The findings of the re-licensure survey conducted 02/28/22 through 03/02/22 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 living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 03/02/22, conducted 05/25/22, 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.

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:

The kitchen was toured on 02/28/22. The following areas were in need of cleaning and/or repair:

* Dried food build up on the wall below the warewashing machine;

* Black debris on the metal transition pieces behind the warewashing machine;

* Multiple areas of missing or chipped pieces of laminate on the drawers in front of the steam table;

* Dried food/spills on the wall near the ice machine;

* Black debris on shelving under the bread warmer;

* Dried splatters/spills on wall near walk in refrigerator;

* Dried splatters/spills on wall behind where plate lids and trays were stored; and

* Dried spills on the shelving with clean dishes stored in the bistro area.

The areas in need of cleaning and/or repair were reviewed with Staff 4 (Dietary Manager) on 08/28/22 at 1:30 pm.  He acknowledged the findings.

1. The following actions have been taken to correct each violation:

* Dried food build up on the wall below the warewashing machine has been removed and area cleaned.

* Black debris on the metal transition pieces behind the warewashing machine has been removed and area sealed and cleaned.

* Multiple areas of missing or chipped pieces of laminate on the drawers in front of the steam table have been repaired.

* Dried food/spills on the wall near the ice machine have been removed and area cleaned.

* Black debris on shelving under the bread warmer has been removed and area cleaned.

* Dried splatters/spills on wall near walk in refrigerator has been removed and area cleaned.

* Dried splatters/spills on wall behind where plate lids and trays are stored has been removed and area cleaned.

* Dried spills on the shelving with clean dishes stored in the bistro area have been cleaned.

2. To prevent this violation from occuring again, the Dietary Manager will inservice dietary kitchen staff on cleaning procedures and implement daily cleaning protocals and assigned tasks to kitchen personnel including check-off task list to ensure thorough cleaning/repair.

3. The area needing correction will be evaluated weekly by dietary manager, or designee, for four weeks, and quarterly thereafter.

4. The Dietary Manager, or designee, will be responsible to see that corrections are complete and monitored.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements and failed to ensure evaluations were updated as needed during the 30 days following the resident's move into the facility for 1 of 2 sampled residents (#3) whose move-in evaluations were reviewed. Findings include, but are not limited to:

Resident 3 moved into the facility in January 2022.

The resident's move-in evaluation was reviewed during survey and the following required elements were not addressed:

* Nutrition habits, fluid preferences;

* Unsuccessful prior placements;

* Elopement risk or history; and

* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature.

There was no documented evidence Resident 3's initial evaluation was updated and modified as needed during the 30 days following the resident's move into the facility.

The failure to address all required elements in the move-in evaluation and to update or modify the evaluation within 30 days after move-in was shared with Staff 1 (Administrator) on 03/01/22. She acknowledged the findings.

Resident 3's move-in evaluation via service plan meeting were updated during suvery to reflect missing information as identified by the surveyor.

2. To prevent this violation from occurring again, the Move-In Evaluation has been updated to include questions pertaining to nutrition habits, fluid preferences (likes and dislikes); unsuccessful prior placement, elopement risk or history and environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature.  

The Move-In Evaluation will be completed prior to move-in, unless there is a an urgent needa and then evaluation is to be completed within 8 hours of move in.   Service plan meeting scheduled within the 30 day re-evaluation time period.  

Administrator and LN will be inserviced on the completion of the move in evaluation requirements and updates within the 30 day period post move in.  

3. Administrator, or designee, will conduct an audit will be scheduled weekly for 90 days, and quarterly thereafter of all new move ins, to ensure evaluation has been completed fully and updated/as indicated wihtin the 30 days post move in.

4. The Administrator, or desgniee, will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status and care needs and provided clear direction to staff regarding the delivery of services for 1 of 4 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility 01/2022 with diagnoses including history of stroke and diabetes mellitus.

