Print Inspection: VL6Q

The findings of the re-licensure survey, conducted 08/08/22 through 08/10/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 08/10/22, conducted 12/01/22 through 12/02/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

3. Resident 2 was admitted to the facility in 04/2022 with diagnoses including dementia.

The resident's 04/29/22 through 08/08/22 progress notes, physician communications, incident reports, and weight records were reviewed. The resident experienced multiple changes of condition without documented monitoring until resolution and/or resident-specific directions to staff in the following areas:

* 04/29/22 Fall with facial hematoma;

* 06/01/22 Significant weight loss of 11.4 pounds, or 8% of total body weight in one-and-a-half months;

* 06/12/22 Fall with reddened facial area and right arm pain;

* 06/18/22 Ingestion of another resident's psychotropic medications;

*  07/08/22 Severe weight loss of 17.2 pounds, or 13.6% of total body weight in two-and-a-half months;

* 07/08/22 Non-injury fall;

* 07/09/22 Decreased, then discontinued psychotropic medication; and

* 07/12/22 Fall with abrasion to forehead.

There was no documented monitoring of the resident's condition at least weekly through resolution, to include effectiveness of interventions. The facility failed to provide resident-specific direction to staff, and there was no evidence the RN was notified of the significant weight loss on 06/01/22.

The need to monitor short-term changes to resolution with clear direction to staff, and to notify the facility RN of significant changes of condition, was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Regional Director of Operations) on 08/09/22. The staff acknowledged the findings.

4. Resident 3 was admitted to the facility in 12/2019 with diagnoses including dementia.

The resident's 05/13/22 through 08/08/22 progress notes and physician communications were reviewed. The resident experienced the following short-term change of condition without documented monitoring until resolution or specific direction to staff:

* On 06/02/22 progress notes indicated Resident 3 was on alert for "possible hand- foot mouth disease". There was no evaluation, clear direction to staff, or monitoring of the resident's condition at least weekly through resolution.

The need to monitor short-term changes to resolution, with clear direction to staff, was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Regional Director of Operations) on 08/09/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate changes of condition, determine and implement interventions needed, provide resident-specific instructions to staff, monitor the conditions at least weekly to resolution, notify the RN of any significant changes, and/or evaluate the effectiveness of the interventions for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2016 with diagnoses including dementia, acute agitation, and diabetes. The resident's service plan, dated 06/03/22, progress notes dated 05/10/22 through 08/08/22, temporary service plans, and incident reports were reviewed.

The resident experienced multiple changes of condition without documentation of interventions developed, specific signs/symptoms to observe, and/or clear directions to staff in the following areas:

* 05/25/22 ER visit for "increased confusion, extremely swollen feet, and pale color";

* 05/31/22 Fall with transport to ER;

* 06/03/22 Admission to hospice; and

* Multiple medication changes.

On 08/10/22 the need to evaluate changes of condition, develop interventions, provide resident-specific directions to staff, and monitor the conditions to resolution was discussed with Staff 1 (ED) and Staff 3 (LPN). They acknowledged the findings.

2. Resident 4 was admitted to the MCC in 09/2020 with diagnoses including hypothyroidism, encephalitis, and hallucinations. The residents progress notes, dated 05/10/22 through 08/08/22, MAR, dated 07/01/22, and temporary service plans were reviewed.

Resident 4 experienced multiple changes of condition without documentation of monitoring until resolution, specific signs/symptoms to observe, and/or clear directions to staff in the following areas:

* 05/13/22 Episode of aggressive, agitated behavior;

* 07/08/22 Skin issue - soreness in perineal area; and

* Multiple medication changes.

On 08/10/22 the need to evaluate changes of condition, develop interventions, provide resident-specific directions to staff, and monitor the conditions to resolution was discussed with Staff 1 (ED) and Staff 3 (LPN). They acknowledged the findings.

1) Residents presenting with any short term change or incidents will be doccumented with a TSP or ISP. TSP and ISP will be individualized to fit individual residents needs. Resident's status will be documented in progress notes until resolved.

2) Resident TSP and ISP will be individualized to fit each residents needs and reviewed by RSC until resolved.

3)Weekly until resolved

4) RSC, ED

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed following significant, then severe, weight loss for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 04/2022 with diagnoses including dementia.

The resident was observed during survey eating independently for short periods of time, then pacing up and down the halls for long periods of the day. The meal monitor record from 08/01/22 through 08/08/22 showed an average meal intake of 100%.

Staff interviewed reported that Resident 2 was difficult to keep at the table for meals due to constant pacing, but did well with finger foods given to him/her to eat while walking. This intervention was not reflected on the service plan.

