Print Inspection: ZKKN

The findings of the re-licensure survey, conducted 07/31/23 through 08/02/23, 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 08/02/23, conducted 10/24/23 through 10/25/23 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 Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 08/02/23, conducted 01/02/24 through 01/03/24, 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 interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 04/2023 with diagnoses including congestive obstructive pulmonary disease (COPD) and dementia . The move-in evaluation failed to address the following elements:

* Customary routines: sleeping, eating and bathing;

* Spiritual, cultural preferences and traditions;

* Mental health issues;

* Cognition, including memory, orientation, confusion and decision-making abilities;

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

* Ability to understand and be understood;

* Eating, dental status, and assistive devices;

* Housework and laundry;

* Pain;

* Skin condition;

* List of treatments to include type, frequency, and level of assistance needed;

* Indicators of nursing needs, including potential for delegated nursing tasks;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Unsuccessful prior placements;

* Elopement risk or history;

* Smoking; and

* Alcohol and drug use.

The need to ensure new move-in evaluations included all required elements was discussed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (Assistant Health Services Director) on 08/02/23. They acknowledged the findings.

Resident 1 service plan has been updated with current condition and needs following an RN assessment and Service Planning Team participation.

Incoming residents will haved pre move in evaluations performed by qualified personnel following the requirements of OAR 411-054-0034 (1-6) and Prestige current policy.  Residents will be evaluated for appropriateness and level of care needs prior to moving, within the first 30 days of move in, at least quarterly and when the resident has a significant change of condition.

The current Prestige RN and LPN will complete the Role of the RN in Community - Based Care scheduled through OHCA October 24-26, 2023.  Resident assessments, evaluations and service plans will be reviewed during the Prestige Orchard Heights health team daily SMART meetings.

The ED will be responsible for continued compliance via review of initial evaluation prior to admission of new residents.  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#9) who recently moved in. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 10/2023 with diagnoses including Type 2 diabetes and chronic obstructive pulmonary disease (COPD). The move-in evaluation failed to address the following elements:

* Customary routines: sleeping, eating and bathing;

* Cognition including orientation and confusion;

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

* Communication including speech and ability to understand and be understood;

* Housework and laundry;

* Pain including non pharmaceutical interventions and how a person expresses pain or discomfort;

* Emergency evacuation ability;

* Complex medication regimen; and

* Environmental factors that impact the resident's behavior.

The need to ensure new move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 21 (Community Relations Director) on 10/24/23. They acknowledged the findings.

Resident service plans have been updated with current condition and needs following an RN assessment and Service Planning Team participation.  Incoming residents will have pre move in evaluations using the updated Prestige evaluation (9/19) to match the requirements of OAR 411-04-0034 (1-6) and Prestige current policy.  Move in evaluations will be performed by qualified personnel.  Residents will be evaluated for appropriatness and level of care needs prior to moving, within the first 30 days of move in, at least quarterly and when the resident has a significant change of condition.

The ED will be responsible for continued compliance via review of initial evaluation prior to admission of new residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff and were consistently implemented, and a copy was offered to residents for 5 of 5 sampled residents (#s 1, 2, 3, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 07/20/23, and progress notes dated 05/01/23 to 07/31/23 were completed. Staff indicated the resident had increased confusion and weakness. The resident had poor safety awareness and tried to get up on his/her own. The staff further indicated they provided full assistance with ADLs and two person assistance with transfers. The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not implemented in the following areas:

* Falls and safety interventions;

* Evacuation assistance and process;

* Hydration needs and fluids in apartment;

* Ability to communicate needs and ability to direct PRN pain medication;

* Walker versus wheelchair use for mobility;

* Number and level of staff assistance required and specific steps for ADL completion;

* Behaviors, including sexually inappropriate actions with staff, aggression, and agitation;

* One-person versus two-person transfers and devices used;

* Edema, elevation of legs, and floating heels in bed;

* Pain locations and interventions; and

* Call light use.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (Assistant Health Services Director) on 08/01/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 04/2023 with diagnoses including chronic obstructive pulmonary disease (COPD) and dementia.

