Oregon DHS Aging and People with Disabilities

Based on interview and record review, it was determined the facility failed to investigate incidents and resident to resident altercations to rule out abuse and neglect and report to the local SPD office when appropriate for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in November 2019 with diagnoses including dementia.

Review of the resident's progress notes, incident investigations and physician communications from 11/6/19 through 1/29/20 showed the following:

* The resident experienced a non-injury fall on 12/30/19, there was no investigation completed.

The need to investigate each resident incident to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 1/30/20. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia.

Review of the resident's progress notes, incident investigations and physician communications for 10/20/19 through 1/29/2020 showed the following:

* Resident 2 was slapped by another memory care resident on 10/25/19, the investigation indicated the incident was reported three days later;

* Resident 2 was choked by another memory care resident on 12/25/19, the investigation indicated abuse was ruled out because the resident was not fearful/tearful; and

* Resident 2 was shoved by another memory care resident on 12/26/19, the investigation did not indicate if the resident was knocked to the ground during the altercation and noted abuse was ruled out because the resident was not fearful/tearful.

There was no evidence the three resident to resident altercations were reported to the local SPD office.

The need to investigate each resident incident to rule out abuse and neglect and report resident to resident altercations to the local SPD office was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 1/30/2020. The staff acknowledged the findings.

Staff 1 was asked to report the injuries that were not investigated to the local SPD office and provided confirmation of the reports prior to survey exit.

3. Resident 3 was admitted to the facility in June 2014 with diagnoses including dementia.

Review of the resident's progress notes, incident investigations and physician communications for 11/1/19 through 1/29/2020 showed the following:

* The resident experienced a non-injury fall on 11/11/19, there was no investigation completed.

The need to investigate each resident incident to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 1/30/2020. The staff acknowledged the findings.

1. Sampled residents were reported the day of the survey. All incidents over the prevoius 5 months were reviewed by the team and incidents found that had resident to resident contact were reported.

2.All current and new hire staff will complete Oregon care partners abuse and neglect training.

All staff training on first responder and incident report training will be completed.

APS to complete an in-service on abuse and reporting.

ED will have root cause analysis training completed and approved by the policy alylis by 2/28/2020.

All Incident reports will be reviewed with the ED and Nurse to complete root cause analysis. Any resident to resident contact will be reported to APS within the guidelines.

4. ED, RN, and RCC will work together to oversee compliance. Ultimately the ED will sign off on all incident reports and assure APS reporting is completed.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and that staff followed safe 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 on 1/29/2020 showed the following:

* Walls, a window, the ceiling and an AC unit in the kitchen had splatters, spills and drips;

* Food debris, dirt accumulation and a large brown spill were located under the shelves in the dry food storage;

* A white powder was spilled across the spice shelves;

* Floors throughout the kitchen had black discoloration and multiple cracked and/or raised sections of linoleum;

* Refrigerator/freezer units had drips and splatters down the doors and kick plates and had food debris on shelves and the bottoms of the units;

* Handles on the center, side by side unit were broken and taped;

* Baseboards throughout the kitchen had black accumulation along the top edges;

* Rust and white accumulation was observed on the dry storage shelves;

* Broken plastic and debris was in the drain under the steam table;

* Exposed wood and chips were on the center shelving unit across from dishwasher;

* A metal pan with discolored liquid and debris was located under a leaking pipe near clean dish/pan storage;

* Debris on lower storage shelves and on trays with clean dishes;

* A large puddle of water that reappeared quickly after clean up, was in front of the double refrigerator;

* Corner guards were cracked and had missing plastic near the steam table and refrigerators; and

* Two boxes of beans, a plastic bin of oats and a bin of flour were opened and uncovered in the dry food storage.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 5 (Dietary Manager) on 1/29/2020. The staff acknowledged the findings.

1. A new kitchen manager was hired, a kitchen team cleaning and repair in-service was scheduled.

ED and Kitchen Manager will review the dining room manual for safety and sanitation expecations.

All dining staff will complete a training on Resident services meals and food sanitation BI-monthly.

ED will check with dining manager weekly for compliance with daily cleaning check off sheets and completion of daily cleaning tasks.

ED will walk through kitchen weekly with kitchen staff to review the cleaniness and ensure cleaning is being addressed.

ED will walk with maintenance manager and ensure completion of repairs of chipped walls, leaking sink and shelving are repaired or replaced.

