Friendsview Retirement Community

The findings of the re-licensure survey, conducted 06/26/23 through 06/28/23, 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 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 06/28/23, conducted 11/20/23 through 11/21/23, 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 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause and resident-to-resident altercations were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 1 of 1 sampled memory care resident (#8) whose incidents were reviewed. Findings include, but are not limited to:Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 06/10/23 service plan, 03/26/23 through 06/26/23 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident was noted to be confused, required one to two staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident could not make his/her needs known, inconsistently answered yes/no questions appropriately, and had frequent agitation. The resident had frequent physical and verbal aggression towards staff, including hitting, yelling, throwing dishes and ramming others with his/her walker or wheelchair.a. Review of the resident's records showed the following:* An incident report dated 04/12/23 indicated the resident was found on the floor on 04/01/23. The investigation was not completed until 04/12/23;* An incident report dated 05/02/23 indicated the resident was found on the floor on 04/28/23, no injuries were noted. The investigation was not completed until 05/16/23;* An incident report dated 05/01/23 indicated the resident had an assisted fall, no injuries were noted. The investigation was not completed until 05/16/23;* An incident report dated 05/09/23 indicated the resident had an assisted fall to the ground outside. No injuries were noted. The investigation was not completed until 05/16/23;* An incident report dated 05/11/23 indicated the resident had an assisted fall to the floor. No injuries were noted. The investigation was not completed until 05/16/23;* An incident report dated 05/22/23 indicated the resident had a fall in his/her room. No injuries were noted. The investigation was not completed until 06/20/23;* An incident report dated 05/27/23 indicated the resident was found on the floor in the living room. No injuries were noted. The investigation was not completed until 06/16/23; * An incident report dated 06/04/23 indicated the resident threw himself/herself out of the wheelchair while experiencing a hallucination. No injuries were noted. The investigation was not completed until 06/20/23;* An incident report dated 06/06/23 indicated the resident was found on the floor near the couch. No injury was noted. The investigation was not completed until 06/22/23; and* An incident report dated 06/08/23 indicated the resident sustained skin tears to the right shin when his/her leg fell down between the foot rest and chair. The investigation was not completed until 06/13/23.The investigations were not completed promptly after the incidents, to rule out abuse and neglect and to determine actions to prevent reoccurrence as a result of the incidents.b. Additional review of the resident's progress notes and investigations showed the following:* A progress note dated 04/06/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 grabbed another resident's arm while yelling at them and was extremely agitated with staff. No investigation was completed of the altercation, and it was not reported to the local SPD office.* A progress note dated 04/11/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 was hit in the face by another resident and Resident 8 was agitated and upset.No investigation was completed of the altercation, and it was not reported to the local SPD office.* An incident report dated 05/16/23 indicated the resident was found to have a skin tear and had a fall the night before. No injury was noted for the fall of 05/15/23. The investigation of the skin tear found on 05/16/23 was not completed until 05/23/23. A progress note dated 05/19/23 indicated a new skin tear was sustained to the forearm. The investigation was unclear how many skin tears were found and how they occurred. The investigation was unclear how abuse and neglect was ruled out and any further information about the previous fall's relationship to the new injuries.* A progress note dated 06/05/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 chased and kicked another resident in the memory care as well as chasing and striking out at staff at the time.No investigation was completed of the altercation, and it was not reported to the local SPD office.* An investigation dated 05/15/23 indicated the resident sustained a fall in the courtyard. Another resident witnessed the fall and stated the resident caught his/her walker on a corner and fell. No injuries were noted. In an interview on 06/28/23, Staff 1 (Director of Health Services) indicated at the time of the fall there were deep edges along the sidewalk which the resident caught his/her walker on. Staff 1 stated the maintenance director rectified the issue at the time of the resident's fall. Staff 1 acknowledged the investigation did not address how the resident fell or properly rule out abuse and neglect. The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD as needed was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.Staff 1 was asked to report the five incidents and provided confirmation of the reports prior to survey exit.

