Elite Care Adams - Hood

Based on observation, interview and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to ensure the service plan was reflective of resident needs and ensure the implementation of services for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to: A review of Resident 1's service plan, dated 09/19/24, indicated: * Resident 1 resided in Adams House * Resident 1 was to be checked for incontinence management every two to three hours. During an observation between 5:50 am and 10:22 am on 10/22/24, Resident 1 was not checked or changed. A review of Resident 2's service plan dated 10/19/24, and a Temporary Service plan dated 09/20/24 indicated: * Resident 2 resided in Hood house. * Resident 2 was incontinent of bowel and bladder and care staff were to check Resident 2 every two to three hours and assist with incontinence care; and * Resident 2 had refused cares and when that occurred and Resident 2 became combative, staff were to leave him/her alone, re-attempt after sometime, and "call for a change of face." During an observation on 10/22/24, Resident 2 was toileted upon waking at 7:08 am. Resident 2 was not provided incontinence care again until 11:01 am. During an interview on 10/22/24, Staff 4 (UW) stated s/he was not able to toilet Resident 2 consistent with his/her service plan because Staff 4 was working alone and was cooking, serving and cleaning up breakfast from 8:00 am to 10:30 am. Staff 4 also stated Resident 2 was having a good day, but if s/he were to become aggressive, Staff 4 would have to call an administrator or other management to provide the change of face due to no other staff in the house. A review of Resident 3's service plan dated 09/27/24 revealed: *Resident 3 resided in Hood house. *Resident 3 required scheduled and as needed medications administered by the MT one time per day. During an interview on 10/22/24, Staff 4 (UW) stated Resident 3 did not have any daily medications. The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24. The facility failed to to ensure the service plans were reflective of residents needs and ensure the implementation of services. Verbal plan of correction: Facility will begin staffing two people in each house as soon as possible. They will begin recruitment immediately and will begin contacting agency until they can hire someone effective 10/22/24. They stated that was the last facility on campus with only 1 UW working in each house on a shift and the other houses have 2 UWs.

Based on observation, interview, and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to: Adams and Hood Houses were separate and distinct homes with no shared entrance, each consisting of two floors. A review of the posted staffing plan (undated) indicated the following: * Adams House - 6:00 am-6:00 pm: one Universal Worker (UW); * Hood House - 6:00 am-6:00 pm: one UW; * Adams House - 6:00 pm-6:00 am: one UW; * Hood House - 6:00 pm-6:00 am: one UW; and * Campus Float: 6:00 pm-6:00 am: one UW. 1 UW were observed working in each house during night shift ending on 10/22/24 and day shift beginning on 10/22/24. A review of the facility's schedule for 10/16/24 through 10/22/24 revealed the facility regulary staffed only one UW per shift in each house. A review of Resident 1's service plan dated 09/19/24 and "Fire and Life Safety Education" dated 03/29/24 revealed: *Resident 1 resided in Adams House. *Resident 1 was to be checked for incontinence management every two to three hours; and *Resident 1 was a two-person transfer out of bed in the event of an emergency evacuation. During an observation between 5:50 am and 10:22 am on 10/22/24, Resident 1 was not checked for incontinence management. In an interview on 10/22/24, Staff 6 (UW) stated Resident 1 was a two-person transfer out of bed. A review of Resident 2's service plan dated 10/19/24, and a Temporary Service plan dated 09/20/24 indicated: *Resident resided in Hood House *Resident 2 was incontinent of bowel and bladder and care staff were to check Resident 2 every two to three hours and assist with incontinence care; and *Resident 2 had refused cares and when that occurred and Resident 2 became combative, staff were to leave him/her alone, reattempt after sometime, and "call for a change of face." During an observation on 10/22/24, Resident 2 was toileted upon waking at 7:08 am. Resident 2 was not provided incotinence care again until 11:01 am. During an interview on 10/22/24, Staff 4 (UW) stated s/he was not able to toilet Resident 2 consistent with his/her service plan because Staff 4 was working alone and was cooking, serving and cleaning up breakfast from 8:00 am to 10:30 am. Staff 4 also stated Resident 2 was having a good day, but if s/he were to become aggressive, Staff 4 would have to call an administrator or other management to provide the "change of face" due to no other staff in facility being available. In an interview on 10/22/24, Staff 6 stated in the event of an emergency, s/he would have to call a neighboring