A review of the resident's 05/03/22 through 08/08/22 progress notes, 04/2022 through 08/01/22 weight records, physician communications, and 07/01/22 through 08/08/22 MAR identified the following:

* From 04/13/2022 to 06/01/22, Resident 2 lost 11.4 pounds, from 146.2 pounds to 134.8 pounds, a decrease of 8.4% in his/her total body weight. This constituted a significant weight loss.

There was no documented evidence the staff who documented the weight information had referred the weight loss to the RN for follow-up. The resident began receiving protein shakes three times a day on 05/11/22.

* Between 04/13/22 and 07/01/22, the resident lost a total of 17.4 pounds, from 146.2 pounds to 128.6 pounds, a decrease of 13.6% of his/her total body weight, which constituted a severe weight loss. Meal monitoring was initiated on 07/09/22.

Staff 2 (LPN) documented on 07/22/22 that due to the resident's decline, recent falls, and severe weight loss, hospice care would recommended. The facility RN was notified.

Resident 2's weight was 129 pounds on 08/01/22.

On 08/03/22 the RN documented the resident was admitted to hospice services due to overall decline, falls, and weight loss.

There were no documented RN significant change of condition assessments of the resident's weight losses, including findings, resident status, and interventions made as a result of the assessment.

The facility RN was not available for interview during the survey.

The need for a significant change of condition assessment, which included findings, resident status, and interventions made as a result of the assessment, to be completed by an RN in a timely manner was discussed with Staff 1 (ED), Staff 2, and Staff 3 (Regional Director of Operations) on 08/09/22. They acknowledged the findings.

1) Significant Change of Condition will be reviewed and reported by staff to Resident Service Coordinator, RSC will review and report to RN, RN will complete COC assesment.

2)Significant Change of Condition form will be created by RN and reviewed by RSC

3)Weekly for COC

4) RN, RSC, ED

Based on interview and record review, it was determined the facility failed to ensure outside service providers left written documentation in the facility for on-site services provided to residents and failed to coordinate care with outside providers to ensure continuity of care, for 3 of 3 sampled residents (#s 1, 2, and 3) who received outside services. Findings include, but are not limited to:

During the acuity interview, Residents 1, 2, and 3 were identified as currently receiving hospice services. Facility records lacked documented evidence of any visits by outside service providers.

In interviews on 08/09/22, Staff 1 (ED) and Staff 2 (LPN) stated the facility had not been keeping written records of outside provider visits.

On 08/10/22 the need to ensure outside service providers left written documentation of all visits, and to implement any recommendations made by the providers was discussed with Staff 1, Staff 2 and Staff 3 (Regional Director of Operations). They acknowledged the findings.

1) A list will be kept on which residents will be reciving home health and Hospice services. Home Health agency and Hospice will need to check in with med tech or nurse and sign in on a separate log daily, who they are seeing and what they are being seen for. Home health agency and Hospice will then have to fill out an outsider provider form and turn it into Med tech prior to leaving the community.

2) The med tech will check sign in log and cross refrence outside provider forms prior to the end of shift daily.

3) weekly

4) resident service coordinator and ED

Based on interview and record review, it was determined the facility failed to notify the physician or practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented medication refusals. Findings include, but are not limited to:

Resident 4 was admitted to the memory care community in 09/2020, with diagnoses including heart failure and hypertension. Resident 4's MAR, dated 07/01/22 through 07/31/22 was reviewed.

The MAR listed two occasions, 07/08/22 and 07/27/22, when Resident 4 refused blood pressures, which was ordered to precede metoprolol administration (for hypertension). This constituted a medication refusal, which required the facility to notify the resident's physician.

There was no documented evidence the facility notified Resident 4's physician of the refusals.

In an interview on 08/10/22, Staff 2 (LPN) stated the facility did not have a system for physician notification following medication refusals.

On 08/10/22, the need to ensure a resident's physician or practitioner was contacted following medication refusals was discussed with Staff 1 (ED), Staff 2, and Staff 3 (Regional Director of Operations). They acknowledged the findings. No further information was provided.

1) Medication refusals and medication peramator refusal will be doccumented on MAR's then recorded on medication refusal forms and faxed to PCP

2) Education for medication techs on proper procedure for medication refusals, medication parameter refusals and when to notify PCP and creation of medication refusal form

3) Weekly

4) RSC

Based on interview and record review, it was determined the facility failed to ensure documented, non-pharmacological interventions had been tried, with ineffective results, prior to administering PRN psychotropic medications and to ensure complete documentation of all PRN administrations for 1 of 1 sampled resident (#4) who was administered a PRN psychotropic.  Findings include, but are not limited to:

Resident 4 was admitted to the memory care community in 09/2020 with diagnoses including hypothyroidism, encephalitis, and hallucinations.

Resident 4's MAR, dated 07/01/22 through 07/31/22, indicated the resident was administered PRN clonazepam (for severe agitation) 38 times in July. The medication "pass notes" showed all doses listed, but multiple entries lacked documentation of the following:

* Non-drug interventions tried, prior to PRN administration;

* Effectiveness of the medication;

* Time of follow-up evaluation; and/or

* Initials of the entry's author.

