.

3. At time of move in, 30-day review, quarterly and as needed if a change of condition occurs.

4. TheFacility Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

3. Resident 3 was admitted to the facility in 09/2021 with diagnoses including dementia.

The resident's progress notes dated 01/17/23 through 04/07/23 and temporary service plans were reviewed. The following short-term changes of condition were identified:

* 03/13/23 fall with abrasion on right knee; and

* 03/15/23 fall with open wound on left elbow.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident. On 03/25/23 interventions were identified in the progress notes, but they were not communicated to staff on all shifts.

The need to ensure the facility determined, documented and communicated to staff on all shifts what actions or interventions were needed for the resident's short-term changes of condition was discussed with Staff 1 (Ashland Administrator) on 04/19/23. He acknowledged the findings.

2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including Alzheimer's disease, early onset and unspecified dementia, unspecified severity with behavioral disturbance.

The resident's progress notes dated 01/24/23 through 04/17/23, temporary service plans (TSP's) and incident reports were reviewed. The following change of condition was identified:

* 04/05/23 fall with three inch laceration to the resident's right eyebrow and resident was sent to the emergency room.

Upon return to the facility on 04/07/23, alert charting for "return from ER" and "skin event" were initiated. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident specific to the fall.

During lunch observation on 04/18/23 at 12:15 pm, Resident 1 was observed using his/her hands instead of utensils to eat a sandwich, chips and dish of peaches. Resident 1 was observed wearing tennis shoes and s/he paced back and forth in the common area when not eating until the surveyor exited the building at 12:45 pm.

An interview on 04/18/23 at 2:20 pm, with Staff 9 (MT/CG), revealed Resident 1 was able to perform the following prior to the fall on 04/05/23:

* Resident 1 was able to use utensils and did not require verbal cues for eating;

* Resident 1 was wearing slippers consistently instead of tennis shoes; and

* Resident 1 was using stairs instead of elevator to access different floors of building.

During an interview on 04/18/23 Staff 9 (MT/CG) confirmed there was no TSP completed for fall interventions. She reported staff were ensuring resident was wearing tennis shoes instead of slippers and using the elevator instead of stairs.

There was no documented evidence the facility evaluated the resident's change of condition related to eating, documented the change, and updated the service plan.

The need to ensure actions or interventions were initiated, reviewed for effectiveness and communicated with staff for short-term changes of condition was reviewed with Staff 1 (Ashland Administrator) on 04/19/23. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate and determine actions or interventions needed, communicate instructions and interventions to staff, monitor the changes in condition with weekly progress documented in the residents record through resolution for 3 of 3 residents (#s 1, 3 and 5) who were reviewed for changes of condition related to falls and skin. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 03/2023 with diagnoses including history of falling.

A review of the clinical record including temporary service plans (TSP's), progress notes dated 01/17/23 through 04/14/23 and 04/01/23 through 04/17/23 MAR identified the following change of condition:

* 03/31/23 fall with skin tear to the left elbow and abrasion to the back of the resident's head.  

The facility documented the fall on a TSP however, there was no information regarding the skin tears and abrasion. A review of the 04/01/23 through 04/17/23 MAR identified there was a treatment order for minor skin tears and abrasions however, there was no documentation that the treatment was administered.

Review of progress note dated 04/14/23 documented resolution of the injury fall, however there was no resolution noted for the skin tear and abrasion on the head.

There was no documented evidence the facility evaluated to determine interventions needed, communicate the interventions instructions to staff and monitor the skin tear and abrasions with weekly progress noted until resolved.

The need to ensure the facility evaluated and determined interventions needed, communicated the interventions and instructions to staff and monitored the residents skin tear and abrasions with weekly progress noted until resolved was discussed with Staff 1 (Ashland Administrator) on 04/19/23. He acknowledged the findings.

OAR 411-054-0040 Change of Condition and Monitoring

1.Actions to be taken to correct the rule violation include the following:

a.Resident #5 RN completed a focused assessment related to skin tear to left elbow and abrasion to back of head. Both skin issues are resolved.

b.Resident #1 RN completed a focused assessment related to laceration to the right eyebrow. Laceration is resolved at this time.