2. Resident 4 was admitted to the facility in February 2023 with diagnoses including dementia, impaired mobility, obstructive sleep apnea, and major depressive disorder.The resident's current service plan, dated 05/23/23, was reviewed, observations were made, and interviews were conducted between 06/26/23 and 06/28/23. Resident 4's service plan was not reflective and did not provide clear instruction to staff in the following areas:* Two-person assist with transfers, brief changes, and dressing;* Specific assistance needed with incontinence care provided in bed;* Use of tilt-in-space wheelchair;* Enjoyed participating in music activities; and* Ability to use the call light.The need to ensure resident service plans were reflective of current status and care needs, and provided clear direction to staff was reviewed with Staff 1 (Director of Health Services), Staff 4 (Resident Care Manager/LPN), and Staff 9 (Resident Care Coordinator) on 06/28/23. They acknowledged the findings.
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 to staff regarding care and services, and were implemented by staff for 2 of 7 sampled residents (#s 4 and 8). Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 06/10/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not consistently implemented by staff in the following areas: * Hearing aides;* Fall risk interventions, including fall mat and motion mat; * Behaviors, including aggression toward staff, hitting and kicking;* Bathing and toileting assistance;* One- versus two-person transfer assistance and gait belt use;* Wheelchair versus walker use;* Dining preferences including use of finger foods versus utensils, use of paper plates and plastic utensils, favorite foods to help with refusals, and location of meals; and* Hospice comfort care interventions, including floating heels when laying down, repositioning every two hours, and oral care every two hours. The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented by staff was discussed with Staff 1 (Director of Health Services), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. They 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 were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and progress was documented weekly until resolution for 1 of 1 sampled memory care resident (#8). Findings include, but are not limited to:Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia.Interviews with staff and review of the resident's 06/10/23 service plan, 03/26/23 through 06/26/23 progress notes, incident investigations, and physician communications were completed.a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas:* New medications and medication changes;* Injury and non-injury falls;* Skin issues, including skin tears; and* Behaviors, including resident-to-resident altercations.b. The resident experienced non-injury falls on 03/29/23, 04/01/23, 04/28/23, 05/01/23, 05/09/23, 05/10/23, 05/11/23, two falls on 05/16/23, 05/22/23, 05/27/23, 06/06/23, and 06/07/23.There was no documentation in the resident's record the facility had promptly documented complete investigations of the falls to determine the cause, minimize reoccurrence, determine actions and interventions, and communicate them to staff for each fall.c. The resident experienced a severe weight gain of 11.8 pounds, or 8.8%, from 05/08/23 to 06/03/23.In interview on 06/28/23, Staff 2 (Clinical Services Manager) indicated she was not aware of the weight changes for the resident and had not completed an assessment of the changes.The need to ensure short-term changes of condition had weekly progress documented until resolution, provided clear, resident-specific directions to staff, and significant changes were reported to the RN for assessment was discussed with Staff 1 (Director of Health Services), Staff 2, and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled memory care residents (#8) who experienced significant changes of condition. Findings include, but are not limited to:Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia. Weight records, dated 03/03/23 through 06/28/23, and progress notes, dated 03/26/23 through 06/26/23, indicated the resident experienced the following:* An 11.8 pound weight gain between 05/08/23 and 06/03/23, which constituted an 8.8% gain in one month.Progress notes, temporary service plans, and physician communications dated 03/26/23 through 06/26/23 indicated the resident had experienced a recent decline in ADL abilities, as well as an increase in behaviors and agitation. The resident was admitted to hospice services on 06/10/23. Multiple observations of the resident between 06/26/23 and 06/28/23 showed the resident attended all meals served in either the living room or the dining room. Staff sat with the resident for all meals and assisted the resident to eat. The resident inconsistently initiated intake and primarily used his/her fingers to eat rather than utensils. The resident ate less than 25% at the meals observed. In interviews between 06/26/23 and 06/28/23, Staff 20 (CG), Staff 16 (CG), Staff 24 (CG), Staff 10 (LPN), and Staff 25 (Agency CNA) indicated the resident's intake varied and that s/he became overwhelmed if there was too much activity or noise. The resident was not able to consistently make his/her needs known. The staff indicated the resident frequently used his/her fingers to eat, regardless of what type of food was being served. The staff further indicated the resident required staff assistance with his/her meals to ensure any intake occurred. In interview on 06/28/23, Staff 2 (Clinical Services Manager) indicated she was not aware of the weight changes for the resident and had not completed an assessment of the changes. She questioned the accuracy of the weight as the resident's intake was poor and s/he did not typically have issues with edema. The facility failed to ensure an RN assessment was completed for the weight gain from May 2023 to June 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 as a result of the assessment was discussed with Staff 1(Director of Health Services), Staff 2, and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop a staffing plan based on care minutes calculated by the acuity-based staffing tool (ABST) and to update the ABST to accurately reflect the time needed to provide care for 6 of 7 sampled residents (#s 2, 4, 5, 7, 8, and 9). Findings include, but are not limited to:The facility's ABST was reviewed with Staff 1 (Health Services Director) on 06/27/23 and 06/28/23.Staff 1 reported the facility was not staffing according to the plan generated by the ABST. She stated medication administration times were not included in the minutes by which the ABST calculated a staffing plan. Staff 1 indicated the facility was struggling to determine the number of minutes for the required 22 ADLs.ABST data for seven sampled residents (#s 1, 2, 4, 5, 7, 8, and 9) was reviewed. For six of the seven residents the data was not reflective of their current care needs.The need to ensure ABST entries accurately reflected resident care needs and a staffing plan was developed based on the ABST data was discussed with Staff 1 (Health Services Manager), Staff 2 (Clinical Services Manager), and Staff 5 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure outside surfaces were maintained in good repair. Findings include, but are not limited to:The courtyard of the MCC was toured on 06/26/23. There were drop-offs of up to one to three inches along the edges of the pathways of the courtyard. This created a potential tripping hazard for residents.The drop-off areas were shown to and discussed with Staff 1 (Director of Health Services), Staff 3 (MT), and Staff 12 (Facility Services Supervisor) on 06/28/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:Observations made on 06/26/23 revealed the following areas needed cleaning or repair:A. On the third floor Residential Care Facility (RCF) unit:* The chair rails in the common area near nurse's station and near the exam/medication room were chipped, scratched, and rough to touch. * The two elevator door frames were chipped and scratched.B. On the second floor RCF unit: * The two elevator door frames were chipped and scratched.C. On the MCC unit:* The second column in hallway had a chipped edge of drywall and paint.* The exit side of the door to the Health Center was scratched and had chipped paint.The environment was toured on 06/28/23 with Staff 1 (Director of Health Services), Staff 3 (MT), and Staff 12 (Facility Services Supervisor). The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed with Staff 1, Staff 3, and Staff 12. They acknowledged the findings.