Observation and interviews with the resident, interviews with staff, and review of the resident's service plan, dated 06/29/23, and progress notes dated 05/01/23 to 07/31/23 were completed. The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not implemented by staff in the following areas:

* Memory and decision-making abilities;

* Religious preference;

* Activity preferences;

* Hearing loss;

* Dressing, grooming, hygiene, and toileting;

* Transfer, ambulation, and mobility, including assistive device used;

* Ability to use call system;

* Safety checks;

* Pain; and

* Oxygen use, including instructions.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (Assistant Health Services Director) on 08/02/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 09/2020 with diagnoses including schizoaffective disorder and abnormality of gait.

Interviews with the resident and staff and review of the current service plan, dated 06/05/23, revealed Resident 6's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Behavioral problems and effective non-drug interventions;

* Ambulation and use of assistive devices;

* How a person expresses pain or discomfort;

* Fluid preferences;

* Recent losses; and

* How bi-level positive airway pressure ventilation device was to be used and monitored for safety.

During an interview on 08/01/23 at 10:00 am, Resident 6 stated s/he was not offered a copy of the service plan.  

The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding delivery of services, and a copy was offered to residents was reviewed with Staff 1 (ED) and Staff 2 (Health Services Director) on 08/02/23 at 2:30 pm. They acknowledged the findings. No further information was provided.

5. Resident 5 was admitted to the facility in 08/2017 with diagnoses including hypothyroidism, major depressive disorder, and dementia.

The resident's service plan, dated 06/19/23, was reviewed, and interviews with staff and the resident were conducted. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Meal assistance needed:

* ADL assistance required; and

* Behaviors.

The need for service plans to be reflective of the resident's current status and care needs, as well as provide clear direction to staff regarding the delivery of services, was discussed with Staff 1 (ED) on 08/02/23. She acknowledged the findings.

4. Resident 3 was admitted to the facility in 08/2015 with diagnoses including hyperglycemia and bipolar disorder.

The resident's service plan, dated 06/14/23, was reviewed, and interviews with staff and the resident were conducted. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Transfer status;

* Refusal of care;

* Behavioral interventions related to refusals; and

* Low salt diet.

The need to ensure the service plan was reflective of Resident 3's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 08/02/23. She acknowledged the findings.

Resident #2: Service plan has been updated with current condition, needs and safety interventions following an RN assessment and Service Planning Team participation.

Resident #1: Service plan has been updated with current condition and needs following an RN assessment and Service Planning Team participation.

Resident #6: Service plan has been updated with current condition, needs, non-drug interventions and clear instructions for device monitoring for safety following an RN assessment and Service Planning Team participation.

Resident #3: Service plan has been updated with current condition, needs and interventions following an RN assessment and Service Planning Team participation.  

Resident #5: Service plan has been updated with current condition, needs and interventions following an RN assessment and Service Planning Team participation.

Residents #2, 1, 6, 3 and 5 signed, acknowledged and were offered a copy of the updated service plan.

The RN, LPN and RCC will update the service plans with current conditions, needs and interventions as identified.  

Regional Nurse will provide in-service for RN, LPN and RCC outlining expectations for ongoing service plan updates to reflect current resident conditions. Regional Nurse will conduct frequest meetings providing clear direction to staff regarding delivery of services.

The RN will be responsible for continued compliance via review of resident service plans within the first 30 days of move in, quarterly and when a resident has a significant Change of Condition.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff and were consistently implemented for 2 of 3 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes.  

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/09/23, were completed. The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not implemented in the following areas:

* Bathing assistance;

* Behaviors and non-pharmaceutical interventions;

* Pain including location, presentation and interventions;

* Type of walker and use inside versus outside apartment;

* Frequency of high blood sugar levels and what that looked like for the resident;

* Diabetic diet; and

* Preference for eating inside versus outside apartment.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED), Staff 3 (Assistant Health Services Director) and Staff 22 (RCC) on 10/25/23. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 05/2021 with diagnoses including lung cancer.  

