Oregon DHS Aging and People with Disabilities

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the Change of Ownership survey, conducted 9/22/20 through 9/24/20, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

C 150SS=FOAR 411-054-0025 (1) Facility Administration: Operation

New Administrator hired on 10/1/2020. The Administrator will oversee and ensure adequate resident care and services are rendered in the facility.

The Administrator or designee will participate in clinical meetings, review the 24hour report log and review EHR daily and ensure follow-up is completed.

The Owner has retained a consultant group for ongoing suppport.

Owner/Administrator will be responsilbe

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 9/22/20 through 9/24/20, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

Refer to the deficiencies in the report.

C 156SS=FOAR 411-054-0025 (9) Facility Administration: Quality Improvement

Administrator will develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

By conducting daily overall staff assessment during shift change, discussing the quality of care being delivered to the residents.

The QA team meet on a monthly basis to review all areas of facility operations needing improvement.

Administrator / designee, is responsible

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:

Observations were made during the survey to determine adherence to precautions for infection control and to prevent the spread of COVID-19.

1. The memory care facility was home to 13 residents. Ten of the residents tested positive for COVID-19. Nine of the positive residents had completed ten days of isolation and were observed to have access to common areas. One resident remained in isolation in his/her room.

Staff were observed to provide care to the positive resident and interact with and provide care and services for all other residents as well. Presenting a risk of spreading COVID-19 to other residents.

2. The use of medical masks and eye protection by all staff is required during the COVID-19 pandemic.

Staff were observed in common areas to wear their masks below their noses, below their chins, or to be without a masks or eye protection.

3. Face shields used for eye protection were re-used multiple times. There was no established process and space to adequately disinfect and store the face shields for staff re-use.

4. Multiple brushes and a comb were observed in the cupboard in common bathroom B2. There was no identification on the grooming items to know to whom they belonged to prevent use on multiple residents.

The need to ensure staff appropriately and consistently used Personal Protective Equipment, limited interactions between COVID-19 positive and negative residents, and grooming items were not shared between residents, was discussed with Staff 1 (Interim Administrator/Owner). He acknowledged appropriate infection control practices were not implemented.

C 160SS=FOAR 411-054-0025 (4) Reasonable Precautions

Administrator or designee has ensure that each staff member has the proper PPE

All staff has been trained on the proper infection controls as recommended from DHS and the CDC. All staff have been provided with PPE gear and educated on the proper usage scheduled 10/23/2020.

A daily shift check will be made to ensure that there is proper usage of PPE

Each resident has been provided with personal hygiene bins located in residents apartment. Locks will be installed on their personal cabinets by 11/15/2020.

Administrator/Nurse will be responsible

Based on observation and interview, it was determined the facility failed to ensure residents received services in a matter that protected privacy and dignity in a homelike environment. Findings include, but are not limited to:

On 9/22/20, it was observed facility cleaning equipment and supplies were stored in a closet in room 1.

Staff accessed this storage closet by walking through the bedroom of two residents.

The need to ensure residents were provided privacy in a homelike environment was discussed with Staff 1 (Interim Administrator/Owner). He acknowledged facility equipment and supplies were stored in residents living space and accessed by going through the rooms.

C 200SS=EOAR 411-054-0027 (1) Resident Rights and Protection

Administrator has secured the door to the storage area.

which no longer allows access

Cleaning supplies are no longer kept in that closet, they have been removed and are kept in a secure designated supply closet.

Staff no longer have access to said door.

Based on interview and record review, it was determined the facility failed to conduct an investigation of an injury of unknown cause to rule-out abuse and report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 7/2017 and was dependent on staff for all ADL care needs. His/her clinical record revealed the following:

* On 7/21/20, facility charting notes and monitoring logs indicated the resident had a 0.5 x 0.5 skin tear of "unknown cause" on his/her left lower arm.

There was no documented evidence the facility immediately investigated the injury to rule out abuse. The facility did not report the injury to the local SPD office as suspected abuse/neglect.

The need to ensure injuries of unknown cause were investigated promptly and reported if necessary was discussed with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). Staff 1 acknowledged there was no documented evidence the facility had investigated the injury to rule out abuse/neglect. The surveyor directed Staff 1 to self-report the incident. Verification the facility had reported the incident to the local SPD office was received during the survey.

C 231SS=DOAR 411-054-0028 (1-3) Abuse Reporting and Investigation

Abuse and Reporting training will be schedueld for 10/23/2020.

Weekly skin tracking will be in place as of 11/23. Administrator to review weekly to ensure completion.