Review of Resident 3's service plan, interviews with Staff 7 (MT) and Staff 6 (CG), and observations of the resident indicated the service plan was not reflective of resident's needs and did not provide clear instructions to staff in the following areas:

* Morning routine;

* Use of slide board;

* Skin;

* Use of compression stockings; and

* What to do related to loss of independence.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (Administrator) on 03/01/22. She acknowledged the findings.

1. Resident 3's service plan has been updated to reflect resident needs and now provides clear instruction to staff regarding morning routine, transfer status, skin condition, compression stocking use and potential loss of independence.

2. To prevent this violation from occurring again, the service plan will be completed prior to move-in by Administrator and LN, with updates to Service plan occuring as needed ongoing.

3. Service Plans will be audited by Administrator, or designee, weekly for residents with Service plan meetings for 90 days and quarterly thereafter.

4. The Admnistrator will be responsible to ensure corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure resident changes of condition were monitored, at least weekly, through condition resolution for 1 of 4 sampled residents (# 4) who experienced changes of condition which required monitoring. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2022.

Resident 1's clinical records were reviewed during survey. The resident received the following new medication orders after an emergency room visit on 01/24/22:

* Hydralazine (for hypertension);

* Lisinopril (for hypertension);

* Narcan nasal spray (for decreased responsiveness);

* Synthroid (for hypothyroid); and

* Discontinue hormone cream.

There was no documented evidence the facility monitored the resident for the multiple changes in medications.

The need to ensure resident changes of condition were monitored, at least weekly, through condition resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/01/22. They acknowledged the findings.

1. Review of Resident 1, and current status post change in medications has been done by facility LN.

2. To prevent this violation from occurring again, residents returning to community following Emergency room visit Emergency room visit will be reviewed by Admin and/or LN to ensure monitoring implemented, as indicated. Resident placed on alert charting to monitor for change of conditions. RSC and Med Techs in-serviced by LN on Alert charting and change of condition protocols.

3. Residents returning from Emergency room visit will be audited weekly for four weeks and quarterly thereafter by faciity LN.

4. The LN or designee will be responsible to ensure corrections are complete and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted in 2017 with diagnoses which included diabetes.

Resident 4's physician orders and MARs, reviewed from 02/01/22 through 02/28/22, revealed the following orders were not followed:

a. Resident 4 had an order for Lantus insulin 22 units daily at bedtime. On 02/16/22 and 02/20/22, staff noted that the insulin was held because either the CBG was "out of parameter" or "see Nurse Notes." However, no CBG was documented for either day. Additionally, staff failed to provide further explanation in the clinical record as to why the order was not followed.

b. The resident had an order for Victoza (diabetic medication) 1.2 mg injection daily before breakfast. On 02/12/22 and 02/18/22, staff documented the medication was not administered, but failed to explain why the order was not followed.

c. S/he had orders for Novolog sliding scale insulin to be given before breakfast, lunch and dinner in varied amounts based on results of the CBGs. On 02/25/22, at 8:00 am and 12:00 pm, staff had not checked the CBG or administered any needed sliding scale insulin.

d. Resident 3 had an order for Nystatin powder twice daily. According to the MAR, staff failed to apply the powder on 19 occasions.

e. Staff were instructed to provide genital perineal care twice daily. The MAR indicated 19 occasions that the care was not provided.

The need to ensure orders were followed was reviewed with Staff 1 (Administrator) and Staff 2 (RN) during interviews on 03/01/22. The findings were acknowledged.

2.  Resident 2 was admitted in 2019 with diagnoses which included chronic pain.

Physician orders and MARs, reviewed from 02/01/22 through 02/28/22, revealed the following orders were not followed:

* Tylenol 500 mg two tablets three times a day was not administered on two occasions: and

* Gabapentin (for pain) 100 mg three times a day was not administered on two occasions.

