Heartwood Place

The findings of the re-licensure survey, conducted 05/30/23 through 06/01/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily 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 revisit to the re-licensure survey of 06/01/23, conducted 08/29/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained and addressed all required elements, for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 5 was admitted to the facility in 02/2023 with diagnoses including dementia.Review of the resident's admission evaluation identified the following deficiencies related to the required elements:* The item "...how a person copes with change or challenging situations" under "Personality" was not included on the evaluation form and not addressed;* The item "...how a person expresses pain or discomfort" under "Pain" was included on the form but was not addressed; and* The items "Memory, orientation...and decision-making abilities" under "Cognition" were addressed accurately in the resident's service plan but were documented incorrectly on the initial evaluation.Resident 5's initial evaluation was reviewed with Staff 1 (Administrator), Staff 2 (Corporate RN) and Staff 3 (RCC) on 06/01/23. They acknowledged the inaccuracies with the initial evaluation form.

2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including dementia, malnutrition, and osteoporosis.Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 05/30/23 thru 06/01/23, revealed Resident 2's service plan was not reflective of the resident's status and not implemented in the following area: * Home health recommendation to slightly tilt wheelchair and float heels to prevent skin breakdown.On 06/01/23, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN). They acknowledged the service plan was not reflective of the resident's status.3. Resident 3 was admitted to the facility in 06/2015 with diagnoses including dementia and chronic kidney disease.Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 05/30/23 thru 06/01/23, revealed Resident 3's service plan was not reflective of the resident's status and not implemented in the following area: * Resident preference to not use a straw for thickened liquids, who would provide nail trimming, and who would provide snacks and fluids.On 06/01/23, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN). They acknowledged the service plan was not reflective of the resident's status.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and services were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including vascular dementia.Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 05/30/23 thru 06/01/23, revealed Resident 1's service plan was not reflective of the resident's status and not implemented in the following areas: * Two-person assist with transfer; and* Use of the clipped call light.On 06/01/23, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN). They acknowledged the service plan was not reflective of the resident's status and was not being implemented.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident needed or was receiving nursing services or experienced a significant change of condition, and at least one other staff person who was familiar with or who was going to provide services to the resident, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2 and 3's most recent quarterly service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the resident and other required members of his/her Service Planning Team.The need to ensure resident service plans were developed with a Service Planning Team was reviewed with Staff 1 (Administrator), Staff 2 (Corporate RN), and Staff 3 (RCC) on 05/31/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor service planned interventions for 1 of 2 sampled resident (#1) who had repeated falls. Findings include, but are not limited to:Resident 1 was admitted to the memory care facility in 03/2021 with diagnoses including vascular dementia. Resident 1 required a wheelchair for mobility.During the acuity interview on 05/30/23, Staff 1 (Administrator), Staff 2 (Corporate RN) and Staff 3 (Resident Care Coordinator) reported the resident had fallen multiple times in the past 90 days when s/he attempted to transfer without staff assistance.Observations of the resident and staff interview from 05/30/23 to 06/01/23 showed the resident required hands on assistance at all transfers, bowel and bladder care management and supervision when the resident was on [his/her] wheelchair due to attempting self-transfer.A 04/18/23 service plan indicated the resident had right sided weakness and listed fall interventions including the use of clipped call light, nonskid socks, pool noodle under the mattress and the bed and the wheelchair in low position.Progress notes, incident reports and Temporary Service Plan (TSP) dated 03/08/23 through 05/30/23 indicated the resident experienced 14 falls. There was no documented evidence the facility consistently evaluated the pattern of the falls after each incident and determined if the service-planned interventions were implemented and/or continued to be effective. On 06/01/23, the findings were discussed with Staff 1 and Staff 2, including the need to evaluate the circumstances of falls and to monitor the effectiveness of the current service planned interventions. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an Infection Control Specialist was trained by 07/01/22, as required in OAR 411-054-0050 and failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:1. In an interview on 05/30/23, Staff 1 (Administrator) was asked to provide training documentation for the facility's designated Infection Control Specialist. Staff 1 (Administrator) confirmed the facility designated an Infection Control Specialist had not yet completed the required training.The need to ensure the facility designated an individual to be the facility's Infection Control Specialist and completed the specialized training in infection prevention and control protocols within the required timeframe was reviewed with Staff 1 on 05/31/23. She acknowledged the findings.
2. Observations were made during the survey to determine adherence to universal precautions for infection control.On 05/31/23, approximately 9:20 am, the surveyor observed Staff 17 (RCF caregiver) provide incontinence care to Resident 1. During the observation, Staff 17 failed to change gloves after wiping urine and fecal matter from Resident 1's bottom area. Staff 17 touched the resident's shirts and pants and the resident's wheelchair while wearing the same soiled gloves.The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN) on 06/01/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 direct care staff (#s 14 and 15) had documented evidence of First Aid certification training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 05/31/23. Staff 14 (CG) hired 03/20/23 and Staff 15 (CG) hired 04/11/23 lacked documented evidence they had completed First Aid certification training within 30 days of hire.The need for staff to complete all required training within 30 days of hire was discussed with Staff 1 (Administrator) on 06/01/23 at 10:15 am. She 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 C295 and C372.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired staff (#s 12, 13, 14 and 15) completed all orientation training, 2 of 3 sampled direct care staff (#s 14 and 15) demonstrated competency in the required topics within 30 days of hire and 2 of 3 sampled direct care staff (#s 5 and 7) completed a minimum of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:Staff training records were reviewed on 05/31/23. Staff 12 (Receptionist) was hired 02/06/23, Staff 13 (CG) was hired 02/21/23, Staff 14 (CG) was hired 03/20/23 and Staff 15 (CG) was hired 04/11/23. The following were identified:1. There was no documented evidence Staff 12, Staff 13, Staff 14, and Staff 15 completed the required pre-service Infectious Disease Prevention training.2. There was no documented evidence Staff 14 and Staff 15 demonstrated competency in the following areas within 30 days of hire:* Role of service plan;* Providing assist with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.3. The following were identified related to annual in-service training:* Staff 5 (CG) was hired 09/17/19. For the annual period from 10/01/21 through 09/30/22, Staff 5 completed 2.5 hours of the required six hours of in-service training on topics related to dementia.* Staff 7 (CG) was hired 02/21/21. For the annual period from 03/01/22 through 02/28/23, Staff 7 completed 3.0 hours of the required six hours of in-service training on topics related to dementia and a total of 12.42 hours of total in-service training.The need to ensure staff completed all required pre-service training, direct care staff demonstrated competency in the required areas within 30 days of hire and staff completed the required annual in-service training was discussed with Staff 1 (Administrator) on 06/01/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C252, C260, C262 and C270.