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/02/23, were completed. The resident's service plan was not reflective and lacked resident specific direction for staff in the following areas:

* Dietary needs;

* Anxiety and panic attacks including interventions;

* Assistance with daily living; and

* Medical treatments.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff, was reviewed with Staff 1 (ED) and Staff 22 (RCC) on 10/24/23. They acknowledged the findings.

Resident #7 & Resident #8 Service Plans have been updated with current condition, dietary needs, behavioral needs, medication requirements and safety interventions following an RN assessment and Service Planning Team participation.  Updated Service Plans are signed and acknowledged.  Residents were offered a copy of the updated Service Plan.

The RN, LPN and RCC will update the service plans with current conditions, needs and interventions as identified.  ED, RN, LPN and RCC meet frequently to discuss resident needs and to review upcoming service plans.  These meetings to follow SMART meetings Monday - Friday, as needed.

The ED will be responsible for continued compliance via frequent review of service plans.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 5 sampled residents (#s 1, 3, 5, and 6). Findings include, but are not limited to:

Resident 1, 3, 5, and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 2 (Health Services Director) on 08/02/23 at 2:30 pm. They acknowledged the findings. No further information was provided.

All resident service plans will be completed utilizing a Service Planning Team following the Prestige Cooperative Service Plan Policy and Proceedure (May 2021) and requirements of OAR 411-054-0036. Current Service Plans will be reviewed by the Service Planning Team and updated as appropriate. The ED and RN will be responsible for continued compliance via review of Service Plans.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 3 of 3 sampled residents (#s 7, 8, and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7, 8, and 10's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 10/25/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director). The staff acknowledged the findings.

All resident service plans will be completed utilizing a Service Planning team following the Prestige Cooperative Service Plan Policy and Procedures and requirements of OAR 411-054-0036.  Current service plans will be reviewed by the Service Planning Team and updates as appropriate.

The ED and RN will be responsible for continued compliance via review of the service plans.

Based on observation, interview, and record review it was determined the facility failed to ensure incidents were investigated to evaluate effectiveness of current interventions, additional interventions were determined as indicated, and short-term changes were monitored weekly through resolution for 2 of 5 sampled residents (#s 2 and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia and congestive heart failure.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 07/20/23, and progress notes dated 05/01/23 to 07/31/23 were completed.

a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Multiple emergency room visits;

* Increased confusion and behaviors;

* Medication changes;

* Right arm pain;

* Falls; and

* Statement of jumping out of 3rd floor window.

b. Staff indicated the resident had increased confusion and weakness. The resident had poor safety awareness and tried to get up on his/her own. The staff further indicated they provided full assistance with ADLs and two-person assistance with transfers. The resident could not consistently make needs known or request assistance from staff. Review of incident reports and investigations showed the following:

* An incident report dated 06/30/23 indicated the resident fell in his/her room, was found inside the closet, and stated s/he hit their head. The resident indicated they were reaching for something and fell over. The resident had complaints of pain, was transported to the emergency room for evaluation, and returned the same day with no new orders.

* An incident report dated 07/08/23 indicated the resident was found on the floor in a kneeling position. The resident stated s/he was reaching for something and fell. The resident's foot was bleeding, and s/he was transported to the emergency room for evaluation. The resident returned with stitches near the pinky toe.

* An incident report dated 07/15/23 indicated the resident was found on the floor with his/her head against the TV stand. The resident could not say how they fell and expressed pain to the head. The resident was sent to the emergency room for evaluation and returned the same day with a referral for hospice services.

There was no documentation in the resident's record the facility had completed thorough investigations of the incidents and potential injuries to determine the cause, minimize reoccurrence, develop and implement interventions, and to re-evaluate existing interventions for appropriateness and effectiveness.

In an interview on 07/31/23, the resident was unable to answer all questions presented and was confused by some information discussed. S/he did not express any specific concerns, but was easily distracted from the current conversation. The resident did not show any signs of fear or anxiousness with staff as they entered the apartment for safety checks and ADL assistance during survey observations.

In an interview on 08/01/23, Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (Assistant Health Services Director) acknowledged the investigations of the incidents were not complete.

c. The resident experienced severe weight loss of 6.83% from 07/03/23 to 07/06/23 and a severe weight gain of 5.23% from 07/19/23 to 07/20/23. The resident's weight changes were not reported to the RN for review and completion of a significant change of condition assessment.