On 08/10/22 the need to ensure non-pharmacological interventions were tried with ineffective results, prior to administration of PRN psychotropic medications, and complete documentation of all such administrations was discussed with Staff 1 (ED) and Staff 3 (Regional Director of Operations). They acknowledged the findings.

Interventions will be listed for all PRN psychotropic medication including those ordered for end of life when reasen for use is not end of life comfort care. Interventions will be listed on MAR's and careplans and doccumented on MAR's

2) All psychotropic and end of life care medications will be reviewed for interventions

3)weekly

4)Resident Service Coordinator and ED

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST which would determine a staffing plan to meet the 24-hour scheduled and unscheduled needs of residents.

On 08/08/22, Staff 1 (ED) reported the facility had not implemented the ABST, as they had not added all the resident information needed. Staff 1 stated he would follow-up to ensure the ABST was implemented as required.

DHS ABST will be used until PCC staffing tool will be implimented.

2) Use of DHS ABST untill PCC staffing tool is used.

3)With move in, quarterly, Change of condition, and move out

4) Resident Service Coordinator and ED

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff  (#s 7, 9, and 11) completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to:

A review of staff training records with Staff 1 (ED) on 08/10/22 revealed the following:

There was no documented evidence Staff 7 (Universal Worker), Staff 9 (Universal Worker), or Staff 11 (Universal Worker), hired 06/29/22, 06/13/22, and 05/17/22, respectively, had completed the required training in First Aid and abdominal thrust.

The need for staff to complete all required training within the appropriate time frame was discussed with Staff 1 and Staff 3 (Regional Director of Operations) on 08/10/22. They acknowledged the findings.

New hire packets will be update for compliance with required training. Universal worker checkoff sheet will be audited prior to staff working with residents.

2) Universal worker checkoff sheets completed

3) Prior to universal worker completing initial training

4) Residential Care Coordinator, ED  

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

Review of facility records on 08/09/22 identified the following deficiencies:

* There was no documented evidence fire drills were conducted every other month, as required; and

* There was no documented evidence fire and life safety instruction was provided to staff on alternating months.

On 08/10/22 the need to conduct regular fire drills and to provide fire and life safety instruction to staff in accordance with the OFC, was discussed with Staff 1 (ED) and Staff 3 (Regional Director of Operations). They acknowledged the findings.

Education and training on how to complete fire drills and fire training provided by Fire Marshal. Fire drills will be conducted every other month and fire education on opposite months

2)Drills and traning recorded and reviewed.

3) Monthly.

4) Maintenance and ED

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

During an environmental tour of the building's interior, on 08/08/22 at 10:20 am, the following deficiencies were observed:

* Paint chipping on window sills in dining room;

* Gouges and scrapes on multiple wood door frames;

* Chipping and missing plaster on numerous walls; and

* Baseboards worn, discolored, and separated from walls in several places.

On 08/10/22 the need to maintain the facility in good repair was discussed with Staff 1 (ED) and Staff 5 (Environmental Services Director). They acknowledged the findings.

Maintenance will conduct a monthly apartment and building check list and make repairs accordingly.

2) Apartment and building repair check list and routine maintinance log will be created and kept.

3) Weekly and monthly

4) Weekly by Maintenance monthly by ED

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 361, C 372, C 420, and C 513.

Refer to C 361, C 372, C 420, C 513

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (# 7) completed all required pre-service orientation prior to performing any job duties and 3 of 3 staff (#s 7, 9,  and 11) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/09/22 and 08/10/22 with Staff 1 (ED).

1. There was no documented evidence Staff 7 (Universal Worker), hired 06/29/22, completed the required pre-service orientation topics prior to performing any job duties.

During review of Staff 7's pre-service orientation, it was identified she had completed her ADL competency training on 07/18/22, which was two days prior to completion of the pre-service orientation dated 07/20/22.

2. There was no documented evidence Staff 7, Staff 9 (Universal Worker), hired 06/13/22, and Staff 11 (Universal Worker), hired 05/17/22, demonstrated competency in all assigned job duties within 30 days of hire in the following areas:

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

* Conditions that require assessment, treatment, observation, and reporting; and

* General food safety, serving, and sanitation.

The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 and Staff 3 (Regional Director of Operations) on 08/10/22. They acknowledged the findings.

New hire packets will be update for compliance with required training. Universal worker checkoff sheet will be audited prior to staff working with residents.

2) Universal worker checkoff sheets completed

3) Prior to universal worker completing initial training

4) Residential Care Coordinator, ED

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

Refer to C 270, C 280, C 290, C 305, and C 330.

Refer to C 270, C 280, C 290, C 305, C 330