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 C231, C361, C510, and C513.

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed, demonstrated competency in assigned duties within 30 days of hire for 3 of 3 newly hired direct care staff (#s 26, 27, and 28), and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics, for 3 of 3 long-term direct care staff (#s 6, 18, and 30). Findings include, but are not limited to:Staff training records were reviewed with Staff 11 (HR Staffing Coordinator) on 06/28/23. The following deficiencies were identified:a. There was no documented evidence Staff 26 (Cook), Staff 27 (CG), and Staff 28 (CG) hired 08/13/22, 02/11/23, and 04/18/23 respectively, completed one or more of the following pre-service orientation topics prior to beginning their job duties:* Abuse reporting requirements; and* Written job description.b. There was no documented evidence Staff 27 and Staff 28 completed the following dementia care training topics prior to providing resident care and services to residents independently:* Dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors which are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident;* How to recognize behaviors which indicate a change in the resident's condition and report behaviors which required on-going assessment;* How to provide personal care to a resident with dementia including an orientation to the residents service plan; and* Use of supportive devices with restraining qualities in memory care communities.c. There was no documented evidence Staff 27 and Staff 28 demonstrated competency in one or more assigned duties within 30 days of hire:* Conditions which require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation; and* Other duties as applicable, including safe medication and treatment administration. d. There was no documented evidence Staff 6 (RCC), hired 12/07/19, Staff 18 (CG), hired 03/19/18, and Staff 30 (CG/MT), hired 11/20/19, completed 16 hours of annual in-service training which included at least six hours of dementia care training.The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Director of health Services) and Staff 11 on 06/28/23. They acknowledged the findings.

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 C260, C270, and C280.

Based on interview and record review, it was determined the facility failed to evaluate residents for activities, to develop individualized activity plans from the evaluations, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 1 of 1 sampled memory care resident (#8) whose service plan was reviewed. Findings include, but are not limited to:A review of the service plan for Resident 8 and an interview with Staff 13 (Therapeutic Rec Coordinator) and Staff 14 (Therapeutic Rec Assistant) on 06/27/23 revealed the following:A. The facility had not completed an activity evaluation which addressed the following:* Past and current interests;* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.B. There was no documented evidence an individualized activity plan had been developed based on their activity evaluation which was reflective of the resident's activity preferences and needs. C. There was no documented evidence a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate and based on the resident's evaluation. The need to ensure the facility completed an activity evaluation addressing the required elements, developed an individualized activity plan based on the evaluation for each resident, and provided daily structured and non-structured activities based on the evaluation was discussed with Staff 1 (Director of Health Services), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

The findings of the kitchen inspection, conducted 10/19/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Service - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 10/19/22, conducted on 12/14/22, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and storage practices prevented cross contamination in accordance with the Food Sanitation Rules OAR 333-150-0000.Finding include, but are not limited to:On 10/19/22 at 9:45 am, the facility kitchen was observed to need cleaning in the following areas:* Mini refrigerator - front doors had food splatters;* The side of the ice machine had build up of hard water stains;* The plexi glass next to the hand washing sink in dish room had build up of hard water stains;* Walk in refrigerator floor had food debris; * Kitchen floor had food debris throughout; and* Dish room floor had food debris, hard water stains on the equipment. The following practices failed to prevent the potential for cross contamination:* One staff was observed to towel dry dishes rather than let air dry. * Large container of lettuce prepped for service was not covered securely in the walk in refrigerator:* A bucket of panko crumbs was not covered in the dry food storage area.The areas identified above were discussed with Staff 1 (Health Service Director) and Staff 2 (Dining Service Director) on 10/19/22. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Finding include, but are not limited to:Refer to C240.