Refer to C 280

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and interventions were reviewed for effectiveness, and provided clear, resident-specific directions to staff, was discussed with Staff 1, Staff 2, and Staff 3 on 08/01/23. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 08/2017 with diagnoses including hypothyroidism, major depressive disorder, and dementia.

Review of the resident's clinical record, including progress notes and incident reports dated 05/01/23 through 07/31/23, identified the following:

a. Resident 5 experienced a non-injury fall on 05/19/23. There was no documented evidence the incident was evaluated to determine resident-specific actions or interventions.

b. The resident was transported to the emergency room by ambulance on 06/24/23. There was no documented evidence the resident was monitored through resolution upon return to the facility.

The need to ensure incidents were evaluated, actions or interventions were determined and communicated to staff, and short-term changes of condition were monitored through resolution, with at least weekly documentation, was discussed with Staff 1 (ED) on 08/02/23. She acknowledged the findings.

Incidents will be reviewed at the daily clinical SMART meetings to ensure they are investigated and evaluated for effectiveness of current interventions, additional interventions and actions are put in to place as needed and short term changes are put in place and monitored weekly at minimum until resolved. Executive Director will complete the Oregon Care Partners "Strategies to Prevent & Reduce Falls Training" on September 13, 2023. RN & LPN will complete the Oregon Health Care Association "Role of the RN in Community Based Care" on October 24, 2023. All incident investigation and reporting will follow the Presige PCC-Incident Reporting Policy and Procedure (April 2021) and the requirements of OAR 411-054-0040 (1-2). The ED will be responsible for compliance through regular monitoring of recorded details, interventions and follow up.

2. Resident 10 was admitted to the facility in 09/2023 with diagnoses including high blood pressure.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 09/08/23 and progress notes dated 09/30/23 to 10/24/23 were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, and/or lacked resident-specific directions to staff in the following areas:

* Increased pain and difficulty breathing;

* Medication changes;

* Fall; and

* Hospital stay.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 10/25/23. She acknowledged the findings.  

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short term changes of condition had actions or interventions determined, resident-specific instructions developed, and the condition was monitored at least weekly to resolution for 3 of 3 sampled residents (#s 7, 8, and 10) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 05/2021 with diagnoses including lung cancer.

Observations of the resident, interviews with staff, review of the service plan dated 06/02/23, MARs from 10/01/23 through 10/24/23, and progress notes dated 09/28/23 through 10/24/23 were completed. The resident experienced multiple short-term changes without documented actions or interventions determined and/or resident-specific directions to staff in the following areas:

* Constipation; and

* Nausea.

The need to ensure short-term changes of condition had documentation of actions or interventions determined and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 10/24/23. She acknowledged the findings.

3. Resident 7 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/09/23 and progress notes dated 09/30/23 to 10/24/23 were completed.

The resident experienced multiple short-term changes without determining and documenting what action or intervention was needed and/or lacked resident-specific directions to staff in the following areas:

* Increased pain and dizziness;

* Medication changes; and

* Constipation.

The need to ensure short-term changes of condition had determination and documentation of action or interventions needed and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 3 (Assistant Health Services Director), and Staff 22 (RCC) on 10/25/23. They acknowledged the findings.

Incidents, Short Term Monitoring and Change of Conditions will be reviewed at the clinical SMART meetings to ensure incidents are investigated and evaluated for the effectiveness of current interventions, additional interventions and actions are put into place and short term changes are put in to place and monitored until resolved.  Monitoring will be documented. Interventions will provide clear, resident specific directions.

ED and RN will be responsible for compliance through regular monitoring of recorded details, interventions and follow ups.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#2) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia and congestive heart failure.

Weight records, dated 07/01/23 through 07/20/23, and progress notes, dated 05/01/23 through 07/31/23, indicated the resident experienced the following:

* A 13.8 pound loss between 07/03/23 and 07/06/23, which constituted a 6.83% severe loss in three days.