Maintenance will complete the weekly QA for first impressions and maintenance weekly QA that includes a walk through of the entire community.

2. ED, Maintenance and Kitchen Manager will complete community QA weekly for completion to ensure all areas of kitchen are being addressed for repairs and cleaniness.

3.Weekly oversight by the ED will occur in addition to Maintenance Manager and Kitchen Manager.

4.ED, Kitchen Manager and Maintenance Manager

Based on interview and record review, it was determined the facility failed to monitor residents' conditions based on their evaluated needs and document on the progress of short term changes of condition at least weekly until resolved, for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in November 2019 with diagnoses including melanoma and chronic pain.

The resident's 11/6/19 service plan, 11/1/19-1/29/2020 progress notes, temporary service plans, physician faxes and January 2020 MARs were reviewed. The resident experienced multiple short term changes without documented monitoring until resolution and/or resident specific directions to staff in the following areas:

* Falls;

* Cut to the head;

* Weight loss;

* Cellulitis;

* Hospitalization/ER; and

* Medication changes.

The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 1/30/2020. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia.

The resident's 1/9/2020 service plan, 11/1/19-1/29/2020 progress notes, temporary service plans, physician faxes and January 2020 MARs were reviewed. The resident experienced multiple short term changes without documented monitoring until resolution and/or resident specific directions to staff in the following areas:

* Resident to resident altercations; and

* Fall.

The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 1/30/2020. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in June 2014 with diagnoses including anxiety and osteoporosis.

The resident's 12/16/19 service plan, 11/1/19-1/29/2020 progress notes, temporary service plans, physician faxes and January 2020 MARs were reviewed. The resident experienced multiple short term changes without documented monitoring until resolution and/or resident specific directions to staff in the following areas:

* Falls;

* Sore throat;

* Missed medications;

* New Medications; and

* Bruises to buttocks and toe.

The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 1/30/2020. The staff acknowledged the findings.

1. The nurse will enter a late entry into the 3 sampled residents progress notes to capture current status of each of these residents in a summary that includes the last 3 months of care that was provided.

2.Charting will be reviewed consistantly during stand up in morning clinical meetings to assure charting is being completed. The Nurse, Resident Care Coordinator or designee will ensure that staff charting is being closed out with ending results.

The Med Tech will begin completing a QA daily sign off prior to leaving their shifts, the Nurse and RCC will oversee compliance and completion of this QA.

Med Techs will have a daily assignment sheet to sign off prior to leaving their shift that includes charting overview.

The RCC and RN will complete a weekly QA that includes charting, ED will hold weekly one on ones with Nurse and RCC to assure compliance is met.

Med Techs will have BI-weekly in-services to go over proper charting, progress notes and ISP's. At these meetings they will review examples of charting.

3.Charting will be evaluated at the morning clinical meetings that occurs 4-5 days a week. ED will meet weekly with RCC and Nurse to go over QA results for the week that include charting oversight.

4.Nurse, Resident Care Coordinator and or assigned designee overseen by the Executive Director.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

C302: Systems: Tracking Controlled Substances;

C303: Systems: Medication and Treatment Orders; and

C330: Systems: Psychotropic Medications.

The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Administrator), and Staff 2 (RN) on 1/30/2020. The staff acknowledged the findings.

See POC for C302, C303, C330

Based on observation, interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 3) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 3 was admitted to the facility in June 2014 with diagnoses including anxiety.

The resident's 10/17/19 signed physician orders showed the resident had an order for Lorazepam 0.5 mg (anti-anxiety) every six hours PRN for anxiety and 0.5 mg Lorazepam twice a day for anxiety which was given at 8:00 am and 2:00 pm.

The resident had three dosing cards (bubble packs) for his/her Lorazepam; one for PRN doses, one for 8:00 am doses and one for 2:00 pm doses.

Resident 3's Controlled Substance Disposition Logs and MARS, reviewed for January 2020, revealed the following:

* Three occasions when staff signed that Lorazepam was given. However, the MARs and/or the Controlled Substance Disposition Logs lacked corresponding time and date documentation for when the resident received the medication.

Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 1/30/2020. The staff acknowledged the findings.

1. The nurse held a med tech inservice on the policy for narcotics.

2. Audit of Narcotic book and MAR to be completed weekly focused on disposition logs and MAR having matching information.