A comprehensive nursing assessment and appropriate follow up will be completed related to but not limited to, eating abilities and falls.

c.Resident #3 RN to complete focused assessment related to falls and communicate interventions to staff via TSP.

2. To ensure the system will be corrected so this violation will not happen again, a 24-hour communication system will be in place to include:

a.Shift to Shift Communication Log

b.Alert Charting Log / Audit Log

c.Significant Change of Condition Log

d. Weekly Skin Monitoring Log

e.Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as skin events, return from the hospital, or fall for example.

1.When a change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician.

2.The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

3.Staff should monitor resident status until resident condition resolves, and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN.

3. The area needed correction will be evaluated daily during clinical review with 24-hour audit system compliance.

Community will also complete a Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule.

4. The Facility Administrator and Registered Nurse will be responsible for ensuring the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence of monitoring changes of condition, and failed to determine and document what actions or interventions were needed for the resident following a change of condition, communicate the actions or interventions to staff on each shift, and document on the progress of the condition at least weekly until resolved for 2 of 2 sampled residents (#s 6 and 7) who were reviewed for changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility 03/14/22 with diagnoses including syncope and dementia.  

Resident 6's progress notes and clinical records, dated 06/15/23 through 07/24/23, were reviewed and revealed the following information:

On 06/29/23 a progress note stated "Possible UTI" indicated onset of UTI symptoms including: "more tired throughout the day, feeling frustrated but can't say why, urinating often" and stating "courier is picking UA sample up today".

Alert monitoring was done on 07/03/23 stating "Resident was helped with going to the bathroom every 4 hours and there was not a lot of output". A urine analysis was obtained, however there was no documentation of the results of the analysis. No further documentation was noted in the clinical record.

The condition above lacked documented evidence actions or interventions had been determined and communicated to staff and the condition monitored through resolution.

The need to determine actions or interventions and monitor conditions through resolution was reviewed with Staff 1 (Administrator) on 07/27/23. The findings were acknowledged.

2. Resident 7 was admitted to the facility in 09/2019 with diagnoses including nutritional deficit related weight loss, hypertension and atrial fibrillation.

Progress notes and Temporary Service Plans (TSPs) dated 06/15/23 through 07/26/23, the current service plan, last updated 07/12/23, and the clinical chart were reviewed and indicated the following:

* 07/01/23: "[Spouse] has been in the hospital since 6/23, not eating as much as before... " and "lost 5.9 lb due to only eating <25% ...LN [licensed nurse] has been notified of change.". There was no documented evidence of interventions implemented to address the weight loss.

* 07/09/23: "Resident sent out with family to get a chest xray for possible aspiration ... resident taking meds and was drinking with a straw, started coughing ...resident has been coughing and said [s/he] felt like gunk in [his/her] throat." The LN was called and resident was sent out after vitals taken. A progress note dated 07/11/23 documented the resident had an "aspiration incident over the weekend and was sent out for a second chest xray." The record did not include information on the results of the second chest xray and did not include any interventions to address the aspiration risk.

* 07/18/23: A progress note and TSP informed staff of recent medication changes and instructed staff to monitor for side effects and document "vital signs day and noc [night]." The record lacked evidence vital signs were being obtained as instructed in the 07/18/23 TSP.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, were communicated to staff on each shift, were resident specific and made part of the resident record with weekly progress noted until the conditions resolved.

The need to ensure an effective monitoring system was implemented and changes of condition were monitored through resolution and included interventions for staff to follow was reviewed with Staff 1 (Administrator), Staff 15 (RN) and Staff 20 (Executive Director) on 07/27/23. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. Actions to be taken to correct the rule violation include:

  a. Resident #6: Ashland Medication Technician called Providence Lab during survey on 07/26/23 to obtain results of Urinary Analysis. On the same day, facility LPN called PCP's office to confirm their office had received and reviewed the results of UA. Both were recorded in a Progress Note by facility LN. LN completed and documented a focused assessment for acute  change of condition.

  b. Resident #7:

     1) LN Called resident's daughter during survey and obtained chest x-rays completed on 7/9/23 and 7/11/23 results from resident's my chart. X-rays were negative for any aspiration. Findings were documented in residents chart.  