facility or call management for assistance. During an interview on 10/22/24, Staff 4 stated in the event of an emergency, s/he would have to have call any management and/or help from other facilities on the campus. S/he further stated if there was a fire s/he would take the residents to the flagpole but s/he didn't know who specifically would monitor residents at the flagpole or in the house during an evacuation. During an interview on 10/22/24, Staff 2 (Administrator) stated the facility used to have a "float" on day shift who worked in both Adams and Hood houses, but their last day was 09/15/24. He further stated residents had eloped from the facility on 10/07/24 and 10/14/24. The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Verbal plan of correction: Facility will begin staffing two people in each house as soon as possible. They will begin recruitment immediately and will begin contacting agency until they can hire someone effective 10/22/24. They stated that was the last facility with only 1 UW working in each house on a shift and the other houses have 2 UW.

Based on observation, interview, and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to develop and maintain and Acuity-Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: Adams and Hood Houses were separate and distinct homes with no shared entrance, each consisting of two floors. A review of the posted staffing plan (undated) indicated the following: * Adams House - 6:00 am-6:00 pm: one Universal Worker (UW); * Hood House - 6:00 am-6:00 pm: one UW; * Adams House - 6:00 pm-6:00 am: one UW; * Hood House - 6:00 pm-6:00 am: one UW; and * Campus Float: 6:00 pm-6:00 am: one UW. 1 UW was observed working in each house during night shift ending on 10/22/24 and day shift beginning on 10/22/24. A review of Hood House's ABST revealed the need for the following care hours: Day (6:00 am - 6:00 pm): 10.38 hours Night (6:00 pm - 6:00 am): 6.87 hours An observation of the morning meal in Hood house revealed breakfast service lasts from 8:00 am to 10:30 am which was cooked, served and cleaned up by a Universal Worker. Interviews on 10/22/24 with Staff 4 (UW) revealed UWs are responsible for preparing, serving and cleaning up the morning meal and serving and cleaning up the noon and evening meals between 6:00 am and 6:00 pm. Staff 4 stated the tasks take about five hours total. Staff 4 stated in the event of an emergency, s/he would have to have call any management and/or help from other facilities on the campus. S/he further stated if there was a fire s/he would take the residents to the flagpole but s/he doesn't know who specifically would monitor residents at the flagpole or in the house during an evacuation. A review of the Adams House's ABST revealed the need for the following care hours: Day (6:00 am - 6:00 pm): 10.63 hours Night (6:00 pm - 6:00 am): 6.72 hours An observation of the morning meal on 10/22/24 revealed breakfast service lasts from 8:00 am to 10:30 am which was cooked, served and cleaned up by a Universal Worker. A review of the facility's schedule for 10/16/24 through 10/22/24 revealed the facility regularly scheduled only one UW in each house per shift. In an interview on 10/22/24, Staff 6 (UW) stated Resident 1, who resided in Adams house required the assistance of two people to transfer out of bed. A review of Resident 1's "Fire and Life Safety Education," dated 03/29/24, indicated  the resident was a two-person transfer out of bed in the event of an emergency evacuation. In an interview on 10/22/24, Staff 6 stated in the event of an emergency, s/he would have to call a neighboring facility or administration for assistance. During an interview on 10/22/24, Staff 2 (Administrator) stated the facility used to have a "float" on day shift who worked in both Adams and Hood houses, but their last day was 09/15/24. He further stated residents had eloped from the facility on 10/07/24 and 10/14/24. In an interview on 10/22/24 at 7:07 am, Staff 7 (UW) stated s/he floated to all facilities on campus during night shift, minus the Specific Needs Contract building, and that s/he helped with resident care, showers, and the delivery of supplies and food. Staff 7 was not observed in the facility again after the interview. After multiple requests on and before 10/22/24, an ODHS-approved float waiver was not provided. A review of Resident 1's service plan, dated 09/19/24, and ABST profile revealed discrepancies in time for the following ADL: * Grooming. A review of Resident 2's service plan, dated 10/11/24, and ABST profile revealed discrepancies in time for the following ADLs: * Monitoring behavioral symptoms; and * Non-pharmacological interventions for behaviors. A review of Resident 3's service plan, dated 09/27/24, and ABST profile revealed discrepancies in time for the following ADL: * Monitoring behavioral conditions or symptoms. The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24. The facility failed to fully develop and maintain an Acuity-Based Staffing Tool.