RCC and Nurse to complete a weekly QA that includes review of narcotic system with a weekly one on one meeting with ED for oversight.

Bi-Weekly inservices with Med Techs for competency and on-going training will be provided on proper procedures for the narcotics,logs and MAR.

3. Weekly and Bi- weekly

4. Nurse and Resident Care Director with Executive Director oversight.

Based on interview and record review, it was determined the facility failed to ensure that physician's orders were followed for diabetic medications for 1 of 1 sampled resident (#3). Findings include, but are not limited to:

Resident 3 was admitted to the facility in June 2014 with diagnoses including diabetes.

Review of the resident's signed physician orders dated 10/17/19 and January 2020 MARs showed the following:

The resident had orders for Novolog sliding scale insulin before meals, blood sugar of 201-250 give 3 units, blood sugar of 251-300 give 5 units, blood sugar of 301-350 give 6 units and blood sugar of 351-599 give 7 units.

* There were 42 occasions when sliding scale insulin was documented as administered, but no blood sugars were documented and there was no documentation of the number of units of insulin given.

The resident had orders for scheduled Novolog give 10 units before meals. Insulin was not to be given if the resident's blood sugar was below 120.

* There were 60 occasions when no blood sugars were recorded to determine if the insulin should be held as directed by the physician orders.

On 1/30/2020 at 10:15 am Staff 2 (RN) and Staff 4 (RCC) were advised of the lack of insulin and blood sugar documentation. In response to the missing documentation, Staff 4 updated the eMAR to prompt staff and require blood sugar and insulin units to be entered. Additionally, Staff 2 and Staff 4 re-educated current Med Tech staff on the expected requirements.

The need to document blood sugars and units of insulin administered to ensure physician orders were followed was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 1/30/2020. The staff acknowledged the findings.

1. The eMAR was immedialty fixed so that it alert the med techs to document the CBGs.

2.MAR audits will be done weekly focused on treatment orders.

eMAR will now alert staff for documentation on CBG's.

BI- Weekly Med Tech inservices for further education on proper procedures for treatment orders will occur.

Nurse and RCC will complete managers QA that includes documenting oversight of the treatement orders with weekly one on one meeting to provide oversight by the ED.

3.Weekly auditing to evaluate system will occur.

4. Nurse and Resident Care Director with Executive Director oversight.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been attempted with ineffective results, prior to administering PRN psychoactive medication for 1 of 1 sampled resident (#3). Findings include, but are not limited to:

Resident 3 was admitted to the facility in June 2014 with diagnoses including dementia and anxiety.

Resident 3 had a physician's order for Haloperidol 0.5 ml every six hours PRN for agitation and an order for Lorazepam 0.5 mg, one tablet every six hours PRN for anxiety/agitation.

The resident's January 2020 MAR showed PRN Haloperidol was administered on two occasions and PRN Lorazepam was administered on eight occasions for agitation and/or anxiety. There was no documentation that non-drug interventions had been attempted with ineffective results prior to administering the PRN psychotropic medications.

The need to ensure non-pharmacological interventions were attempted with ineffective results prior to administering the PRN psychoactive medication was reviewed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 1/30/2020. The staff acknowledged the findings.

1. Nurse added invervetions to all PRNS immediatly

2.Weekly Mar Audits focused on all psychotropic medication to ensure non pharmacological interventions are documented.

Bi-Weekly Med Tech inservices will be completed to ensure staff compentency with policies and procedures with psychotropics.

Weekly Nurse and RCC QA audits to ensure oversight in addition to weekly one on ones with the nurse and RCC with the ED.

3.Weekly QA audits to evaluate systems will occur in addition to a bi-weekly Med Tech training focused on psychotropic policies are executed.

4. Nurse and Resident Care Director with Executive Director oversight.

Technical Assistance was provided in the following area:

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC).

(a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts.

(b) Fire and life safety instruction to staff must be provided on alternate months.

(c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department.

(d) A written fire drill record must be kept to document fire drills that include:

(D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

(F) Staff members on duty and participating; and

Technical Assistance was provided in the following area:

(f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff.

(g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop offs that could cause tripping hazards for residents. Findings include, but are not limited to:

Observations of the exterior facility courtyard on 1/29/2020 showed drop offs at the pathway edges and near the fence of approximately 2-5 inches in multiple areas.