     2) Facility LN will assess resident's weight loss. All findings and interventions will be documented via TSP, with clear instructions for staff to follow. Weight loss will be assessed by LN, with weekly updates until it is resolved, or a new baseline is established.

2. To ensure the system will be corrected so this violation will not happen again, a 24-hour communication system will be in place to include:

     oShift to Shift Communication Log

     oAlert Charting Log / Audit Log

     oSignificant Change of Condition Log

     oWeekly Skin Monitoring Log

Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as skin events, return from the hospital, or fall for example.

  a. When a change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician.

  b. The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

  c. Staff should monitor resident status until resident condition resolves, and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN. All Medication Technicians will be provided training on the 24 communication system and the importance to read and follow the temporary service plan including ensuring that vital signs are taken if indicated. All staff responsible for documenting short-term change of condition monitoring have also been provided with additional recources regarding the frequency vitals are to be taken.

3. The area needing correction will be evaluated daily during stand up with 24-hour audit system compliance.

Community will also complete a Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule.

4. The Administrator and Registered Nurse will be responsible for ensuring the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications administered to residents for 1 of 3 sampled residents (# 3) whose MARs were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2021 with diagnoses including dementia. The resident's 04/01/23 through 04/17/23 MARs and physician's orders were reviewed.  

There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record since 05/2022 for the following medications and treatments that the facility was responsible to administer:

* Donepezil (for dementia);

* Memantine (for dementia);

* Acetaminophen (for pain);

* Loperamide (for loose stool);

* Magnesium hydroxide (for constipation);

* Trazodone (for insomnia); and

* Estrace cream (for dryness).

The need to ensure current signed physician's orders were in place for all medications and treatments administered was discussed with Staff 1 (Ashland Administrator) on 04/19/23. He acknowledged the findings.

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

1. Actions to be taken to correct the rule violation include; full audit of physician orders for Resident #3,  to ensure there are current physician orders for all medications and treatments and that they are being carried out per MD order.

2. The system will be corrected to eliminate further violations as follows: 100% of all resident medication and treatment orders will be reconciled to ensure that there are current physician orders for all medications and treatments and that all medications and treatments are dispensed as ordered.

3. Medication reconciliations will be completed on a quarterly basis.

4. The Licensed Nurse, Facility Administrator or designee will be responsible for ensuring the corrections are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents, to compensate for staff duties beyond direct resident care, and failed to follow the Acuity Based Staffing Tool (ABST) that defined the appropriate number of caregivers needed based on resident acuity and service needs. Findings include, but are not limited to:

Observations, interviews and record review, during the survey revealed the following:

* At the time of the relicensure survey, the facility was a three level home separated into two houses, Ashland and Jefferson, with a total of 25 residents.

* Observations on 04/17/23 and 4/18/23 identified one staff working in Ashland, one staff working in Jefferson and one Chef for both houses. There wasn't a float caregiver between the two houses. The caregivers were observed providing medication management, meal service, housekeeping, kitchen tasks, and direct care.

* During the acuity interview on 04/17/23, the facility was noted to have nine residents with heavy care needs, including requiring full assistance with ADL's or memory care diagnoses.

* Review of House Meeting minutes from 01/2023 through 04/2023 identified on multiple occasions the residents had complaints about the lack of staff and requested more staff.

* According to the UDS (Uniform Disclosure Statement), the facility used Universal Workers (whose job duties included providing care and services to residents in addition to having other tasks, such as housekeeping, laundry and meal service.) The UDS indicated the facility would schedule two staff from 6:00 am - 6:00 pm and a float between Ashland and Jefferson houses between 7:00 am - 7:00 pm and one Chef, and one universal worker from 6:00 pm - 6:00 am the following morning.

* Review of the staffing schedule and interview with Staff 1 (Ashland Administrator) on 04/18/23 revealed the majority of the month 04/01/23 - 04/30/23, the facility scheduled one universal work for "meds" from 6:00 am - 6:00 pm, and one universal worker for "meds" from 6:00 pm- 6:00 am the following morning. There was no documented evidence the facility was scheduling a float caregiver between the two houses.