Based on interview and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to review the initial service plan within 30 days of move-in to ensure that any changes made to the plan accurately reflect the resident's needs and preferences for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of the admission records for Resident 1 indicated a move-in date of 12/13/21. A review of the "30-Day Evaluation/Assessment" for Resident 1 indicated an assessment was completed approximately 53 days after move-in on 02/05/22. Resident 1's service plan was then updated on 02/18/22. The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 07/08/24. The facility failed to review the initial service plan within 30 days of move-in to ensure that any changes made to the plan accurately reflect the resident's needs and preferences. Verbal Plan of Correction: The facility created a spreadsheet that is shared with management to track resident's due dates and their new system Point Click Care "triggers" due dates for service plans. These two systems provided a "double check system."

Based on observation, interview, and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: CS observed the facility consisted of two separate, distinct buildings referred to as "Adams House" and "Hood House" with resident apartments on two separate floors. The facility's resident roster, dated 07/08/24, indicated the facility was home to 23 residents. A review of the posted staffing plan (undated) indicated the following: * Adams House - 6am-6pm: 1 Universal Worker * Hood House - 6am-6pm: 1 UW * Float 6am-6pm: 1 UW * Adams House - 6pm-6am: 1 UW * Hood House - 6pm-6am: 1 UW *Campus Float: 6pm-6am: 1 UW In an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the following: * The facility had an approved waiver for a "float" between buildings. * The "float" was counted towards the staffing hours. On 07/08/24 at 4:00pm, the CS requested a copy of the approved waiver from Staff 1 and a second request was submitted via email on 07/10/24 at 10:46am to Staff 5 (CEO). The facility was unable to provide evidence of an approved waiver after repeated requests. In an interview, Witness 3 (Operations and Policy Analyst) stated the facility's "float" did not count towards the facility's required staffing hours. On 07/08/24, throughout the site visit, the Compliance Specialist (CS) observed the following: * There was one UW in each house. * No "float" staff were observed. In an interview, Resident 5 stated the following: * Only one staff member worked during the day. * Resident 3 required two staff members for transfers and incontinent care. * Wait times for help were often 30 minutes. A review of Resident 3's service plan, dated 06/25/24, stated that resident required the assistance of four staff members to evacuate the building in the event of an emergency. In an interview, Witness 1 (Outside Provider) stated the following: * It was hard to find staff. * Staff worked "between buildings." * S/He was instructed to call a phone number to request staff assistance. During the interview with Witness 1 at 11:28am, an unsampled resident wandered into Resident 2's room. The unsampled resident required redirection, which was done by the Compliance Specialist. Witness 1 stated s/he often had to redirect that unsampled resident because staff were hard to find. In an interview, Witness 2 (Outside Provider) stated the following: * It was hard to find staff. * Only one staff person worked in each building. * S/He was hired due to lack of staff available to care for Resident 3. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 07/08/24. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Verbal Plan of Correction: Management will talk with the owner about the need for more staff and work to hire more staff.