The need to ensure pathways in the resident courtyard did not have potential tripping hazards related to drop offs was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance) on 1/29/2020. The staff acknowledged the findings.

1. Items listed are scheduled to be completed.

2.Bark Mulch will be layed down along all pathways.

Bar will be placed to ensure sturyness of fence until fence is replaced.

New bar will placed in fence to ensure sturdyness.

All court yards will have fresh new mulch layed to ensure safety for residents

Maintenance QA audits will be reveiwed ongoing compliance to include weekly one on ones with ED and maintenance.

3. Weekly

4 Maintenance Manager with Executive Director oversight

C420/422

Fire Life Safety Drills will be conducted per the OAR

Fire and Life Safety will be conducted per the OAR

Staff training and drills will be conducted monthly.

ED and Maintance will assure complaince.

Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair and free of unpleasant odors. Findings include, but are not limited to:

Observations of the memory care unit conducted on 1/27/2020 and 1/28/2020 showed the following:

* Chipped, dinged, gouged, scratched and scuffed walls, doors and door frames throughout the unit;

* Splatters and spills on multiple walls throughout the unit;

* Multiple dining room chairs had scrapes, dings, chips and spills to the arms, seats and legs;

* Multiple common area chairs and benches had stains, spills and chips/scrapes to wooden legs and arms;

* Multiple dark stains and red stains on carpets throughout the unit common areas;

* Numerous long black scrapes and gouges on the dining room and activity room floors;

* Strong urine odors in the common living room and halls of the 100 hall, that did not dissipate throughout the day;

* Room 101's bathroom had gouges and scrapes to wood doorframes and linoleum was separating;

* Room 108 had large pieces of paint missing from the bedroom wall, bathroom doorframe was chipped and dinged, linoleum was pulling away from the bottom of the shower and near the toilet, the bathroom baseboard was pulling away from the wall and masking tape that was wrapped around the bottom seat frame of a commode chair, was stained black and brown;

* Room 214 had deep gouges to the bathroom door frame; and

* Thick white accumulation and debris was in the drain behind the dryer and garbage/debris was on the floor behind the dryer.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) and Staff 3 (Maintenance) on 1/29/2020. The staff acknowledged the findings.

1. All items are scheduled to be cleaned/repaired.

Chipped, dinged, gouged, and scuffed walls and doors will be filled in and fresh paint

cleaning check list will be reviewed for compeletion

New furniture has been ordered

Shampoo carpets on weekly scheduled cleaning list to help eleminate orders

Rm 101 will have linoleum will be sealed and door frames through out community will be filled and repainted.

108 will have the lenoleum sealed and counter will be repaired walls will be repainted

Masking tape has been remove from commode and cleaned

Laundry rooms will be cleaned weekly

2. Weekly QA audits will be reviewed for completetion

3. Weekly

4. ED and Maintenance

Technical assistance was provided in the following areas:

Z163: Nutrition and Hydration

OAR 411-57-0160

(2)(c) A daily meal program for nutrition and hydration must be provided and available throughout each resident's waking hours. The individualized nutritional plan for each resident must be documented in the resident's service or care plan. In addition, the memory care community must: (A) Provide visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and

(B) Provide adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

C310: Systems: Medication Administration

OAR 411-54-0055

(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.

(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.

(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:

(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).

(D) Resident allergies and sensitivities, if any.

(E) Resident specific parameters and instructions for p.r.n. medications.

The findings of the re-licensure survey conducted 1/29/20 through 1/30/20 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 C refer to the Residential Care and Assisted Living Facilities 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 living

bid: twice a day

CBG: capillary blood glucose or

blood sugar

cc: cubic centimeter

CG: caregiver

cm: centimeter

F: Fahrenheit

HH: Home Health

HS or hs: hour of sleep

LPN: Licensed Practical Nurse

MA: Medication Aide

MAR: Medication Administration

Record

MCC Memory Care Community

mg: milligram

ml: milliliter

O2 sats: oxygen saturation in the

blood

OT: Occupational Therapist

PT: Physical Therapist

PRN: as needed

qd: every day or daily

qid: four times a day

RN: Registered Nurse

SP: service plan

TAR: Treatment Administration

Record

tid: three times a day

The findings of the first re-visit to the re-licensure survey of 1/29/20, conducted 12/28/20 through 12/29/20, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.