* A 10.0 pound weight loss between 07/19/23 and 07/20/23, which constituted a 5.23% severe weight gain in one day.

A weight of 197.0 was obtained on 08/02/23, at the request of the surveyor. This represented a four pound loss from the last weight on 07/20/23. This was not a significant loss for the resident.

Progress notes, temporary service plans, and physician communications dated 05/01/23 through 07/31/23 indicated the resident was independent with meals, but did require some encouragement and reminders. The resident had experienced a recent change of condition with increased confusion and weakness. The resident was admitted to hospice on 07/19/23.

Multiple observations of the resident between 07/31/23 and 08/01/23 showed the resident in the dining room for all meals. The resident was observed to eat between 50% and 100% of foods and fluids that were provided. The resident was provided his/her foods cut up and was able to eat independently.

Interviews with staff on 08/01/23 showed the following:

Staff 1 (ED) indicated the resident had been eating well, from what she had seen. Staff stated they had recently started cutting up the resident's foods before delivering to him/her. Staff 1 further indicated the facility scales were moved in July and not recalibrated properly, so she questioned the accuracy of some of the weights which were obtained.

Staff 2 (Health Services Director) indicated she had been at the facility since June 2023. She was not aware of the resident's significant weight loss or gain. Staff 2 stated the resident did have a history of edema and his/her diuretic (medication to remove fluids) had been recently discontinued. The resident was a new admission to hospice services on 07/20/23, due to a decline in condition. Staff 2 did not complete a significant change of condition for the weight loss, weight gain, or hospice admission.

Staff 9 (MT) and Staff 16 (CG) indicated the resident could sometimes make his/her needs known, but staff typically anticipated needs. The staff stated the resident could eat and drink on his/her own, but did need intermittent cues to keep eating. The staff indicated the resident had good intake for most meals.

The facility failed to ensure an RN assessment was completed for the weight changes between 07/01/23 and 07/20/23 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1, Staff 2, and Staff 3 (Assistant Health Services Administrator) on 08/01/23. The staff acknowledged the findings.

An RN assessment for weight change has been completed on Resident 2 documenting findings, resident status and intervantions. Resident status is reviewed weekly All weights and vitals for residents will follow the Presige Weights and Vitals Policy and Procedure (February 2022) and the requirements of OAR 411-054-0045 (1)(a-f)(A)(C-F). RN will complete an assessment of any significant change of condition within 48 hours. RN will be responsible for compliance through monitoring of monthly weights and monitoring of Resident STM's.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed and documented findings, resident status, and interventions made as a result of the assessment, for 1 of 1 sampled resident (#8) who experienced severe weight loss. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 05/2021 with diagnoses including lung cancer and chronic pain.  

Weight records, dated 09/01/23 through 10/12/23, and progress notes, dated 09/28/23 through 10/24/23, indicated the resident had a 9.4 pound weight loss between 09/01/23 and 10/12/23, which constituted a 9.1% severe loss.

Resident 8's weight on 10/25/23 was 97.5 pounds. A three pound weight gain from 10/12/23.

Observations of the resident and interviews with Resident 8 and staff on 10/24/23 and 10/25/23 indicated the resident was independent with meals and ate only in his/her apartment. Resident 8 had no teeth and stated his/her dentures "did not fit" and were not used. The resident required soft items that were cut up for easy chewing and swallowing. Resident 8 was provided a nutritional supplement twice daily.

Observations of the resident between 10/24/23 and 10/25/23 showed the resident up in his/her hospital bed in his/her room for all meals. The resident was observed to eat between 25% and 50% of foods and fluids that were provided. The resident was able to eat independently once meals were delivered.  

No RN assessment could be located for the severe weight loss.

The facility failed to ensure an RN assessment was completed for the weight loss identified from September 2023 to October 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED) on 10/24/23. She staff acknowledged the findings.

An RN assessment for resident weight changes have been completed for all residents.  Findings have been documented, including resident status and interventions.  A Weight Team including a Med Tech and Dietary staff member has been created to ensure timely weights and dietary participation in interventions.