On 03/01/22 at 1:15 pm, the surveyor, Staff 2 (RN) and Staff 7 (MT) observed/checked the MARs and medication supply. Staff 7 was unable to verify if the above orders had been followed.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) on 03/01/22 at 2:50 pm. She acknowledged the findings.

1. Resident 4 and Resident 3 February MAR and TAR have been reviewed, any identified ommissions have been communicated to provider.  

2. To prevent this violation from occurring again, Medication Technicians have been inserviced on facility policy regarding administration and documentation of Medications and treatments, per physician orders. Including appropriate process for when a medication/treatment cannot be administered.

3. LN, or designee, will audit weekly for four weeks and quarterly thereafter, for any Medication and/or treatment omissions.

4. The RN will be responsible to see ensure the correction is complete and monitored.

3. Resident 4 was admitted in 2017.

Residents 4's MARs were reviewed from 02/01/22 through 02/28/22 and the following was noted:

* Lack of resident-specific instructions for multiple PRN bowel medications, including sequential order of use.

In an interview on 03/01/22 at 1:15 pm, Staff 7 (MA) reviewed the resident's MAR. She confirmed the multiple PRN bowel medications lacked specific instructions for staff. She stated she was unsure which medication should be given first. No further information was provided.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 03/01/22 at 2:50 pm. No further information was provided.

4. Resident 2 was admitted in 2019.

The 02/2022 MAR directed staff to administer Haldol 0.5 mg one tablet every four hours PRN agitation or delirium, and Lorazepam 0.5 mg one tablet every four hours PRN for anxiety. However, the MAR lacked resident specific instructions for how s/he expressed agitation and anxiety. Additionally, there were no parameters directing staff regarding which one to administer first.

During an interview on 03/01/22 at 1:15 pm, Staff 7 (MT) reviewed the MAR and confirmed the lack of parameters for the PRN Haldol and Lorazepam.

In an interview on 03/01/22 at 2:50 pm, Staff 1 (Administrator) reviewed the MAR and acknowledged it lacked clear parameters for staff.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and reasons for use for medications, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed.  Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2022 with diagnoses including diabetes.

Resident 3's physician orders and 02/01/22 through 02/28/22 MARs were reviewed.

Resident 3 had orders for:

* Blood sugar checks two times daily with instruction to staff if the blood sugar level was less than 70;

* Bisacodyl 10 mg suppository as needed for bowel care;

* Milk of  Magnesia given 30 ml by mouth as needed for bowel care; and

* Polyethylene powder as needed for bowel care.

There were no resident specific parameters and instructions for which PRN medication to use first for bowel care and there was no upper limit parameter identified relating to the resident's blood sugars.

The need to ensure there were clear parameters regarding blood sugar checks and bowel medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/01/22 at 2:30 pm.  Staff acknowledged the findings.  

2. Resident 1 was admitted to the facility in 2022.

Resident 1's February 2022 MAR and physician's orders were reviewed during survey.

On 01/25/22, Resident 1 was ordered Narcan nasal spray, as needed, for decreased responsiveness. The MAR lacked resident specific parameters as to how the resident might display decreased responsiveness, specific instructions for staff related to when the medication should be administered and any after care instructions required.

The need to ensure the MAR included resident specific parameters and medication specific instructions was discussed with Staff 1 (Administrator) and Staff 2 RN on 03/01/22. They acknowledged the MAR lacked clear parameters and medication specific instructions.

1. Action taken to obtain resident specific parameters and reason for use to Resident 1, 2, 3 & 4 MAR's.

2. To prevent this violation from occuring again, all new admissions will have specific parameters and reason for use included with each med/tx, as indicated.  In addition, all current residents will have orders reviewed for clarification, resident specific parameters put in place and reason for use indicated.

3.  LN will inservice RSC and Med Tech on medications that need parameters and protocol for obtaining those parameters. LN, or designee, will review weekly for four weeks and quarterly thereafter all new medication orders to ensure parameters are in place, as indicated.

