Laurel Parc at Bethany

The findings of the re-licensure survey conducted 03/27/23 through 03/30/23 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 03/30/23, conducted 10/11/23 through 10/12/23, 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 second re-visit to the re-licensure survey of 03/30/23, conducted on 12/14/23, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, actions or interventions were determined and communicated with staff, and/or changes were monitored through resolution, with progress noted weekly, for 2 of 5 sampled residents (#s 4 and 7) reviewed with changes of condition. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 08/2021 and had diagnoses including hypertensive heart disease and compression fractures.The resident's clinical record including progress notes, dated 01/03/23 through 03/13/23, temporary service plans (TSP's) and incident reports and investigations were reviewed. The following changes of condition were identified:a. Resident 4 experienced a fall and required an evaluation at the emergency department on 02/04/23. The resident was diagnosed with an "L1 compression fracture" (lower back). The resident was placed on alert monitoring upon return to the facility and staff instructed to monitor for discomfort, pain, bruising, swelling ...related to a fall. Progress notes documented monitoring for pain and changes 02/05/23 through 02/08/23, including a note on 02/05/23 that the resident had been "needing additional help from caregivers." There was no documented evidence, past 02/08/23, that the condition related to the compression fracture was monitored through resolution.b. On 03/12/23, Resident 4 reported s/he fell near his/her bed. The resident was placed on alert monitoring to observe for any further injuries. There was no documented evidence the facility determined what action or interventions were needed for the resident.c. Progress notes from 02/25/23 through 03/16/23 documented a "skin irritation" to the left groin area. The resident was placed on alert monitoring of the skin condition. However, there was no documented evidence of what actions or interventions were needed for staff to follow and no documentation that the condition had resolved. During an interview on 03/29/23, Staff 7 (Assisted Living Facility - RN) provided a form used by the facility to document skin monitoring by the RN and LPN. No documentation was available for the "skin irritation" to the left groin.The need to monitor changes of condition, determine and review interventions for effectiveness and document progress, at least weekly, through resolution was discussed with Staff 2 (Business Office Coordinator), Staff 6 (Assisted Living Facility - RCC) and Staff 7 on 3/30/23. No additional information was provided.
2. Resident 7 was admitted to the facility in 05/2020 with diagnoses including ankle fracture, fibromyalgia, and sleep apnea.The resident's progress notes dated 12/30/22 through 03/28/23, temporary service plans (TSP's), incident reports and investigations were reviewed. The following changes of condition were identified:a. On 01/21/23 the resident experienced a fall next to his/her bed and was complaining of right knee pain after the fall. Staff 6 (Assisted Living Facility - RCC) documented a fall investigation in the progress notes on 01/24/23. On the fall investigation provided on 03/30/23, Staff 6 documented "resident is supposed to call staff for all transfers." During an interview on 03/29/23, Staff 6 stated there was no TSP completed for the fall intervention instructing staff to encourage the resident to call for assistance with transfers. Staff 6 acknowledged there was no documented evidence the intervention had been communicated to staff at the time of the fall and Staff 6 verified the intervention had not been monitored for effectiveness. b. On 03/21/23 Resident 7 complained of left foot pain. On 03/22/23 Staff 7 (Assisted Living Facility - RN) documented in the progress notes for staff to "please offer [him/her] ice and Tylenol for foot pain." There was no documentation of a TSP or other communication to staff regarding these interventions. c. On 03/25/23 Resident 7 experienced a non-injury fall next to his/her recliner. The record lacked evidence that any interventions were determined or reviewed for effectiveness.The need to ensure actions or interventions were reviewed for effectiveness and communicated with staff for short-term changes of condition was reviewed with Staff 2 (Business Office Coordinator), Staff 6 and Staff 7 on 03/30/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure RN assessments were completed following significant changes of condition and included documented findings, resident status and interventions made as a result of the assessment for 1 of 2 sampled residents (# 4) who experienced significant changes of condition. Findings include, but are not limited to:Resident 4 moved into the facility in 08/2021 with diagnoses including atrial fibrillation and tachycardia. The resident experienced the following significant changes of condition:a. On 02/26/23, Staff 8 (LPN) documented "Stage 2-3 raw linear lesion (3 cm and 0.5 cm length) on crevice of inguinal area, left side." The progress note documented the physician was notified, via fax, of the open areas and the LPN provided wound care treatment. A skin monitoring sheet was provided and reviewed. The records did not include any evidence the assessment by the LPN had been reviewed by the RN.During an interview on 03/29/23, Staff 7 (Assisted Living Facility - RN) stated she was not aware of the open areas and had not completed an assessment of the skin condition.b. On 02/25/23, Resident 4 returned to the facility following an emergency department visit for severe back pain. Progress notes documented a note by Staff 7 that the resident was "requiring bed rest and needed three person assist." On 02/26/23, Staff 8 documented the resident was in severe pain, could not move or get out of bed and had a significant decline in physical movement. The record did not include an RN assessment that included documented findings, resident status and interventions made as a result of the assessment. The need to ensure RN oversight of LPN duties and that RN assessments included all required information was discussed with Staff 2 (Business Office Coordinator), Staff 6 (Assisted Living Facility - RCC) and Staff 7 on 3/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure outside providers left written information in the facility that addressed any clinical information necessary for facility staff to provide supplemental care for 1 of 2 assisted living residents (#7) who