The findings of the re-licensure survey conducted 03/13/23 through 03/16/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 first revisit to the re-licensure survey of 03/16/23, conducted 07/26/23 through 07/28/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.
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 second re-visit to the re-licensure survey of 03/16/23, conducted 10/12/23, 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 interview and record review, it was determined the facility failed to document monitoring of short term changes of condition until resolution and failed to document monitoring of residents consistent with their evaluated needs for 3 of 5 sampled residents (#s 2, 3, and 6) who experienced falls and short term changes of condition. Findings include but are not limited to:
1. Resident 6 was admitted to the facility in 04/2019 and was evaluated as a fall risk.
a. Resident 6's service plan included interventions to reduce falls.
Resident 6's progress notes and incident investigations for 12/13/22 through 03/13/23 revealed Resident 6 fell 14 times.
There was no documented evidence the service planned fall interventions were monitored and reviewed to determine effectiveness with each incident.
b. The resident's November 2022 service plan, 12/13/22 through 03/13/23 progress notes, temporary service plans, and incident reports were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution in the following areas:
* Multiple Emergency Department visits;
* Swelling, redness, heaviness, and "pins and needles" in legs;
* Chest pain;
* Shortness of breath;
* Bruising from a fall;
* Changes in orientation and responsiveness; and
* Flushed and "... voice more garbled"
There was no documented evidence the changes had been monitored at least weekly until resolved.
The need to monitor changes of condition to resolution was discussed with Staff 1 (Administrator) on 8/10/21. She acknowledged the findings.
The need to monitor residents per their evaluated needs and to monitor changes in condition to resolution was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 6 (Resident Service Manager) and Staff 5 (RCC). They acknowledged the findings.
2. Resident 2 was admitted to the facility in 03/2021 with diagnoses including Post Traumatic Stress Disorder (PTSD).
Resident 2's clinical record and progress notes, reviewed from 12/13/22 through 03/13/23, revealed the following:
a. Staff documented the resident had thrown up and had been nauseous. Review of the record revealed there was no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved.
b. Resident 2 was involved in a resident to resident verbal altercation on 01/07/23, 01/25/23 and 02/04/23. Review of the record revealed there was no documented evidence the facility evaluated the incidents, monitored and documented on the progress of the resident's condition at least weekly until resolved.
c. On 01/10/23, staff documented that Resident 2 reported s/he had a fall. There was no monitoring until resolution documented for the short-term change in condition.
d. Resident 2 was prescribed oral antibiotic medications on 01/11/23 and 02/02/23 to treat an infection. Although the resident was placed on alert charting and monitoring was initiated, there was no documented monitoring of the resident's condition until resolution.
e. The resident had a chronic wound on the left foot. There was no documented evidence the facility consistently monitored and documented monitoring of the resident's condition at least weekly.
On 03/15/23 and 03/16/23, the need to monitor changes in condition until resolution was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Director of Nursing Services), Staff 4 (RN) and Staff 5 (RCC). They acknowledged the findings.
3. Resident 3 was admitted to facility in 05/2021 with diagnoses including seizure disorder and depression.
The resident's service plan dated 01/24/23, progress notes from 01/25/23 through 03/13/23, temporary service plans, and incident reports were reviewed. The resident experienced multiple short term changes without documented monitoring at least weekly until resolution in the following areas:
* Thoughts of self harm and harming others;
* Rib pain;
* Increased agitation; and
* Constipation.
During an interview on 03/15/23 at 2:15 pm, Staff 3 (Director of Nursing) acknowledged that the short term changes of condition were not monitored weekly until resolution. There was no documented evidence the changes had been monitored at least weekly until resolved.
The need to monitor changes in condition to resolution was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 5 (RCC) on 03/16/23 at 10:45 am. They acknowledged the findings.
C 270 OAR 411-054-0040 (1-2) Change of Condition and Monitoring
1. The leadership team has reviewed the OARs for resident Change of Condition (SOC) and Significant Change of Condition (SCC). The leadership team completed root cause analysis of the systems and processes and extended the training to all staff and a newly formed interdisciplinary team has been created to review COC and SCC and ensure compliance and best practice outcomes.
2. The Director of Nursing will oversee the licensed nursing teams following all OARS for COC and SCC assessments and interventions. In addition an interdisciplinary team (including administration, dietary, behavioral health, direct care staff, and nursing staff) will review all open COC and SCC on bi-weely basis to evaluate, and root cause possible solutions.
