Print Inspection: VFYY

The findings of the re-licensure survey conducted 04/04/23 through 04/07/23 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 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

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of  0407/23, conducted from 08/07/23 through 08/09/23, 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, OARS 411 Division 57 for Memory Care Communities and OARS 411 Division 004 for Home and Community Based Regulations.

Based on interview and record review, it was determined the facility failed to ensure the initial move-in evaluation contained all required elements for 1 of 1 sampled resident (#4) who was recently admitted to the facility. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 01/2023.  

Review of the initial evaluation dated 01/30/23 revealed the following elements were missing:

* Spiritual, cultural preferences & traditions;

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

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

The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN). The findings were acknowledged.

C 252 OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation  

1.The leadership team has reviewed the OARs for Resident Move-in and evaluation and cross referenced the internal tools to ensure all OARs are captured on the pre-admit, admission, and evaluation forms. The internal systems, processes, policies, procedures, and protocols were reviewed by the leadership team to ensure ongoing compliance. The Health Services Director, Administrator, and nursing support team reviewed focused education for support and compliance.

2. The Administrator and Health Services Director will ensure ongoing compliance, following the required OARs, for all aspects of the Resident Move-in and evaluation requirements. The pre-admit, admission, and ongoing evaluation forms have been cross-referenced, updated, and the root cause for incomplete data collection was identified.

3. The Health Services Director will routinely audit and the Administrator will spot audit on a monthly basis.

4. The Health Services Director and Administrator will maintain ongoing compliance.   

Based on interview and record review, it was determined the facility failed to monitor each resident consistent with his or her evaluated needs and service plan, for 3 of 3 sampled residents (#s 1, 2 and 3) who required monitoring following multiple changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 10/2022 with diagnoses including vascular dementia with behavioral disturbance.

Resident 1's progress notes, short term monitoring documentation, service plan and incident reports were reviewed during the survey.

a. Between 01/29/23 and 03/26/23, the resident had nine falls. For five of the nine falls, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the falls, and whether the interventions were effective or that new interventions needed to be developed and implemented.

b. Between 01/29/23 and 03/26/23, the resident had three physical altercations with peers. For all three of the altercations, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the incidents, and whether the interventions were effective or that new interventions needed to be developed and implemented.

The need for the facility to document that it was monitoring a resident's service plan following changes of condition was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the lack of monitoring.

2. Resident 2 was admitted to the MCC in 10/2022 with diagnoses including unspecified dementia, psychotic disturbance and mood disturbance.

Resident 2's progress notes, short term monitoring documentation, service plan and incident reports were reviewed during the survey.

Between 01/31/23 and 04/03/23, the resident had five incidents where the resident was found on the floor or dropped his/her weight while staff were transferring him/her and had to be lowered to the ground.

* For three of the incidents, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the incidents, and whether the interventions were effective or that new interventions needed to be developed and implemented.

* For two of the incidents, the person who reviewed what had happened documented new interventions on the incident report form. However, there was no documented evidence the new interventions were added to the resident's service plan and communicated to staff.

The need for the facility to document that it was monitoring a resident's service plan following changes of condition, and adding new interventions to the service plan as needed was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 10/2021 with diagnoses including dementia and type 2 diabetes.

Resident 3's progress notes, short term monitoring documentation, service plan and incident reports were reviewed during the survey.

Between 02/04/23 and 04/01/23, Resident 3 had three incidents where the resident had unwitnessed falls in his/her room and one fall that was witnessed by staff.

For the four incidents, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the incidents, and whether the interventions were effective or that new interventions needed to be developed and implemented.

The need for the facility to document that it was monitoring a resident's service plan following changes of condition, and adding new interventions to the service plan as needed, was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the findings.

C 270 OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. The leadership team reviewed the OARs for resident Change of Condition (COC) and Monitoring and evaluated systemic changes to improve the required and best practice documentation. The team also discussed strategies for continued education. Root cause analysis was reviewed using the who ,what when, where, how, and the 5 Why's for incidents, accidents, and human expressions (behaviors). A Care Coordination workgroup was created to provide interdisciplinary support. The Care Coordination team will utilize the same root cause tools.  

2. The Health Services Director (HSD) will oversee the licensed nursing and Care Coordination teams and staff education following all OARS for COC and monitoring. The interdisciplinary Care Coordination workgroup will meet on a weekly basis to root cause, update, educate, and evaluate resident needs.