were receiving services from outside providers. Findings include, but are not limited to:Resident 7 was admitted to the facility in 05/2020 with diagnoses including fibromyalgia and sleep apnea and had a history of falls.Resident 7 was receiving physical therapy from an outside provider. Physical therapy notes were reviewed, dated 01/27/23 through 03/27/23.During an interview on 03/29/23, Staff 6 (Assisted Living facility - RCC) stated the facility did not receive physical therapy notes until a week following the therapist's visit. Review of the physical therapy notes revealed a lack of clinical information necessary for facility staff to provide supplemental care. The notes did not provide clear direction on any recommendations made as a result of the services provided. There was inconsistent documentation that the notes were being reviewed by facility staff.The need to ensure outside providers left written information in the facility that addressed any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 2 (Business Office Coordinator) and Staff 6 on 03/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to carry out orders as prescribed for 1 of 5 sampled residents (# 4) whose orders and MARs were reviewed. Resident 4 was administered two medications the physician had prescribed not to be administered at the same time, putting them at risk of serious harm. Findings include, but are not limited to:Resident 4 moved into the facility in 08/21 with diagnoses including atrial fibrillation and tachycardia. Resident 4's physician's orders and the 02/01/23 through 03/27/23 MARs, were reviewed. The following were identified:On 02/27/23, following an emergency department visit for severe back pain, the physician ordered "Methocarbamol 750 mg TID PRN pain for 2 weeks." The order stated "Do not mix the Flexaril with Methocarbamol. Only give 1 or the other as they can lead to respiratory depression and/or death." The MAR showed the resident had an order for cyclobenzaprine (Flexaril) 5 mg tablet, twice daily for muscle spasms. On 02/26/23, 02/27/23, 02/28/23 and 03/01/23, the resident was administered both the methocarbamol and the cyclobenzaprine (Flexaril). In an interview on 03/28/23, Staff 6 (Assisted Living Facility - RCC) and Staff 7 (Assisted Living Facility - RN) stated they were not aware of the administration of both medications as contra-indicated by the doctor's order. Staff 6 and 7 ensured the resident was no longer receiving both medications and requested a discontinuation of the methacarbamol from the physician. The medication error put the resident at potential risk of harm.Upon further review of the error, Staff 6 stated it appeared the physician's handwritten order had not been provided to the pharmacy. Adult Protective Services was notified of the medication error on 03/30/23 and verification of the report was provided.The need to ensure physician's orders were carried out as prescribed was discussed with Staff 2 (Business Office Coordinator), Staff 6 and Staff 7 on 03/30/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use and addressed all required elements for 1 of 1 sampled resident (# 3) who had side rails. Findings include, but are not limited to:Resident 3 was admitted to the facility in 03/2017 with diagnoses including cerebrovascular accident and hypertension.During an interview on 03/28/23, Resident 3's hospital bed was observed to have half-length side rails on both sides of the bed. The side rails were in the up position and securely fastened to the bed.In an interview with Staff 6 (Assisted Living Facility - RCC) on 03/28/23, side rail assessment documentation was requested. A side rail assessment, dated 03/28/23, was provided by Staff 7 (Assisted Living Facility - RN) at 12:20 pm on 03/28/23. The facility reported the siderails were in place when the resident received a hospital bed on 3/17/23 and that the facility did not provide a siderail assessment prior to the time of the survey. The assessment was reviewed and documented the following: "Benefit of hospital bed with bed rails is that it protects [resident] from falling out of bed." The assessment did not provide the following required information:* Documentation that other less restrictive alternatives had been evaluated prior to the use of the device. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 6 and Staff 7 on 3/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 2 of 2 long term staff working in the assisted living community (#s 11 and 12) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed with Staff 6 (Assisted Living Facility RCC) on 03/29/23. Staff 11 (MT) was hired 03/2009. Staff 12 (CG) was hired 03/2021. Annual training records, provided through online training courses and monthly staff meetings, between 03/2022 and 03/2023 were reviewed. The records indicated Staff 11 and 12 did not complete all six hours of in-service training on topics related to dementia care.The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (ED), Staff 2 (Business Office Coordinator), Staff 5 (Memory Care Director) and Staff 6 on 03/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided and documented on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records for 09/2022 through 03/2023 identified the following:1. The facility had not documented the following areas related to fire drills conducted:* escape route used;* problems encountered; * comments relating to residents who resisted or failed to participate in the drills;* evacuation time period needed; and* number of occupants evacuated.2. There was no documented evidence fire and life safety instruction for staff had been conducted and documented on alternate months.The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 4 (Maintenance Director) on 03/29/23 and with Staff 6 (Assisted Living RCC) on 03/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided and documented on alternate months. This is a repeat citation. Findings include, but are not limited to:Review of fire drill and fire and life safety records from 06/2023 through 09/2023 identified the following:1. The facility had not documented the following information related to fire drills conducted:* escape route used;* problems encountered; * comments relating to residents who resisted or failed to participate in the drills; and* number of occupants evacuated.2. There was no documented evidence fire and life safety instruction for staff had been conducted and documented on alternate months.The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 19 (Maintenance Director) on 10/11/23 and with Staff 1 (ED) on 10/12/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C420.