3. COC and SCC OARS will be followed on an individual resident basis. The Director of Nursing will evaluate the systems on a weekly basis and the interdisiplinary team will evaulate on a biweekly basis.
4. The Director of Nursing will oversee the COC and SCC compliance on a daily basis. The licensed nurses will follow all COC and SCC OARS on a daily individualized resident needs basis, and the interdisciplinary team will oversee the compliance on a biweekly basis.
Surveyor: An, Eun-Suk
3. Resident 7 was admitted to the facility in 04/2021 with diagnoses including hidradenitis suppurativa (skin condition with lumps to groin and armpits, which drain pus) and major depressive disorder.
Interviews with staff between 07/26/23 and 07/28/23, temporary service plans, incident reports and progress notes, dated 05/16/23 through 07/25/23, were reviewed.
a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and documentation of resolution:
* 05/20/23 - Left axilla (armpit) wound and right axilla blisters;
* 05/27/23 - Oral lesions with antibiotic;
* 06/10/23 - Inner right thigh wound;
* 07/09/23 - Fall from bed; and
* 07/11/23 - Resident-to-resident altercation.
b. The following short-term changes of condition lacked documentation of progress, at least weekly, through resolution:
* 05/31/23 - Increased depression; and
* 06/30/23 - Increased depression with discussions of hospice.
The need to ensure short-term changes of condition had actions or interventions documented in the resident's record, the determined actions or interventions communicated to staff on all shifts and progress noted, at least weekly, until resolution was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Nursing Services) on 07/28/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure resident specific instructions or interventions were developed for short-term changes of condition, the interventions were communicated to the staff, and the condition was monitored at least weekly through resolution for 3 of 3 sampled residents (#7, 8, and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the facility in 03/2023 with diagnoses including chronic obstructive pulmonary disease and congestive heart failure.
Interviews with staff, temporary service plans, incident investigations, and progress notes dated 05/25/23 through 07/26/23 were reviewed.
The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and documentation of resolution:
* 05/14/23 - Right ankle swelling;
* 05/16/23 - Bruise to right toe and foot;
* 05/31/23 - Out to hospital due to chest pain and coughing; and
* 07/18/23 - One inch circular bump on left cheek.
The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 3 (Director of Nursing Services) on 07/28/23. They acknowledged the findings.
2. Resident 9 was admitted to the facility in 09/2017 with diagnoses including type 2 diabetes, asthma, and chronic obstructive pulmonary disease.
Interviews with staff, temporary service plans, incident investigations, and progress notes dated 05/13/23 through 07/24/23 were reviewed.
The following changes of condition lacked documented evidence interventions were identified and communicated to staff on each shift and/or monitored weekly to resolution:
* 05/17/23: UTI; and
* 07/03/23: Fall with injury.
The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff on each shift and and monitored changes of condition at least weekly to resolution was discussed with Staff 1 (Administrator) and Staff 3 (Director of Nursing Services) on 7/28/23. They acknowledged the findings.
1. The Licensed Nursing staff attended continued education on the RN role in CBC settings. All incoming Licensed Nursing staff will be enrolled in the RN role in CBC settings for best practice and continued education. The Director of Nursing in coordination with the leadership team has reviewed the OARs for resident Change of Condition (SOC) and Significant Change of Condition (SCC). The leadership team completed root cause analysis of the systems and processes and extended the training to all staff and the interdisciplinary team will continue to review COC and SCC and ensure compliance and best practice outcomes.
2. The Director of Nursing (DON) will oversee the Licensed Nursing teams following all OARS for COC and SCC assessments and interventions. The Licensed Nurse will electronically notify the direct care teams of COC and SCC through Point Click Care (PCC) and develop a paper Temporary Service Plan (TSP) outlining the actions, interventions and staff education. The Licensed Nurse will complete weekly assessments and final resolution documentation in PCC for all COC and SCC. The Behavioral Health Manager will oversee the Behavioral Health team following all OARS for COC and SC assessments and interventions. The Behavioral Health team will provide oversight for all routine mental health behavioral plans, service plan integration, and work in collaboration with the IDT for assessments and interventions as appropriate per scope of practice. In addition the IDT workgroup will review all open COC and SCC to inlcude but not limited to incident reports, resident to resident altercations, skin integrity, and acute infection on bi-weekly basis to evaluate root cause, and implement interventions as appropriate.
3. COC and SCC OARS will be followed on an individual resident basis. The Director of Nursing and Behavioral Health Manager will evaluate the systems on a weekly basis and the interdisiplinary team will evaulate on a biweekly basis.