* On 04/18/23, the surveyor requested the facility's ABST and the defined number of staff that the tool had generated. Upon review of the ABST, multiple residents that had been entered into the ABST had not been updated quarterly and was not reflective of resident care needs. Further review noted the two houses combined should have had 4 to 5 caregivers, depending on the day of the week; to provide the evaluated resident care and services.   

* During an interview on 04/18/23 at 2:20 pm, Staff 9 (MT/CG) confirmed she was the only scheduled caregiver at Jefferson building during the morning and day shift.

* During an interview on 04/18/23 at 12:00 pm, Staff 13 (Chef) reported "I cook for Larch-Tabor [different license on the facility campus] and for Ashland. Hood [different license on the facility campus] cooks for Jefferson. It's always like this because we don't have enough staff."

The need to increase staffing levels to compensate for increased staff duties when utilizing universal workers and the need to ensure the facility was staffing according to the staffing plan generated by the ABST was discussed with Staff 1 on 04/18/23. He acknowledged the findings.

OAR 411-054-007 (1) Staffing Requirements and Training: Staffing

1. Actions to be taken to correct the rule violation include;

a.A designated float is scheduled to work between Jefferson and Ashland daily from 6am-6pm. UDS has been updated to reflect the time change from 7am-7pm to 6am-6pm.

b.Facility Administrator completed acuity-based staffing tool for the community.  

2. The system will be corrected to eliminate further violations as follows:

a.Facility will ensure that policies and procedures are in place for the required acuity-based staffing tool.

b.Facility will maintain ABST and the ABST will be updated with each resident evaluation: initial, within 30 days of admission, quarterly, and with significant change of condition.

c.Facility administrator will review staffing schedule to ensure that the schedule is reflective of staffing requirements based on ABST.

3. This system will be evaluated as follows:

a.The ABST will be updated with each resident evaluation: initial, within 30 days of admission, quarterly, and with significant change of condition.

b.Facility administrator will review monthly schedule to ensure the schedule is reflective of staffing needs based on resident care needs, per the ABST, at least once monthly.

4.) Facility Administrator or designee will be responsible for ensuring the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST), no less than quarterly and use the results generated by the ABST to maintain and update the facility's staffing plan. Findings include, but are not limited to:

A review of the ABST being used by the facility and an interview with Staff 1 (Ashland Administrator) on 04/18/23 identified the following:

* The facility had not conducted quarterly updates of the ABST tool for each resident as required; and

* The staffing hours generated by the ABST were not used to maintain and update the staffing plan.

Staff 1 acknowledged the above findings.

Refer to C 360 Staffing Requirements.

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool:  

1. Actions to be taken to correct the rule violation include;

a.Facility administrator completed acuity-based staffing tool for the community.  

2. The system will be corrected to eliminate further violations as follows:

a.Facility will ensure that policies and procedures are in place for the required acuity-based staffing tool.

b.Facility will maintain ABST and the ABST will be updated with each resident evaluation: initial, within 30 days of admission, quarterly, and with significant change of condition.

c.Facility administrator will review staffing schedule to ensure that the schedule is reflective of staffing requirements based on ABST.

3. This system will be evaluated as follows:

a.The ABST will be updated with each resident evaluation: initial, within 30 days of admission, quarterly, and with significant change of condition.

b.Facility administrator will review monthly schedule to ensure the schedule is reflective of staffing needs based on resident care needs, per the ABST, at least once monthly.

4.) Facility Administrator or designee will be responsible for ensuring the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records from October 2022 through March 2023 were reviewed and lacked documentation of the following required components:

* Evidence alternate escape routes were used;

* Evidence occupants were evacuated or relocated to the point of safety;

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

* Evidence of immediate changes that were made for residents who were unwilling to participate in the fire drills to ensure the evacuation standard could be met.

On 04/18/23 the requirements regarding fire drills were reviewed with Staff 1 (Ashland Administrator) and Staff 8 (Facilities Director). They acknowledged the findings.