Resident status, including weights and vitals, is reviewed mohtly or more frequently in accordance with the Prestige Weights and Vitals Policy and Procedure and the requirements of OAR 411-054-0045 (1)(a-f)(a)(C-F). RN will conduct an assessment within 48 hours of any significant change of condition.

RN will be responsible for compliance through monitoring of monthly weights and monitoring of Resident STM's.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 5 sampled residents (#s 3 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 09/2020 with diagnoses including schizoaffective disorder and abnormality of gait.

Review of Resident 6's current facility records and MAR from 07/01/23-07/31/23 revealed the following:

Resident 6's current facility records included a physician order dated 02/17/23 to "obtain monthly weight and enter in PCC in Weight/Vitals area. Report any weight gain or loss of over 5 pounds to Nurse/DHS and retake weight. If unable to get weight please document and notify Nurse/DHS."

Review of Weights and Vitals Summary from the PointClickCare (PCC) electronic records system showed the following:

* 05/04/23 weight of 206.6 pounds;

* 05/31/23 weight of 194.8 pounds, a loss of 11.8 pounds from the prior recorded weight;

* 06/19/23 weight of 187.8 pounds, a loss of 7.0 pounds from the prior recorded weight;

* 06/30/23 weight of 183.2 pounds, a loss of 4.6 pounds from the prior recorded weight;

* 07/05/23 weight of 191.6 pounds, a gain of 8.4 pounds from the prior recorded weight; and

* 07/30/23 weight was not taken, and the MAR was coded "Other / See Progress Notes"; however, no records were found in the progress notes on 07/30/23 related to weights.

In an interview on 08/02/23 at 10:15 am, Staff 2 (Health Services Director) stated she was not notified of either weight losses or gains of over five pounds, and there was no documented evidence the weights were retaken.

The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 on 08/02/23 at 1:55 pm. They acknowledged the findings. No further information was provided.

2. Resident 3 was admitted to the facility in 08/2015 with diagnoses including hyperglycemia, bipolar disorder, and lymphedema.

Resident 3's 07/01/23-07/31/23 MAR and signed physician's orders, dated 04/17/23, were reviewed during the survey.

An order for monthly weights, dated 03/31/20, included the parameters to obtain weight before breakfast, reweigh if significant difference from last weight obtained, and notify nurse and physician with change of 5 pounds in 1 month.

Resident 3's weight record from 02/14/23 through 07/14/23 was reviewed and the following was identified:

a. Six out of nine weights were obtained between 11:20 am and 5:25 pm.

b. Weight fluctuations of 5 pounds or greater occurred four times, with documentation variably indicating Resident 3 was standing or in a wheelchair.

* Between 03/03/23 and 03/14/23, Resident 3 gained 5.9 pounds;

* Between 03/14/23 and 04/03/23, Resident 3 lost 11.9 pounds;

* Between 06/02/23 and 07/06/23, Resident 3 gained 7.5 pounds; and

* Between 07/06/23 and 07/14/24, Resident 3 lost 8.5 pounds.

There was no documentation of reweighs when a significant difference occurred, and no documentation that nursing or the physician had been notified of these greater than 5 pound weight fluctuations.

Findings were reviewed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (Assistant Health Services Director) on 08/02/23. They acknowledged the findings.

Resident 6 & Resident 3 monthly weights have been placed on the eMar for a monthly record.  Weights are taken in the a.m. on a calibrated scale.  RN reviews monthly with more frequent reweighs when risk factors are present or there is a significant difference from last weight.  RN reviews reweighs which are documented on Resident Point Click Care chart.  Weights outside of parameters are done weekly with a Short Term Monitor put into place including actions to follow.  Medical provider is notified of weights with a greater than 5 pound fluctuation. ED and RN will be responsible for compliance via review weights monthly or more frequently as needed at SMART meetings.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) to accurately reflect the time needed to care for residents. Findings include, but are not limited to:

The ABST was reviewed on 08/01/23 and 08/02/23 with Staff 1 (ED).

Data for Residents 1, 2, 3, 5, and 6 were reviewed, and it was determined the ABST failed to accurately reflect the residents' current status and care needs in multiple areas.