4. The Director of Nursing and Behavioral Health Manager will oversee the COC and SCC compliance on a daily basis. The licensed nurses will follow all COC and SCC OARS on a daily individualized resident needs basis, and the interdisciplinary team will oversee the compliance on a biweekly basis.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 1 of 2 sampled residents (# 3) who experienced significant changes of condition. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 05/2021 with diagnoses including seizure disorder and hypertension.
a. Resident 3's weight records were reviewed and revealed the following:
* 02/10/23 - 131 pounds; and
* 03/10/23 - 123.8 pounds.
From 02/10/23 to 03/10/23, Resident 3 had a weight loss of 7.2 pounds or 5.5% of his/her body weight in one month. This weight loss indicated a significant change of condition and required an RN assessment.
During an interview on 03/16/23 at 10:30 am, Staff 6 (Residential Services Manager) reported Resident 3 was independent with his/her food choices, demonstrated no issues with nutrition and ate well.
On 03/15/23 at 3:30 pm, Staff 3 (Director of Nursing) confirmed there was no nursing assessment for the weight loss.
There was no documented evidence the facility RN completed an assessment of Resident 3's significant weight loss.
b. Resident 3's progress notes, dated 01/25/23 through 03/13/23, were reviewed. Resident 3 underwent an outpatient surgical procedure to help aid in the control of seizures that resulted in an overnight stay secondary to low blood pressure. This represented a significant change of condition for the resident.
On 03/01/23, Staff 4 (RN) documented he attempted to observe the surgical site and perform a RN assessment, however, Resident 3 declined. Staff 4 attempted a RN assessment one additional time on 03/01/23, but Resident 3 declined.
On 03/15/23 at 3:30 pm, Staff 3 confirmed there was no nursing assessment for the surgical site including documentation of findings, resident status or interventions made as a result.
The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 5 (RCC) on 03/16/23 at 10:45 am. They acknowledged the findings, and no additional documentation was provided.
C 280 OAR 411-054-0045 (1) (a-f) (A) (C-F)
Resident Health Services
1.The leadership team has reviewed the OARs for Resident Health Services. The leadership team completed root cause analysis of the systems and processes for 24-hour care needs of residents, written policies and procedures on medical emergencies and responses for all shifts, licensed nursing services, monitoring, service planning, health care teaching and counseling, and intermittent direct nursing services. Administration reviewed the SOW to ensure all licensed nursing special contract requirements are met. Once the Resident Health Services systems, policies, and processes were reviewed additional All Staff training was developed for comptency based training. An interdisciplinary team was developed to include administration, nursing, dietary, direct care, behavioral health to ensure all Resident Health Services are adequetly met. The interdisciplinary team has developed an outline framework to review falls, weight loss, COC, SCC, and all other residents needs.
2. The Director of Nursing will oversee the licensed nursing teams following all OARS for Resident Health Services. In addition an interdisciplinary team (including administration, dietary, behavioral health, direct care staff, and nursing staff) will review all open COC and SCC on bi-weekly basis to evaluate, and root cause possible solutions.
3. Resident Health Services will be followed evaluated on an individual resident basis following all OARs. The Director of Nursing will evaluate the systems and processes on a daily and weekly basis and the interdisiplinary team will evaulate all open COC and SCC on a bi-weekly basis.
4. The Director of Nursing will oversee the Resident Health Services compliance on a daily basis. The licensed nurses will follow all Resident Health Services OARS on a daily individualized resident needs basis, and the interdisciplinary team will oversee the compliance on a bi-weekly basis.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:
According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.
During the acuity interview on 03/13/23, Resident 2 was identified to be administered insulin injections by non-licensed staff.
Resident 2's MARs, reviewed from 03/01/23 through 03/13/23, revealed the resident received Admelog (insulin to treat diabetes) three times daily and Lantus (insulin to treat diabetes) twice daily. The insulin had been given by Staff 9 (Direct Care Specialist/MT), Staff 10 (Direct Care Specialist/MT) and Staff 18 (Direct Care Specialist/MT) on multiple occasions.
Interviews with staff, review of delegation records and the 03/01/23 - 03/13/23 MAR, revealed the following:
* There was no current RN assessment of the resident's diabetes condition including documented evidence to determine that the resident's condition was stable and predictable, prior to deciding to delegate the task. The last RN assessment of the resident's condition was completed on 08/12/22;
* There was no documentation of the rationale for the frequency for reassessing the resident's condition based on the resident's needs; and
* There was no documentation of the rationale for the frequency for supervising and reevaluating the unlicensed person based on the unlicensed person's skills and abilities.