All staff will complete "Elder Abuse Prevention, Investigation and Reporting" provided by Oregon Care Partners. Completion certificates will be on file by 11/15.

Based on observation and interview, it was determined the facility failed to ensure staff followed food handling practices in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen and food storage areas revealed:

* Food items in the reach in refrigerators were not labeled and dated;

* Raw eggs were stored on a wire shelf above the fresh produce;

* Raw meat was observed left on a counter to thaw;

* Food temperatures were not monitored;

* The back door to the facility was left open without a screen, allowing the entrance of flies; and

* The residential dishwasher was not monitored to ensure the water was reaching 140 degrees Fahrenheit and a chemical disinfectant was not used to ensure sanitation of the dishes.

The need to ensure safe food handling practices are followed was discussed with Staff 1 (Interim Administrator/Owner). He acknowledged the findings.

C 240SS=FOAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

Administrator will check that all food items in refrigerator are labeled and dated daily for the next 30days and then checked weekly for 90days and then quarterly thereafter.

Kitchen will follow all USDA protocols to ensure cleanliness.

All food prior to being platted will be temped daily and monitored in log.

Dishwasher will be temped and monitored daily for the next 60days then weekly thereafter.

New screen door will be installed by back kitchen door by 12/15.

Based on observation, interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and indicate who was involved, including the 30-day update, for 1 of 1 sampled residents (#2) whose initial and 30-day evaluations were reviewed, and the facility failed to ensure quarterly evaluations indicated who was involved for 2 of 2 sampled residents (#s 1 and 2) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 4/2020.

a. Resident 2's move-in evaluation failed to address:

*Customary routines;

*Spiritual, cultural preferences;

*Vital signs;

*Personality, including how copes with change or challenging situation;

*Hearing, Vision Speech, Assistive devices and the ability to understand and be understood;

*Ability to manage medications;

*Ability to use the call light;

*Housekeeping and laundry;

*Transportation;

*Pain;

*Treatments;

*Indicators for nursing needs;

*Emergency evacuation ability;

*Complex medications;

*History of dehydration or unexplained weight change;

*Elopement risk;

*Smoking;

*Alcohol and drug use;

*Environmental factors that impact the residents behavior;and

*Smoking, alcohol use or drug abuse.

There was no indication of who had completed Resident 2's initial evaluation.

b. Resident 2's evaluation was dated as updated on 5/21/20. The evaluation did not address:

*Customary routines;

*Spiritual, cultural preferences;

*Ability to manage medications;

*Transportation;

*Emergency evacuation ability; and

*Environmental factors that impact the residents behavior.

There was no indication of who had completed Resident 2's evaluation on 5/21/20.

2. The quarterly evaluations of Resident 1 and Resident 2 were reviewed.

There was no indication of who had completed the residents' quarterly evaluations.

The failure to address all areas in the move-in and 30 day evaluations of Resident 2, and the failure to indicate who had completed all evaluations was shared with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

C 252SS=EOAR 411-054-0034 (2-4) Resident Move-in and Eval: Res Evaluation

All evaluations and service plans will be re-reviewed and updated. All corrections made by 11/23.

Consultant will have training regarding Resident Move-in and Evalutations completed with Administrator or designee, RCC and RN by 10/26.

Administrator has implemented new evalutation tool for new admits. Signature line has been added on all evaluations and assesments to indicate assessor.

The Administrator will be responsible

Based on observation, interview and record review it was determined the facility failed to ensure 1 of 2 sampled residents' service plans (#1) was reflective of current care needs and provided clear direction to staff. Findings include, but not limited to:

2. Resident 1 was admitted to the facility in 7/2017 and was dependent on staff for all care.

Resident 1's bed was observed with an alternating pressure mattress in place.

Resident 1 was observed seated in a tilt-in-space wheelchair without foot rests in place. Resident 1 was reclined about 25 degrees with his/her legs dangling. A seat cushion was in place.

Resident 1 was observed to be transferred from the wheelchair into bed using a Hoyer lift and the assistance of two staff.

In interview, caregiving staff stated Resident 1:

*Required full assistance with transfers to and from wheelchair and bed with two staff at times;

*Was provided incontinent care in bed;

*Was not able to ambulate; and

*The wheelchair footrests were not used because they were too far apart for the resident's legs.

During a phone conversation, Staff 2 (Resident Care Coordinator) explained staff were to use a cushion behind Resident 1's legs with the footrests so they could be used.

Resident 1 was receiving scheduled pain medication.