4. The LN will be responsible to ensure corrections are complete and monitored.

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, documented evidence the resident was informed of the risks and benefits associated with the device, documentation of less restrictive alternatives prior to use, and documented instructions to caregivers on the correct use and precautions of the device for 1 of 2 sampled residents (#2) who had a half-length side rail on his/her bed. Findings include, but are not limited to:

Resident 2 admitted to the facility in 04/2019 with a diagnosis of fibromyalgia with chronic joint pain.

Observations during the survey on 02/28/22 revealed Resident 2 had a hospital bed. The left side of the bed was against the wall and the right side had a half-length side rail in the raised position. Resident 2 stated in an interview on 02/28/22 that s/he used the side rail for mobility and positioning.

Documentation review during the survey revealed the following required elements were not complete:

* Assessment by an RN, PT or OT;

* Documentation of less restrictive alternatives prior to use of the device;

* Documentation the resident was informed of risks and benefits associated with the device; and

* Instruction provided to staff on the correct use and precautions of use of the device.

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT and completion of all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/01/22. They acknowledged the findings.

1.Resident 2 has been assessed by RN for safe use of the supportive device, less restrictive options available and education to all staff on proper use of device.

2. To prevent this violation from occurring again, each resident with use of a supportive device will be assessed by an RN, PT or OT with documentation of less restrictive options considered, documentation that resident is informed of risks and benefits of device and that all staff have been educated on use of device.

Staff have been inserviced to notify Admin or RN, if outside healthcare service or family brings in new side rails /adds to exisiting bed, to allow for required assessment.

3. Admim, or designee, will audited weekly for four weeks, and quarterly thereafter.

4. The Admin will be responsible to ensure corrections are complete and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 10, 11 and 12) completed all required training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 03/01/22 and with Staff 3 (Resident Services Coordinator) on 03/02/22. There was no documented evidence Staff 10 (CG), hired 12/21/21, Staff 11 (CG), hired 01/03/22, and Staff 12 (CG), hired 01/22/22 completed training in the use of the abdominal thrust and First Aid.

The need to ensure staff have completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 3 on 03/03/22. She acknowledged the findings.

1. Immediate actions taken to correct the rule include confirming copies of First Aid and abdominal thrust training certification are within employee file, including employees 10, 11 and 12.

2. To prevent this violation from occuring again, Abdominal Thrust and First Aid Training has been included in Pre-Day One schedule, to be completed prior to on-the-floor training.

Staffing director has been inserviced on the requirement for Abdominal Thrust and First Aid Training.

3.  Administrator, or designee, will audit weekly for four weeks, and quarterly thereafter.

4. The Staffing Director will be responsible to ensure corrections are complete and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 direct care staff (#8) completed the minimum required 12 hours of annual in-service training. Findings include, but are not limited to:

Annual staff training, including monthly staff meetings and online training, were reviewed on 03/01/22 and with Staff 3 (Resident Services Coordinator) on 03/02/22.

* Staff 8 (CG) hired 01/02/16 did not have documented evidence of completing the required 12 hours of annual in-service training.

The need to ensure direct care staff completed the required annual training was reviewed with Staff 3 on 03/02/22. She acknowledged the findings.

1. Immediate action taken to correct this violation included scheduling necessary annual in-service training for staff #8.

2. To ensure this violation does not occur again, Maquis Wilsonville ALF has implemented Oregon Care Partners approved trainings for annual in-service requirement. Documentation will be maintained by facility.

3. The area needing correction will be audited weekly for four weeks, and quarterly thereafter by administrator, or designee

4. The Staffing Director will be responsible to ensure corrections are complete and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was conducted with staff every other month. Findings include, but are not limited to:

Fire and life safety training records, dated 03/31/21 through 02/28/22, were reviewed during survey. There was no documented evidence fire and life safety instruction was provided to staff every other month.