Based on observation, interview and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Findings include, but are not limited to: CS observed the facility consisted of two separate, distinct buildings referred to as "Adams House" and "Hood House" with resident apartments on two separate floors. The facility's resident roster, dated 07/08/24, indicated the facility was home to 23 residents. In an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the facility used the ODHS Acuity Based Staffing Tool and employed Universal Workers (UW) who worked 12 hour shifts. A review of the posted staffing plan (undated) indicated the following: * Adams House - 6am-6pm: 1 Universal Worker * Hood House - 6am-6pm: 1 UW * Float 6am-6pm: 1 UW * Adams House - 6pm-6am: 1 UW * Hood House - 6pm-6am: 1 UW *Campus Float: 6pm-6am: 1 UW In an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the following: * The facility had an approved waiver for a "float" between buildings. * The "float" was counted towards the staffing hours. On 07/08/24 at 4:00pm, the CS requested a copy of the approved waiver from Staff 1 and a second request was submited via email on 07/10/24 at 10:46am to Staff 5 (CEO). The facility was unable to provide evidence of an approved waiver after repeated requests. A review of the facility's Acuity Based Stafffing Tool (ABST) indicated the following: * All residents were entered into the tool. * The tool generated a staffing plan. * The total hours of care needed was 23.92 hours. * Five residents' profiles had not been updated in the last quarter. On 07/08/24, throughout the site visit, the Compliance Specialist (CS) observed the following: * There was one UW in each house. * No "float" staff were observed. * At 11:30am, a resident wandered into Resident 2's apartment. CS redirected the resident. * At 11:37am, the CS observed Staff 3 (UW) was sitting at the kitchen table located on the upper floor. There was no staff available on the lower floor to supervise or rediect the resident who wandered into Resident 2's apartment. In an interview at 11:30am, Witness 1 (Outside Provider) stated s/he had to redirect a male resident out of a female resident's room multiple times because it was difficult to find staff. In an interview, Resident 5 stated wait times for help were often 30 minutes. In an interview, Witness 2 (Outside Provider) stated the following: * It was hard to find staff. * On the morning of 07/08/24, s/he was unable to find staff. * A private caregiver was hired because of a lack of staff and lack of care for Resident 3. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 07/08/24. The facility failed to fully implement an Acuity Based Staffing Tool.

2. Resident 2 moved into the facility in 11/2021 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the 01/03/24 service plan, and Temporary Service Plans, dated 01/07/24 through 02/15/24, identified Resident 2's service plan was not reflective of the resident's care needs and lacked clear direction to staff in the following areas: * Diet status, vegetarian; and * Use of right eye prothesis. The need to ensure the service plans were reflective of the residents care needs and provided clear direction to staff was reviewed with Staff 1 (Administrator), Staff 4 (Health Consultant) and Staff 10 (Campus Manager) on 02/22/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services, including a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and/or was implemented for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. The following was identified: 1. Resident 1 admitted to the facility in 01/2024 with diagnosis including dementia. Observations of the resident, interviews with staff, review of the 02/11/24 service plan, Temporary Service Plans dated 01/18/24 through 02/15/24 and current evaluation identified Resident 1's service plan lacked clear direction to staff and/or was not implemented in the following areas: * Safety checks related to: falls, diagnoses of dementia, disorientation, wandering, inability to use the facility provided call system, and frequent independent walks on facility grounds; * Use of GPS tracing device (JioTracker); * Resident specific activities to decrease risk for potential elopement; and * Bathing assistance, four times weekly. The need to ensure the service plans provided clear instruction to staff and was implemented was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 4 (Health Consultant) on 02/22/24. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1. Actions to be taken to correct the rule violation include: a. TSP was immediately put into place for Resident 1 to detail a clear safety plan to staff, including documented safety checks; plan on who to contact if resident was observed wandering towards the main gate; specific activiy plan to engage resident in meaningful activities and who would be responsible for encouraging activities; and clear plan with direction for use of JioBit tracker. A copy of each tsp were provided to surveyors, and signed by all staff working in license. b. Adams house shower schedule was updated to reflect Resident 1's bathing assistance 4x weekly, as per the resident's service plan. c. TSP implemented for Resident 2 to reflect that she no longer has a preference of Vegetarian meals, but is able to decline foods she does not like. d. TSP implemented to convey plan for nursing and staff monitoring of Resident 2's eye prosthesis, which will also be added to subsequent service plan updates. e. Education will be provided to staff in case of removal or replacement needed. 