Resident 1's service plan was not reflective of:

*Toileting assistance and incontinent care;

*Ambulation ability;

*Transfer ability, including the use of a Hoyer lift and two staff;

*The use of a tilt-in space wheelchair including a seat cushion and a cushion for use with the footrests;

*The use of an alternating pressure air mattress; and

*Pain.

Resident 1's service plan lacked clear instructions for caregivers for the use of the Hoyer lift, the air mattress, the tilt-in-space wheelchair, cushions, and footrests.

The need for service plans to reflect resident care needs and provide clear direction to staff was discussed with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). They acknowledged the service plan was not reflective of Resident 1's care needs and lacked clear caregiving instructions.

C 260SS=DOAR 411-054-0036 (1-4) Service Plan: General

All service-plans will be reviewed and re-done by 11/23. Consultant will review for accurancy and provide ongoing support and training.

SP will be evaluated on a monthly base to ensure accuracy and that the SP is being followed

DON/Administrator will be responsible to make sure it is followed

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 had a physician order, dated 7/23/20, to administer Olanzapine 2.5 mg twice a day at 2:00 pm and 7:00 pm for dementia related behaviors.

Resident 2's 9/1 through 9/22/20 MAR revealed the medication was documented as not administered because "Waiting for delivery from Pharmacy" for the 7:00 pm dose 9/2, 9/4, 9/5 and 9/8/20, and for both doses on 9/3 and 9/6/20. The medication was documented as given at 2:00 pm on 9/2, 9/4, 9/5 and 9/8/20.

Resident 2's Olanzapine order was changed to three times a day on 9/11/20. Review of the medication cards could not verify if the medication had been given.

There was no documented evidence the medication had been administered as ordered.

The physician orders and current MARs were reviewed with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

C 303SS=DOAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

Administrator/RCC will ensure accuracy and timely delivery of all medications and will record and follow-up with any discrepencies.

Residents MAR's will be reviewed daily for the next 30days then quarterly thereafter.

All the staff will be retrained on competency of medication management and treatments.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate, and included specific instructions for PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:

1. Residents 1's 9/1 through 9/22/20 MARs were reviewed.

Resident 1 had physician's orders for:

*Acetaminophen 500 mg as needed for pain; and

*Morphine Sulfate 5 mg as needed for pain.

There were no resident specific parameters directing non-licensed staff on the administration of the two pain medications.

2. Resident 2's 9/1 through 9/22/20 MARs were reviewed.

Resident 2 had a physician's order for Rivastigmine 9.5 mg patch to be applied daily for memory.

There was no indication of the removal of the patch prior to the application of a new one.

On 9/8/20, it was documented the patch was applied to the left deltoid. It was also documented the resident refused the medication.

The need to ensure MARs were accurate and included clear direction and resident specific parameters to guide non-licensed staff was discussed with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

C 310SS=EOAR 411-054-0055 (2) Systems: Medication Administration

Nurse, Administrator and RCC, review resident mar to ensure accuracy for resident 1&2.

Administrator, Nurse, and RCC will review all new/changing medication orders to ensure that all parameters are present and will contact ordering physician immediately if patient specific parameters are missing from order.

Administrator will continually review medication orders to ensure proper documentation.

During each QA meeting with med tech, will train on proper documentation.

Based on interview and record review, it was determined the facility failed to employ a qualified full-time Administrator. Findings include, but are not limited to:

Staff 1 (Interim Administrator/Owner) was acting as the administrator of the Residential Care Facility, Endorsed Memory Care Facility.

Staff 1 acknowledged the facility had not yet hired a qualified full time Administrator.

C 350SS=FOAR 411-054-0065 (1) Administrator Qualification and Requirements

Ownership has hired a full-time administrator that will work 40 hours a week.

Based on interview and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:

The facility was an endorsed Memory Care home to thirteen residents at the time of the Change of Ownership licensure survey. During the acuity interview on 9/22/20 the facility was identified to have residents with high ADL care needs and dementia diagnoses.

In addition to caregiving and medication duties, staff were responsible for:

* All housekeeping duties;

* All laundry service;

* All meal service including cooking, serving and cleaning; and

* Engaging residents in activities.

The staffing plan posted indicated two Universal Workers from 7:00 am to 7:00 pm, one Medication Aide from 7:00 am to 1:00 pm, and one Universal Worker from 7:00 pm to 7:00 am.

Resident 2 was observed to be assisted by two staff with a transfer using a Hoyer lift on 9/23/20.

In interviews with staff, they indicated Resident 2 required the assistance of two staff for transfers.