On 03/15/23 and 03/16/23 the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Director of Nursing Services), Staff 4 (RN) and Staff 5 (RCC). They acknowledged the findings.
C 282 OAR 411-054-0045 (1) (f) (B) RN Delegation
SS=D Delegation and Teaching
Delegation of unlicensed staff
1. The Administration and nursing team reviewed the Delegation and Teaching OARs and Oregon State Board of Nursing chapter 851, division 47 rules. The Director of Nursing has completed a comprehensive audit of all resident required delegations. The RNs are adopting an up-to-date delegation form and completing all required Delegation and Teaching assessments, supervision of special tasks, competency, and evalutations.
2. The Director of Nursing and licensed nursing team will update all of the delegations and complete routine audits for ongong compliance. The RCC will also provide monthly spot audits. The Director of Nursing will ensure that all new delegation forms include the RN resident assessment including a statement that the resident is stable and predictable, evaluation of the unlicensed persons, rationale for determined frequency for supervision and reevaluation of unlicensed person, teaching the task and observing staff demonstration of task.
3. The RNs will utilize a calendar outlining when redelegations are due.
4. The RN will complete the individual resident delegation and teaching. The Director of Nursing will ensure ongoing compliance on a daily, weekly, monthly basis. The Resident Care Coordinator (RCC) will complete monthly spot audits.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 4 sampled residents (# 2) who received outside services. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 03/2021 with diagnoses including type 2 diabetes mellitus.
During the acuity interview, 03/13/23, the resident was identified to receive regular on-site visits from a home health nurse for wound care.
Resident 2's clinical records, including recommendations, revealed the following:
* 01/17/23 - "Encourage pt [Resident] to not smoke", eat low in carbohydrate food and elevate lower legs;
* 01/26/23 - Declutter the resident's room, "very high risk for fall";
* 01/31/23 - Encourage the resident to drink plenty of water, elevate legs and eat low in carbohydrate and sugar food;
* 02/02/23 - Please encourage the resident to elevate the left foot; and
* 02/07/23 - Encourage the resident to take all insulin dosages, eat low in sugar food and to elevate lower legs.
There was no documented evidence the recommendations from an outside Healthcare Services provider were reviewed and/or communicated to staff.
On 03/16/23 at 9:15 am, the need to ensure on-going coordination of care was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 4 (RN) and Staff 5 (RCC). They acknowledged the findings.
C 290 OAR 411-054-0045 Res Hlth Srvc: On-and off- SS=D site Health Srvc
1. The leadership team reviewed the internal system and process for on-site and off-site health services. For on-site health services action was taken immediately after Survey exited. Purchased and mounted secured box(which is labled) for Outside Healthcare Providers to submit documentation for staff. The licensed nurse (LN) will check box daily. LN will use an approved stamp and initial that documentation has been reviewed and/or communicated to all appropriate staff and any additional documentation is completed. For off-site resident appointments, all After Visit Summary (AVS) paperwork will be provided to the front desk staff for additional appointment scheduling, then all new orders and interventions on the AVS will be reviewed and implemented by the med tech and LN as appropriate.
2. The LN's were educated to check the secured Outside Healthcare Providers box daily. The LNs communicated with each on-site healthcare provider the following: 1.) All daily documentation must be placed in the secured box labeled Outside Healthcare Providers and 2.) All SCC requires additional verbal warmhandoffs between the outside providers and MacRes RNs. For all off-site appointments the AVS will go through the front desk staff for scheduling, med techs for immediate medication ordering and processing, and LNs for final review and completion of interventions.
3. The LNs will check the Outside Healthcare Providers secured box daily. The Director of Nursing will do a final check at the end of each day to ensure ongoing compliance and coordination of care. The AVS for all off-site appointments will be reviewed daily by the frontdesk for scheduling, the med tech for immediate medication ordering, and the LN for all interventions and education.
4. The Director of Nursing Services will be responsible for monitoring the compliance on a daily/weekly basis and the Administrator will spot monitor for compliance and maintain accountability for completion of tasks.
There are no detail notes for this visit.
3. Resident 7 was admitted to the facility in 04/2021 with diagnoses including hidradenitis suppurativa (skin condition with lumps to groin and armpits which drain pus).