The need to ensure ABST entries accurately reflected resident care needs was discussed with Staff 1 (ED) on 08/02/23. She acknowledged the findings.

Residents 1, 2, 3, 4, 5 and 6 ABST have been updated based on current condition and needs following an RN assessment and Service Planning Team participation. The ABST will be updated per OAR 411-054-0037 (1-8) prior to move in, amendments within the first 30 days of admission, whenever there is a significant change of condition and no less than quarterly  The ED and RN will be responsible for compliance via review of the ABST at SMART meetings.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) at least quarterly for resident care needs. This is a repeat citation. Findings include, but are not limited to:

The ABST was reviewed on 10/24/23 with Staff 1 (ED).

Data for all residents in the facility was reviewed and showed that 29 residents ABST data were not updated at least quarterly, within 30 days of admission or after a significant change of condition.

Additionally,one resident admitted to the facility on 10/20/23, had an incomplete ABST data record.

The need to ensure ABST entries were complete for all residents and updated at least quarterly was discussed with Staff 1 (ED) on 10/24/23. She acknowledged the findings.

The ABST for all residents has been updated based on current conidtion and needs following an RN assessment and Service Planning team participation.  The ABST will be updated per OAR 411-054-0037 (1-8) prior to move in, amendments within the first 30 days of admission, whenever there is a significant change of condition and no less than quarterly.  Resident ABST entries will be complete.

The ED and RN will be responsible for compliance via review of the ABST at SMART meetings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 new staff completed all pre-service orientation topics prior to beginning job responsibilities and 4 of 4 new staff complete pre-service dementia training prior to providing care to residents. Findings include, but are not limited to:

Staff training records were reviewed on 08/01/23.

1. There was no documented evidence Staff 11 (CG), Staff 12 (CG), Staff 13 (CG), or Staff 15 (CG), hired 06/02/23, 05/02/23, 06/13/23, and 06/02/23, respectively, completed one or more of the following pre-service orientation topics:

* Infectious Disease Prevention; and

* Fire safety and emergency procedures.

2. There was no documented evidence Staff 11, Staff 12, Staff 13, or Staff 15 completed the required dementia care training prior to providing care to residents:

* Dementia disease process, including progression, memory loss, psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to behaviors and reducing the use of anti-psychotics;

* Strategies for addressing social needs and engaging them in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach.

The need for newly hired staff to complete all required pre-service orientation and dementia care training was discussed with Staff 1 (ED) on 08/01/23 and 08/12/23. She acknowledged the findings.

Staff 11, 12, 13 and 15 will complete the Oregon Care Partners PreService Dementia Care, PreService Infection Prevention Class and training on fire safety and emergency procedures.  All staff will have their classes and training completed by 9/30/23. Per OAR 411-054-0070 (3-4), new hires will complete these classes and training.  Classes and training will be completed within 7 days of hire.  Staff will not be scheduled for further training until these have been completed.  The ED will ensure compliance via monitoring of completion by obtaining certificates of completion from each employee.  Certificates of completion will be placed in employee training files. Training files will be kept on an ongoing basis to track all training requirements for each staff member.  Files will be maintained by ED and/or RCC.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 12, 13, and 15) 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 08/01/23.

There was no documented evidence Staff 11 (CG), Staff 12 (CG), Staff 13 (CG), or Staff 15 (CG), hired 06/02/23, 05/02/23, 06/13/23, and 06/02/23, respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

* General food safety, serving, and sanitation;

* Other duties as applicable (med pass, treatments); and

* First aid/abdominal thrust.

The need for newly hired staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (ED) on 08/01/23 and 08/02/23. She acknowledged the findings.

Staff 11, 12, 13 and 15 will demonstrate competency in all assigned job duties by 9/30/23.  A competency checklist will be collected in order for staff membes to continue working directly with residents.  The ED will ensure all the skills and competency checklists will be completed on new hires within 30 days of hire.  The RCC will track the training requirements of OAR 411-054-0070 (6)(9) and place the completed checklists in the employee training file.  The ED will ensure compliance via oversight of New Hire Training and Onboarding.  

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long-term staff (#s 7, 8, 10, and 16) completed 12 hours of annual in-service training, including a minimum of six hours of dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 08/01/23.