The need to ensure fire and life safety instruction was conducted with staff, every other month, was discussed with Staff 1 (Administrator) on 03/02/22. She acknowledged the findings and stated the facility did not have any further documentation of fire and life safety training for staff.

1. Fire and Life Safety Training meeting for all staff and will continue per regulation ongoing.

2. To ensure the violation does not occur again, Fire and Life Safety Training will be included every other month during scheduled all-staff meetings.

Maintenance director has been inserviced on the requirements for Fire and life safety instruction training requirements.

3. Administrator, or designee, will audit every other month for 90 days to ensure compliance.

4. The Maintenance Director will be responsible to ensure corrections are complete and monitored.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained and in good repair. Findings include, but are not limited to:

A tour of the exterior of the facility on 03/01/22 at 8:30 am revealed the following:

* A concrete pathway near the outdoor patio had a four inch drop off which posed a potential tripping hazard.

The need to ensure exterior pathways were maintained and in good repair was discussed with Staff 1 (Administrator) and Staff 5 (Plant Operations Manager) on 03/01/22. They acknowledged the findings.

1. Action has been taken to correct the violation includes ordering gravel to fill four inch drop off which posed potential tripping hazard.

2. To prevent the violation from occuring again, the grounds will be toured/inspected as scheduled by the maintanence Director.

Maintanance director has been inservices on expectations on exterior pathways

3. Administrator, or designee will be audited monthly X 90 days, then quarterly thereafter.

4. The Administrator and Maintenance Director will be responsible to ensure corrections are complete and monitored.

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

Exterior and interior areas of the facility were toured on 02/28/22 at 11:00 am and 03/01/22 at 8:30 am respectively and the following was observed:

*  Cushions on outdoor furniture were soiled, had a build up of mold, and were torn with inside stuffing exposed;     

* Carpeting in several areas of the facility was soiled and stained. Specific areas included, but were not limited to; the hallway near room 203, rooms 103, 215 and 310; and

* Rooms 103, 215 and 310 had unpleasant odors during the survey on 02/28/22 and 03/01/22.

The need to ensure the environment was maintained, clean and in good repair, and free from unpleasant odors was discussed with Staff 1 (Administrator) and Staff 5 (Plant Operations Manager) on 03/01/22. They acknowledged the findings.

1. Immediate actions taken include disposal of old outdoor cushions, with new outdoor cushions ordered. Professional carpet cleaning has been scheduled for all common areas and hallways of ALF, to include rooms 103, 215 and 310.

2. To prevent this violation from occuring again, outdoor cushions will be stored away from winter elements, and replaced as needed.  In addition, soiled carpeting will be immediately reported to Maintenance Director via TELS system, and individual rooms will be inspected at least quarterly to ensure carpet is in good repair.  Those residents with frequent and unexpected bowel accidents will have washable runner mats within room to alleviate soiled carpeting.

3. The area needing correction will be audited weekly for four weeks, and quarterly thereafter by Administrator, or designee.

4. The Maintenance Director and Administrator will be responsible to ensure corrections are complete and monitored.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

The facility was toured on 03/01/22 at 10:45 am with Staff 5 (Plant Operations Manager).

Observations and interviews with Staff 1 (Administrator) and Staff 5 confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with an alarming device to alert staff when residents exited the building was discussed with Staff 1 and Staff 5 on 03/01/22. They acknowledged the findings.

Facility will have secured bid for alert door monitoring by POC date, request will be made to contractor for earliest completion as possible, given current supply issues as reported by contractor.

Pending door alerts, facility will continue with process of resident sign out book at the receptionist desk.

Administrator is responsible to ensure bid and contract is completed and monitoring for earliest date to schedule by vendor.   

The following information was provided via email by Stephanie Swayne on 3/28/22 related to C655

"We have secured wireless cameras/motion sensors at each exit door, notifying the med tech on shift of resident exiting the building.  These will be in place until our permanent system is installed.