3. The Care Coordination workgroup will meet on a weekly basis to review all incidents and accidents. The Care Coordination team will meet twice weekly for service plan reviews, short term monitor reviews, and personalized expression plan reviews.

4. The HSD will ensure the Care Coordination team continues to meet twice weekly and weekly, per the interdisciplinary review schedule. In absence of the HSD the Administrator will faciliate the meeting and ensure scheduled meeting compliance. The licensed nurses and resident care coordinators will follow all COC and OARS on a daily individualized resident needs basis.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC) every other month, and to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:

Fire and life safety records were reviewed and Staff 5 (Maintenance Director) was interviewed on 04/05/23 and the following deficiencies were identified:

There was no documented evidence the facility conducted fire drills every other month as required and provided fire and life safety instruction to staff on alternating months from fire drills.

On 04/07/23, the need to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC), and staff instruction was provided on alternating months was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN). They acknowledged the findings.

C 420 OAR 411-054-0090 Fire and Life Safety: Safety

1. The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. BlueStep electronic modifications were made by the IT department for improved efficiency, tracking, notifications, and compliance documentation. The maintenance team received focused education on their role and responsibilities, BlueStep electronic integration, staff education, and scheduling.

2. Fire Drills and staff education have been added to the tracking in Bluestep (the staff and resident EHR). The Maintenance Director and the Administrator will receive email alerts with the schedule alternating every other month. The Maintenance Director will document and upload a copy of the fire logs into BlueStep to increase transparency for auditing by the Administrator.

3.The Maintenance team will provide continous compliance and the Administrator will audit compliance on a monthly basis.

4. The Maintenance Director and Administrator will be responsible for upholding ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission and were re-instructed at least annually in fire and life safety procedures as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 04/05/23, Staff 5 (Maintenance Director) was interviewed, and the following deficiencies were identified:

There was no documented evidence residents were instructed within 24 hours of admission and re-instructed annually on general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire.

On 04/07/23, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and re-instructed, at least annually, as required by the OFC was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN). They acknowledged the findings.

C 422 OAR 411-054-0090 (5) Fire and Life safety: Training for Residents

1.The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. The maintenance team received focused education on their role and responsibilities for resident training, on fire and life safety within 24 hours of admission, and re-instruction, at least annually, and the electronic integration of BlueStep for their compliance documentation.

2. The Maintenance team will document resident training on admission and re-instruction, per the OARs and OFC directly into BlueStep.

3.The Maintenance team will provide continous compliance and the Administrator will audit compliance on a monthly basis.

4. The Maintenance Director and Administrator will be responsible for upholding ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exit the RCF. Findings include, but are not limited to:

The facility was toured on 04/04/23. The MCC consisted of two separate buildings - the Tuscan House and the Ranch House. Each building had two exit doors which led outside - one main door in the front of the building and a side door. None of the doors had an operating system that would alert staff when a resident left the building.

The need to provide an alarm or other system on the exit doors for each of the buildings was reviewed with Staff 5 (Maintenance Director) on 04/06/23. He stated the doors had sensors on them but acknowledged there was no current system that notified staff when the door was opened.

The findings were reviewed with Staff 1 (ALF Administrator) on 04/07/23. She also acknowledged the findings.

C 555 OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, Cable

1.The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. The maintenance and direct care teams received focused education on their role and responsibilities for memory care home exit door, audible alarms, that must be in place to alert staff when residents are potentially exiting the building.

2. The Maintenance and direct care team will routinely check the exit door audible alarms. All staff will receive continued education to listen for the audible alarms and check the exits when sounded. The maintenance team will ensure operational and mechanical compliance and the direct care team will ensure safety responses. The Health Services Director (HSD) will oversee continued education for direct care. The Administrator will oversee maintenance education. The HSD and Administrator will oversee all staff continued education.

3.The Maintenance and direct care teams will provide continous compliance and the Administrator will spot audit routinely.

4. The Maintenance Director and Administrator will be responsible for upholding ongoing 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 C 420, C 422 and C 555.

Please refer to the POC for citation C 420, C 422 and C 555

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 252 and C 270.

Please refer to the POC for citation C 252 and C 270

Based on observation, interview and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3 and 4's records were reviewed, and observations were made during the survey. The current activity evaluations did not address the following required components:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitation;

* Adaptations needed to participate; and

* Identification of activities for behavioral interventions.