There was no documented evidence Staff 7 (MT), Staff 8 (MT), Staff 10 (MT), or Staff 16 (CG), hired 06/17/17, 04/27/20, 07/01/21, and 06/06/19, respectively, completed a minimum of 12 hours of annual in-service training, including a minimum of six hours of training related to dementia care.

The need to ensure long-term staff complete the required number of annual in-service training hours was discussed with Staff 1 (ED) on 08/01/23 and 08/12/23. She acknowledged the findings.

Staff 7, 8, 10 and 16 will complete 12 hours of required topics in OAR 411-054-0070 (5-7), including a minimum of six hours of dementia training through the Oregon Care Partners or the Health Care Academy by 9/30/23.  The ED will ensure that a minimum of 12 hours of annual in-service training, including a minimum of six hours dementia training, abdominal thrust training and infectious disease training will be completed by all staff.  Completion of annual training records will be maintained by the ED and/or RCC for all staff members in staff training files.  The ED will be responsible for compliance through regular audits of the files and monthly employee progress reports provided through the Health Care Academy.  

Based on interview and record review, it was determined the facility failed to conduct fire drills consistently every other month and to document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. Findings include, but are not limited to:

Fire and life safety records, dated 02/20/23 through 05/31/23, were reviewed on 08/1/23. The following was identified:

Fire drills were not consistently conducted every other month, and written fire drill documentation did not include all the required elements, including:

* Escape route used;

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

* Evacuation time-period needed;

* Evidence alternate routes were used during fire drills; and

* Staff interviewed did not know the designated point of safety.

The need to consistently conduct fire drills every other month, to document all required elements for fire drills, and to ensure all staff knew the designated point of safety in accordance with the OFC requirements was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 08/01/23. The staff acknowledged the findings.

Fire drills were conducted on day shift and swing shift on 8/25/23.  Evacuation training, including location of the designated point of safety, will be completed at an All Staff meeting on 9/29/23 and periodically throughout the year. A NOC shift fire drill will be conducted prior to 8/31/23. A full evacuation will take place in September 2023.  Unannounced fire drills will be conducted each shift on a monthly basis. Per OAR 411-054-0090 (1-2), written documentation of required elements will be completed with each fire drill and stored with the Maintenance Director.  The ED will ensure fire drills and documentation are completed via quarterly audits.   

Based on interview and record review, it was determined the facility failed to ensure all residents were re-instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed on 08/01/23. There was no documented evidence residents were re-instructed on general fire and life safety procedures, evacuation methods, and responsibilities at least annually.

The need to ensure all residents received re-instruction on general fire and life safety training at least annually was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 08/01/23. They acknowledged the findings.

All residents will be reinstructed on general safety procedures, evacuations methods, resonsibilites during fire drills and the designated meeting place inside and outside the building by 9/30/23. Written documentation of resident reinstruction including elements in OAR 411-054-000 (5) will be completed and stored by the Maintenance Director. Residents will participate in a full evacuation drill in September. New residents will be instructed on all required elements of OAR 411-054-000 (5) within 24 hours of admission by the Maintenance Director or his designee. The ED will ensure compliance through quarterly audits.  

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

Refer to C 252, C 260, C 262, C 270, C 280 and C 361.

OAR 411-054-0105 (2-2) will be followed during all inspections and investigations.

ED will be responsible for continued compliance.

Based on observation and interview, it was determined the facility failed to ensure the design of an ALF emphasized a residential appearance while retaining the features required to support special resident needs relating to handrails installed on one or both sides of resident-use corridors. Findings include, but are not limited to:

During a tour of the ALF on 07/31/23 at 09:20 am the following was identified:

Approximately 40 feet of the corridor on the second floor between the corner seating area and the activity room did not include handrails on either side of the corridor.

The need to ensure handrails were installed on one or both sides of resident-use corridors was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 08/01/23 at 10:55 am. They acknowledged the findings. No further information was provided.

Hand rail was installed in the area noted on 8/9/2023 by a third party contractor, Leonard Schindler.  Work has been completed.