Marquis Hope Village ALF

Based on on interview, observation, and record review, conducted during a site visit on 07/01/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to:In an interview with Staff 1 (RN) on 07/01/24, s/he stated the facility used a "staffing matrix" to determine the staffing needs for any given day.A review of the facility's ABST showed a need for 52.53 care staff hours.An observation of the staff present for day shift on 07/01/24 showed 45.5 care staff hours were scheduled for that day.A review of the facility's ABST revealed Resident 4, who admitted on 06/25/24, was not entered into the tool as of 07/01/24.In an interview, Staff 1 stated the facility's expectation for answering calls was within 10 minutes.A review of call light logs for Resident 3, dated 06/24/24 to 07/01/24, revealed 13 instances where wait times were greater than 15 minutes.A review of call light logs for Resident 2, dated 06/24/24 to 07/01/24, revealed seven instances where wait times were greater than 15 minutes.In an electronic communication recieved on 07/08/24, Staff 3 (Administrator) stated the facility's posted staffing plan reflected the minimum staffing required based on census.The findings were reviewed with and acknowledged by Staff 1 on 07/01/24.The facility failed to fully implement and update an Acuity Based Staffing Tool.

The findings of the re-licensure survey conducted 06/06/22 through 06/08/22 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 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 revisit to the re-licensure survey of 06/08/2022, conducted 08/22/2022 through 08/24/2022, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure investigations of incidents were thorough and complete and incidents of suspected abuse or neglect were reported to the local SPD office in a timely manner for 1 of 1 sampled resident (#2) reviewed with an altercation. Findings include, but are not limited to:Resident 2 was admitted to the facility in 09/2014 with diagnoses including vascular dementia and chronic kidney disease.On 05/11/22 staff documented another resident approached Resident 2 and "took the flowers on the table from Resident 2 and Resident 2 slapped at their hand and told them no". The incident of a resident to resident altercation required a documented investigation to rule out neglect of care or abuse.On 06/08/22, the survey team requested the incident investigation, and was provided a form dated 05/11/22 labeled "Resident to Resident - Staff Questionnaire".The Resident to Resident staff questionnaire failed to document:* The time the incident occurred;* The names of staff that were present;* Follow-up actions to protect the residents;* Plan to prevent reoccurrence:* Determination if abuse or neglect had been ruled out; and* Administrator review and signature.The incident had not been reported to the local SPD. On 06/08/22 the survey team discussed the incomplete investigation with Staff 2 (RN), and requested the facility report the resident to resident altercation to the local SPD. A fax confirmation of the report was received prior to survey exit. The need to ensure any resident to resident altercations were immediately investigated to rule out abuse or neglect, documented completely, and reported if necessary was discussed with Staff 2 (RN) on 06/08/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 6/6/22 at 9:15 am, the main kitchen was observed to need cleaning and repair in the following areas:* Entrance and exit door to the kitchen had chipped paint, gouges and dirt and debris on them;* Grease build-up and food debris was observed on stainless steel knobs on the steam table and stove, stove front, sides and top, and floor by the stove;* The Cupboard underneath the steam table was missing the front laminate, exposing wood underneath and had cracks in it; and* The window where clean dishes were stored had paint peeling off.On 6/6/21 at 10:21 am, the surveyor toured the areas that needed to be clean and repaired with Staff 4 (Dietary Manager) and Staff 5 (Maintenance Director). They acknowledged the areas that needed to be cleaned and repaired.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, monitored or referred to the RN for 1 of 1 sampled resident (# 2) who experienced a significant change of condition. Findings include, but are not limited to:Resident 1 was admitted to the facility in 09/2014 with diagnosis including vascular dementia and kidney disease.The most recent service plan (dated 04/22/22) noted Resident 1 required pureed food texture and required a staff person to actively assist with eating.Weight records identified the resident had a significant loss between 02/16/22 (90 lbs.) and 03/17/22 (81.4 lbs.) s/he lost 8.6 lbs. or a decrease of 9.56% of his/her total body weight in one month.During the survey, Resident 2 was observed to receive pureed food and meal assistance at two meals, consuming approximately 50-75% of his/her meals. There was no documented evidence Resident 1's significant weight loss had been evaluated, referred to the facility nurse, and the service plan updated to reflect the change of condition. The