The current activity plans were not individualized to each resident based on their activity evaluation, and lacked instructions for staff on what activities to provide, how to provide them, when and how often.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the findings.

Z164 OAR 411-057-0160(2d) Activities

1. The leadership team has reviewed the OARs for Resident Activity assessment and cross referenced the internal tools to ensure all OARs are captured on the internal systems, processes, policies, procedures, and protocols were reviewed by the leadership team to ensure ongoing compliance. IT to assist with including shadow text in all activity headings on the service plan to ensure requirements are captured including * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitation; * Adaptations needed to participate; and * Identification of activities for behavioral interventions.  The life stories will be completed for Residents 1,2,3, and 4 and the information collected included in their specific evaluation and careplan with instruction on how to provide the resident with activity, with their limitations and the suggested frequency in which the resident is offered the activities according to their activity plan.

2. The Administrator and Activity Director will ensure ongoing compliance, following the required OARs, for the activity assessment and activity plan requirements. The pre-admit, admission, and ongoing evaluation forms have been cross-referenced and the root cause for incomplete data collection was identified.

3. The Activity Director will routinely audit and the Administrator will spot audit on a monthly basis.

4. The Activity Director and Administrator will maintain ongoing compliance.   

Based on observation, interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impact the resident and others in the community are evaluated and included on the service or care plan, for 1 of 3 sampled residents (#1) who had challenging behaviors in the MCC. Findings include, but are not limited to:

Resident 1 was admitted to the MCC in 10/2022 with diagnoses including vascular dementia with behavioral disturbance.

The current "Evaluation and Service Plan" document, dated 02/09/23, indicated the resident was "verbally aggressive or abusive, demanding, uncooperative or disruptive" and the behavior required a "Behavior Plan." In an interview on 04/05/23, Staff 9 (Direct Care) reported Resident 1's most challenging behaviors were:

* Screaming, because it triggered other residents on the unit;

* Trying to stand up from the recliner in the common living room area because s/he might fall;

* Hitting staff when they were assisting with ADLs; and

* Throwing peers' plates and drinks on the floor during mealtimes.

The record indicated multiple incidents between 01/29/23 and the date of the survey of Resident 1 having falls, physical altercations with peers, and resisting care from staff.

During the survey, the resident was observed on multiple occasions yelling/screaming and trying to stand up from his/her chair.

Resident 1's behavior plan, called the "Personalized Expression Plan," identified becoming "physically and verbally aggressive with staff" and becoming "agitated and not wanting to sit still [up and down]" as behaviors of concern.

There were eight interventions for staff to consider for responding to behaviors, but the plan did not indicate for which behavior the various interventions should be attempted. Staff 9 reported talking about chickens or showing him/her a video about chickens was effective in calming Resident 1 down - this intervention was not on the behavior plan. Further, the behavior plan did not address Resident 1's screaming and throwing plates and drinks on the floor.

Resident 1's behaviors and behavior plan was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They explained they viewed the behavior plan as a fluid document which changed often, but acknowledged not all Resident 1's challenging behaviors were addressed on the plan.

Z 165 - OAR 411-057-0160(e) Behavior

1. The leadership team has reviewed the OARs for behavior planning and cross referenced the internal tools to ensure all OARs are captured on the internal systems, processes, policies, procedures, and protocols were reviewed by the leadership team to ensure ongoing compliance. Resident 1's personal expression plan aka behavior plan was reviewed by a work group including nursing, resident care coordinators, wellness techs, and direct care staff to separate the behaviors and match the interventions accordingly. Interventions were added based on direct care staff input. Care staff will be involved moving forward monthly in the monthly house meeting to contribute in the development of the behaviors of all the residents in the home.      

2. The leadership team has developed a Behavior Plan (Personal Expression Plan) work group including but not limited to nursing, resident care coordinators, wellness techs and direct care staff to approach training in the moment on the floor as well as meeting twice weekly to review and update PEP's for all residents.   

3. Resident Care Coordinators will ensure Behavior plan/PEP training is on peer training checklist and include ongoing training, adding the PEPs reviews to the small monthly house meetings to seek feedback on the baseline expressions and effectiveness of the interventions and staff documentation and for the care team to encourage comments/notes in comments section of Service Plan to gather observations and input.  

4. The RCC's, LPN, and RN will be responsible for upholding ongoing compliance.