The failure to adjust staffing levels, based on caregiving staff duties that included meal preparation and service, activities, housekeeping, laundry services, and meeting the needs of resident's requiring the assistance of two staff, was discussed with Staff 1 (Interim Administrator/Owner) and Staff 3 (resident Care Coordinator). They expressed understanding of the need to adjust staffing levels for the 7:00 pm to 7:00 am shift to meet the needs of residents.

C 360SS=FOAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

Staffing Ratio has been met by having a 1 to 6 ratio in the community. That would mean we will have 2 care staff member per shift. Having one unverisal work and a caregiver per shift.

Med Tech from 7 am to 2pm

Administrator will ensure sufficient number of staff be scheduled each shift to meet the scheduled and unscheduled needs of each resident.

Staff will be evaluated on a shift by shift bases for the next 60 day and monthly there after.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics, including pre-service dementia training, was completed prior to providing services to residents, for 2 of 2 newly hired staff (#s 4 and 5). Findings include, but are not limited to:

Facility's training records were reviewed on 9/23/20.

Staff 4 (Universal Worker) hired 1/6/20, and Staff 5 (Universal Worker) hired 5/4/20, lacked documented evidence of completing pre-service orientation including:

*Residents' rights and the values of community-based care;

*Abuse and reporting requirements;

*Standard precautions for infection control;

*Food Handler's certification; and

*Fire safety and emergency procedures.

Staff 4 completed the pre-service dementia training on 7/18/20. Staff 5 completed the pre-service dementia training on 7/16/20.

The need for staff to complete the required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

C 370SS=EOAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

Administrator/RCC will oversee the training and qualification of each current staff member and new hire. All staff member will be required to have the following training prior to working on the floor:

Administrator has created a checklist to ensure the following is completed.

6 hour approved dementia course

Approved First Aid

Approved CPR

Med Tech Training (Universal Workers)

Abuse and Neglect Reporting training

Standard precautions for infection control.

Fire safety and emergency procedures

Food handlers certification

Pre-service orientation to residents and community

Competency training done by Nurse before working independently.

Monthly performance reviews for all staff both current and new hires.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 4 and 5) had documented demonstration of competency in all required areas, completed First Aid certification, and been trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 9/23/20 indicated the following:

1. Staff 4 (Universal Worker) hired 1/6/20, and Staff 5 (Universal Worker) hired 5/4/20, lacked documented evidence an observation and evaluation of competency had been completed within the first 30 days of hire for:

*The role of service plans in providing individualized resident care;

*Providing assistance with the activities of daily living.

*Changes associated with normal aging;

*Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

*Conditions that require assessment, treatment, observation and reporting; and

*General food safety, serving and sanitation.

2. Staff 5 lacked documented evidence of First Aid certification and training in abdominal thrust.

The need to document demonstrated competency in job duties and complete First Aid certification within 30-days of hire was discussed with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

C 372SS=EOAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff

Administrator to educate and train current staff on role of service plans, ADL's changes associated with normal aging and how to identify changes in condition.

Documentation of observed competency in job duties will be created, signed off and on file for all employees.

Administrative team will check each team member file to ensure they completed competency testing

There will be a weekly evaluation done by Nurse/Administrator

Technical assistance was provided in the area of ongoing caregiver training.

All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Annual in-service training hours are based on the anniversary date of hire.

(b) Requirements for annual in-service dementia training:

(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.

(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.

(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.

(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.

(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee's assessed competency.

Training records were reviewed and the only documented on-going training was the Pre-service dementia training completed in July 2020.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. Findings include, but are not limited to:

Fire and life safety records for January - September 2020 were reviewed and lacked the following components:

*Fire drills conducted and recorded every other month at different times of the day, evening and night shifts;

*Specific location of simulated fire;

*Escape route used; and

*Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

There was no evidence of Fire and life safety instruction on alternate months.

The need to ensure the facility was in compliance with all required fire drill components and fire and life safety training was discussed with Staff 1 (Interim Administrator/Owner) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

C 420SS=FOAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and Instruction

Administrator to develop and implement new form for fire drill recording. Form to include location of simulated fire, escape route used, and any problems encountered or comments regarding residents during evacuation.

Administrator will perform fire and life safety instructions on alternate months, with documentation of said education on file in the fire and safety binder.

Based on interview and record review, it was determined the facility failed to include required components on fire drill records. This is a repeat citation. Findings include, but are not limited to:

On 01/11/21, fire and life safety records for 12/2020 through 1/2021 were reviewed. The following deficiencies were identified:

The December fire drill failed to include the following required components:

*Number of occupants evacuated; and

*Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

On 1/12/21, the need to ensure fire drills included all required components was discussed with Staff 8 (Administrator). He acknowledged the findings.