facility's failure to report a resident's significant change of condition to the RN for assessment was discussed with Staff 2 (RN) on 06/08/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by an RN for 1 of 1 sampled resident (#2) who experienced significant weight loss. Findings include, but are not limited to:Resident 1 was admitted to the facility in 09/2014 with diagnosis including vascular dementia and kidney disease.Weight records identified the resident had a significant loss between 02/16/22 (90 lbs.) and 03/17/22 (81.4 lbs.) s/he lost 8.6 lbs. or a decrease of 9.56% of his/her total body weight in one month.There was no evidence the facility RN had completed a significant change of condition assessment to include documented findings, resident status, and interventions made as a result of the assessment. The need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 2 (RN) on 06/08/22 . She acknowledged the findings. Refer to C270.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to providing services to residents for 2 of 3 newly hired staff (#s 8 and 11) whose training records were reviewed. Findings include, but are not limited to:Facility training records for Staff 8 (CG), hired on 04/04/22, and Staff 11(CG), re-hired on 04/19/22, were requested on 06/07/22 at 10:25 am. The following were revealed:a. The facility lacked documented evidence Staff 11 completed all required pre-service training and pre-service orientation with all required elements prior to beginning her job duties including:* Resident rights and the values of community based care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures; * Written job description; and* Pre-service dementia training. b. The facility lacked documented evidence Staff 8 completed all required pre-service training and pre-service orientation with all required elements prior to beginning her job duties including:* Resident rights and the values of community based care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures; * Written job description; and* Pre-service dementia training.The need to ensure newly hired staff completed pre-service training with all required elements prior to beginning their job duties was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/08/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 11) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to:Facility training records for Staff 8 (CG), hired on 04/04/22, and Staff 11(CG) re-hired on 04/19/22 were requested on 06/07/22 at 10:25 am. The following were revealed:a. The facility lacked documented evidence Staff 11 demonstrated satisfactory performance in the following required areas within 30 days of re-hire including:* Role of service plans in providing individualized care;* Changes associated with normal aging;* Identification, documentation and reporting;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* First aid/abdominal thrust. b. The facility lacked documented evidence Staff 8 demonstrated satisfactory performance in the following required areas within 30 days of hire including:* Role of service plans in providing individualized care;* Changes associated with normal aging:* Identification, documentation and reporting;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* First aid/abdominal thrust.The need to ensure newly hired staff demonstrated satisfactory performance in any duty they were assigned within 30 days of hire was reviewed with Staff 1 (Administrator) and Staff 2 (Director of Health Services) on 06/08/22. 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 3 of 3 long-term staff (#s 5, 9 and 12) whose training records were reviewed. Findings include, but are not limited to:Annual in-service training records for Staff 5 (CG), hired on 05/24/18, Staff 9 (CG), hired on 03/25/13 and Staff 12 (MT), hired on 03/04/14 were requested on 06/07/22 at 10:25 am, 1:17 pm and 3:15 pm and on 06/08/22 at 10:25 am. The records were not received prior to the end of the record review process as requested. The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/08/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and failed to provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:Fire drill records from 12/2021 through 06/2022 were reviewed on 06/07/22. The facility lacked documented evidence fire drills included the following required components:* The escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and* Number of occupants evacuated.The need to ensure all required components of fire drills were documented was discussed with Staff 5 (Maintenance Director) on 06/07/22 and Staff 1 (Administrator) on 06/08/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair. Findings include, but are not limited to:Observations of the facility on 06/06/22 revealed the following:* Elevator doors had scratched and chipped paint;* Doors and door frames, including but not limited to Room 212, 213 and 238, were damaged; and* Carpet with dark stains throughout dining room, first floor hall, second floor hall, and common areas.During an interview on 06/07/22 Staff 5 (Maintenance Director) acknowledged the findings.