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

1. Actions taken to correct the rule violation will include;

a.Facility will conduct unannounced fire drills every other month at different times of the day and night. No less than 3 on each shift (day/night) annually.

b.Fire and life safety instruction for staff will be provided on alternate months.

c.Community will implement a fire drill tool that encompasses all required pieces including but not limited to; Evidence alternate escape routes were used; Evidence occupants were evacuated or relocated to the point of safety; problems encountered and comments relating to residents who resisted or failed to participate in the drills; and evidence of immediate changes that were made for residents who were unwilling to participate in the fire drill to ensure the evacuation standard could be met.

2. The system will be corrected so this violation does not happen again by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in servicing for maintenance staff who are conducting fire and life safety drills and education on process and documentation required.

3. The area needing correction will be evaluated every other month  at stand up the day after the fire drill has been completed.

4. The facility administrator or designee will be responsible for ensuring the corrections are completed and monitored.

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

Refer to C 270 and C 513.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

Actions to be taken to correct the rule violation include:

Refer to C 270 and C 513

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

Observations of the outside of the Jefferson and Ashland buildings on 04/17/23 revealed the following areas contained drop-offs from two to five inches in depth:

a. Ashland building:

* From concrete pathway to adjacent to tree outside front of building;

* From concrete pathway to mailbox; and

* From concrete pathway to fire hydrant.

b. Jefferson building:

* From concrete pathway to chair yoga area;

* From concrete pathway to bridge by koi pond; and

* From concrete pathway to outdoor patio with raised beds.

The drop-offs areas were shown to and discussed with Staff 1 (Asland Administrator) and Staff 8 (Facilities Director) on 04/18/23. They acknowledged the need to prevent drop-offs.

OAR 411-054-0200 Residential Care Facility Building Requirements

1. Immediate actions to correct the rule violation include filling in and building up the drop-offs

a.Ashland building: from the concrete pathways adjacent to tree outside the front of building; from concrete pathway to mailbox; and from concrete pathway to fire hydrant.

b.Jefferson Building: from concrete pathway to chair yoga area; from concrete pathway to bridge by koi pond; and from concrete pathway to outdoor patio with raised beds.

2. The system will be corrected so this violation will not happen again by completing consistent environmental walk throughs to ensure all exterior pathways and an outside area are in good repair and any concerns identified and followed up on timely.

3.The area needing correction will be evaluated on a monthly basis with an environmental audit.

4. The Maintenance Director, Facility Administrator or Designee will be responsible for ensuring the corrections are completed and monitored.

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

The interior of the buildings were toured on 04/17/23 at 11:15 am. The following areas were observed to need cleaning and/or repair:

Ashland building:

* Main entrance/exit door had scrapes and gouges;

* Laundry room was missing an electric outlet cover;

* Laundry room was missing lower left cabinet door;

* Dirt, dust and debris behind washers and dryers;

* Walls throughout laundry room had chipped paint, scrapes, holes and debris;

* Apartment 2 E had a leak in the living room window; and

* Multiple resident doors had scuffs and dings.

Jefferson building:

* Main entrance/exit door had scrapes and gouges;

* Laundry room dryer was in disrepair;

* Dirt, dust and debris were behind washers and dryers;

* Walls throughout laundry room had chipped paint, scrapes, holes and debris;

* Multiple resident doors had scuffs and dings;

* Cabinet outside of elevator on main floor had multiple holes;

* Kitchen window air conditioning unit had dust and debris;

* Kitchen cabinets had discoloration;

* Windowsills in common area had gouges and chips;

* Side table in common area had stains;

* Elevator light covering had tan stain; and

* Television stand had chips and scrapes.

The exterior of the buildings were toured on 04/17/23 at 11:50 am. The following areas were observed to need repair:

Ashland building:

* Building had cracked concrete wall to the left of the main door;

* Top of fire escape handrail was loose and was not smooth;

* Fire escape stairs and rails had green matter;

* Fire escape patio had moss;

* Exterior patio door frames and doors had green and brown debris; and

* All raised beds were in disrepair.

Jefferson building:

* Exterior patio door frames and doors had green and brown debris;

* Outdoor wall near gutter had buildup of lint below fan;

* Moss was outside of the basement entrance doors;

* Chipped paint, gouges and exposed wood throughout lower level maintenance walls;

* Patio chairs had rust;

* Fire escape stairs and rails had green matter;

* Fire escape patio and lower level had moss; and

* Support beam above main entrance had rotted wood.