2. To ensure the system will be corrected so this violation does not happen again: a. During service plan reviews and updates, evaluation will be thoroughly reviewed for completeness and clarity of information and staff direction. b. When reviewing at-risk residents (risk of falls, wandering, elopement, saftey risk, etc) during weekly Clinical Meeting with administrator, nursing staff, and other clinical team memers, the team will ensure there is a clear and concise plan available to staff to ensure resident saftey. c. Diet requirements and preferences will be reviewed with the Dietary manager and Marketing Director in charge of updating and distributing the dietary binders to ensure accuracy and completeness across staff sources. d. During move-in and service plan updates, RN/LPN will review and ensure completenss of information regarding prosthesis, braces, and other supportive/assistive devices. 3. To ensure the system will be corrected so this violation does not happen again, evaluations will be reviewed and updated with any acute or significant change of condition, as well as with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the residents' current status per Oregon State Rule. Clinical services and Facility Administrator participate with this process to ensure accuracy. 4. The Facility Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to conduct and record fire drills every other month according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire drill records were reviewed from 08/2023 through 01/2024, on 02/21/24. Fire drill records reviewed within the look back period were dated 11/28/23 and 01/31/24. The following was identified: a. Fire drills were not conducted every other month or at different times of day. A fire drill conducted on 11/28/23 was not audible, and one or both lacked documentation of the following information: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Number of occupants evacuated; and * Alternate exit routes to react to varying potential fire origin points. b. Fire and life safety instruction was not provided to staff on alternating months between 08/2023 through 01/2024. The fire and life safety instruction reviewed revealed the following: * 10/27/23 training on how to use a fire extinguisher; * 11/28/23 training on how to use a fire extinguisher; and * 12/21/23 training on how to use a med sled. c. There was no documented evidence the facility made an effort to identify residents who were unwilling or failed to participate in fire drills and/or make changes to ensure the evacuation standard was met. In an interview on 02/22/24 at approximately 11:30 am, Staff 1 (Administrator) stated the facility had recently identified the same areas and since has initiated a new system. The need to ensure fire drills, and fire and life safety training was provided and documented as required was reviewed with Staff 1, Staff 3 (RN), and Staff 4 (Health Consultant). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety 1. Actions to be taken to correct the rule violation include: a. Facility will conduct unannounced fire drills every other month at different times of the day and night. No less than 3 on each shift (day/night) annually. b. Fire and life safety instruction for staff will be provided on alternate months. c. Community will implement a fire drill tool that encompasses all required pieces including but not limited to: Evidence alternate escape routes were used; Evidence occupants were evacuated or relocated to the point of safety; problems encountered and comments relating to residents who resisted or failed to participate in the drills; and evidence of immediate changes that were made for residents who were unwilling to participate in the fire drill to ensure the evacuation standard could be met. 2. To ensure the system will be corrected so this violation does not happen again: a. Facility Administrator and Facilities director or designee will complete a comprehensive review of: current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule; in-service for maintenance staff who are conducting fire and life safety drills and education on process and documentation required. b. Facility Administrator and Facilities Director or designee will compile a reference for multiple subjects to utilize during staff safety in services. 3. Facility Administrator and Facilities Director will review documentation for fire drills and staff saftey trainings at the end of each month during stand-up to ensure completeness and accuracy of documentation. 4. Facility Administrator or designee will be responsible to ensure the system has been corrected and that the system is monitored.

The findings of the re-licensure survey, conducted 02/20/24 through 02/22/24, 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 revisit to the re-licensure survey of 02/22/24, conducted on 05/13/24, 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.