The findings of the on-site investigation, conducted 05/17/2023 through 05/17/2023, are documented in this report. The investigation 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. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes on Abbreviations: - The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. - Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.- Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. - If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation, interview, and record review, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to: The facility's ABST was reviewed on 05/17/23 and discussed with Staff 1 who explained the tool they used is Eldermark. S/He showed CS their acuity tool to determine care staff needed but was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The tool did not address all 22 ADLs for each resident and the amount of staff time needed to provide care. In an interview on 05/17/23 at 10:45am, Staff 1 explained the facility staffing per shift, stating that there are two wings of the building. On day and swing shift there are six CG with three on each side of the building and one shared MT. On NOC shift there are two CG, one on each side of the building and one shared MT. Staff 1 stated that the facility has 13 residents who require the assistance of two staff persons for transfers. CS observed the posted staffing plan to have been created on 12/20/22. The posted staffing plan indicated that for day and swing shift to schedule three-to-four CG and one MT. On NOC shift there is one CG, one MT, and one universal worker. The facility failed to implement and update an acuity-based staffing tool that addressed all the 22 activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care and, as a result, the facility's acuity-based staffing tool does not reflect the correct care time for each resident. On 05/17/23, the findings were reviewed with and acknowledged by Staff 1 (Executive Director). Verbal plan of correction: Not provided.