The surveyor toured the environment with Staff 1 (Ashland Administrator) and Staff 8 (Facilities Supervisor) on 04/18/23. They acknowledged the above areas needed to be cleaned and repaired.

OAR 411-054-0200 (4)d-i Doors, Walls, Elevators, Odors

1. Immediate actions taken to correct the rule violations include the following: The following items will be cleaned and or repaired:

Interior building:

a.Ashland building: Main entrance/exit door had scrapes and gouges; Laundry room was missing an electric outlet cover; Laundry room was missing lower left cabinet door; Dirt, dust and debris behind washers and dryers; Walls throughout laundry room had chipped paint, scrapes, holes and debris; Apartment 2 E had a leak in the living room window; and Multiple resident doors had scuffs and dings. Cabinet outside of elevator on main floor had multiple holes;  Kitchen window air conditioning unit had dust and debris; Kitchen cabinets had discoloration; Windowsills in common area had

gouges and chips; Side table in common area had stains; Elevator light covering had tan stain;

and Television stand had chips and scrapes.

b.Jefferson building:

Building had cracked concrete wall to the left of the main door; Top of fire escape handrail was loose and was not smooth; Fire escape stairs and rails had green matter; Fire escape patio had moss;  Exterior patio door frames and doors

had green and brown debris; and All raised beds were in disrepair

Exterior Building:

a.Ashland building:

Building had cracked concrete wall to the left of the main door; Top of fire escape handrail was loose and was not smooth;  Fire escape stairs and rails had green matter; Fire escape patio had moss; Exterior patio door frames and doors had green and brown debris; and All raised beds were in disrepair.

b.Jefferson building:

Exterior patio door frames and doors had green and brown debris; Outdoor wall near gutter had buildup of lint below fan; Moss was outside of the basement entrance doors; Chipped paint, gouges and exposed wood throughout lower level

maintenance walls; Patio chairs had rust; Fire escape stairs and rails had green

matter;  Fire escape patio and lower level had

moss; and Support beam above main entrance

had rotted wood.

2. The system will be corrected so this violation will not happen again by ensuring Housekeeping and maintenance schedules include review of all areas identified in the survey and ensure all areas are routinely cleaned and the environment is in good repair.

3. The area needing corrected will need to be evaluated on a monthly basis as part of the environmental audits.

4. Maintenance Director or Designee will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

The interior of the buildings were toured on 07/26/23 at 9:30 am. The following areas were observed to need cleaning and/or repair:

Ashland building:

* Laundry room was missing an electric outlet cover; and

* Laundry room was missing lower left cabinet door.

Jefferson building:

* Cabinet outside of elevator on main floor had multiple holes;

* Kitchen cabinets had discoloration; and

* Elevator light coverings had tan stains.

The surveyor toured the environment with Staff 1 (Administrator), Staff 17 (Facilities Director) and Staff 18 (Maintenance Coordinator) on 07/26/23 at 11:30 am. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls,

Elevators, Odors

1. Actions to be taken to correct the rule violation include:

  a. Ashland building:

    1) Electrical outlet cover and cabinet door in laundry room installed during survey 07/27/2023 by Maintenance team

  b. Jefferson building:

    1) Elevator light coverings replaced following survey 07/30/2023 by Maintenance team

    2) Kitchen cabinets to be refinished (see attached quote for services to be performed)

    3) Cabinet door with holes will be repaired or replaced by Maintenance crew.

2. The system will be corrected to prevent repeat occurrences by:

  a. Training all staff on inputting work orders in TELS app (available on all building cell phones)

  b. Performing reviews of open work orders with Facilities Director or Designee and Administrator or Designee

  c. Ensuring Housekeeping and maintenance schedules include review of all areas identified in the survey and ensure all areas are routinely cleaned and the environment is in good repair.

3. Facility Director or Designee and Administrator or Designee will perform monthly environmental audits to identify any additional areas in need of correction and ensure previous issues were corrected.

4. Administrator, Facilities Director, or Designee will be responsible for ensuring system is corrected and monitored