Based on observation and interview, it was determined the facility failed to ensure the stoves in the memory care house common areas had a keyed, remote switch or other safety device to ensure staff control. Findings include, but are not limited to:A tour of the environment on 03/27/23 revealed the stovetops were disconnected, but each oven in the three memory care common houses were able to be turned on without the use of a keyed, remote switch or other safety device. During an interview on 03/28/23, Staff 4 (Maintenance Director) confirmed the memory care ovens lacked a keyed, remote switch or other safety device.The need to ensure stoves in common-use areas had a keyed, remote switch or other safety device to ensure staff control was discussed with Staff 5 (Memory Care Director) on 3/30/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:The facility was toured on 03/27/23 and fireplaces observed in all three memory care houses were located where residents could come into contact with them. The surface temperature of all fireplaces exceeded 150 degrees F.The need to ensure associated heating elements did not exceed 120 degrees F was discussed with Staff 2 (Business Office Coordinator) and Staff 5 (Memory Care Director) on 3/30/23. Staff turned off the fireplaces during the survey. 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 C 420, C 522, C 640 and Z 155.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C420.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled long term direct care staff, working in the memory care community, (#s 14 and 15) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:Training records were reviewed with Staff 5 (Memory Care Director) on 03/29/23. The following were identified:* Staff 14 (MT) was hired 01/23/2015. Staff 15 (CG) was hired 01/28/2020. For the annual period of their respected hire dates, there were no documented hours of the required 16 hours of in-service training on topics related to dementia and provision of care.The need to ensure that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 1 (ED), Staff 5 and Staff 6 (Assisted Living Facility - RCC) on 03/30/23. They acknowledged the findings.

The findings of the kitchen inspection, conducted 01/17/23, 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 Services - Meals, Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.
The findings of the kitchen inspection, conducted 03/27/23 to 03/29/23, are documented in this report. It was determined the facility was 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 in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 01/17/23 the main kitchen and second floor kitchen were observed to need cleaning and repair in the following areas:a. Main kitchen: Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside or underneath the following: * Entryway door frame and entryway, and elevator doors;* Tile behind elevator control panel;* Floor throughout the kitchen including the walk-in refrigerator and the dry storage areas;* Black serving carts; * Cooler between convection oven and gas range;* Cooler next to cold food prep area; * Spice and cooking oil containers;* White and clear dry storage bins in bread prep areas;* Tile walls behind food prep areas and three-compartment sink;* Metal bakers rack next to ice machine;* Ice machine;* Convection oven, gas grill, and gas range; * Stainless steel backsplash behind convection oven, gas grill and gas range; and * Stainless steel prep tables and stainless steel upper and lower shelves throughout the kitchen.b. Second floor kitchen: Black or brown substance was found on the following surfaces:* Ceramic floor drain covers throughout the kitchen; and* Elevator door. c. The following areas in main and second floor kitchens were in need of repair:* Elevator doors had chipped paint, nicks and gouges and were un-cleanable in some areas.The need to ensure the kitchens were clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) on 01/17/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure it complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a medical grade face masks while in the facility except when the employee is alone in a closed room.Observations made in the kitchen during the survey revealed multiple dietary staff failed to wear a medical grade face mask.The observations and the need to ensure staff wore medical grade face masks while in the facility was reviewed with Staff 1 (ED) on 01/17/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 240.

Based on observation and interview, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 295.