Resident 7's current physician orders and MAR, dated 07/01/23 through 07/26/223, was reviewed and revealed the following:
The resident had physician orders for the following treatments:
* "Lidocaine 4% injection ampule (for pain), apply to open wounds topically one time a day;
* Miconazole 2% powder (for rash), topically apply to affected areas two times daily;
* Clindamycin phosphate 1% solution (for hidradenitis suppurativa), apply to affected areas topically two times daily;
* Silver sulfadiazine 1% cream, topically apply to wound under left axilla every day at each wound change; and
* Temp[erature] check two times a day."
Resident 7's MAR had the following blanks:
* Lidocaine on four occasions;
* Miconazole powder on four occasions;
* Clindamycin phosphate on 16 occasions;
* Silver sulfadiazine on 15 occasions; and
* Temperature checks on 13 occasions.
During an interview on 07/28/23 at 10:09 am, Staff 9 (RCC) was unable to confirm whether the treatments had been administered as prescribed.
The need to ensure all treatments were administered as prescribed was reviewed with Staff 1 (Administrator) and Staff 3 (Director of Nursing Services) on 07/28/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 3 of 3 sampled residents (#s 7, 8, and 9) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 8 was admitted to facility in 03/2023 with diagnoses including COPD and CHF.
The resident had an order for the following medications and treatment:
* Cephalexin 250 mg (for infection), one capsule by mouth four times daily for three days;
* Furosemide 20 mg (for congestive heart failure), four tablets by mouth every day for three days; and
* Please weigh resident every day in the morning. Notify doctor if gain of two pounds for two days in a row or if gain four pounds or more in one week.
Resident 8's 07/01/23 through 07/26/23 MAR/TAR was reviewed and the following blanks were identified:
* Cephalexin on one occasion;
* Furosemide on one occasion; and
* Daily weight in the morning on three occasions.
During an interview 07/27/23, Staff 9 (RCC) was not able to confirm whether the medications and treatments had been administered.
The need to ensure all medications were available and administered as prescribed was reviewed with Staff 1 (Administrator) and Staff 3 (Director of Nursing Services) on 07/28/23. They acknowledged the findings.
2. Resident 9 was admitted to the facility in 09/2017 with diagnoses including type 2 diabetes, asthma, and chronic obstructive pulmonary disease.
Resident 9's 07/01/23 through 07/26/23 MAR/TAR was reviewed and the following was identified:
The resident had an order for the following medications and treatments:
* "Toujeo Max Solostar 300 unit/ml, inject 100 units subcutaneously every day;
* Check in with resident at 10:00 pm, and assist resident with putting on continuous positive airway pressure mask;
* Deliver diabetic snack at bedtime;
* Take blood pressure daily. Notify primary care physician's clinic if less than 95/55. Encourage extra fluids if blood pressure low or dizzy;
* Weight daily. Alert primary care physician...if weight increases more than 2 pounds in 2 days or 5 lbs in 1 week;
* Drink one health shake for breakfast and drink one shake for night snack; and
* Temp[erature] check two times a day."
The following blanks were identified:
* Toujeo Max Solostar 300 unit/ml on two occasions;
* Check in with resident at 10:00 pm. Assist resident with putting on continuous positive airwway pressure mask on five occasions;
* Deliver diabetic snack at bedtime on five occasions;
* Take blood pressure daily on six occasions;
* Weight daily on seven occasions;
* Health shake for breakfast and night on five occasions; and
* Temperature check two times a day on ten occasions.
During an interview on 07/27/23, Staff 3 (Director of Nursing Services) was not able to confirm whether the medications and treatments had been given.
The need to ensure staff carried out medication and treatment orders as prescribed was discussed with Staff 1 (Administrator) and Staff 3 on 07/28/23. They acknowledged the findings.
1. The Director of Nursing (DON), Licensed Nursing staff, and Resident Care Coordinators (RCC) have reviewed the OARs and completed root cause analysis on the medication administration systems and processes. The DON will oversee the ongoing RN delegation and medication administration training.
2. The Licensed Nurse will cross check all medications entered directly by the pharmacy for accuracy within 24-hours of receipt, due to root cause analysis determining that the discontinuation date of the pharmacy entered medications were a direct result of the medication errors. The RCCs in collaboration with the Licensed Nurse will pull weekly MAR reports to ensure ongoing compliance. The pharmacy is sending a Licensed Nurse represenative on a monthly basis to provide additional medication training and cart audits in coordination with the Licensed Nurses and RCCs.
3. The Director of Nursing in coordination with the Licensed Nurses will complete daily medication accuracy checks. The RCCs and Licensed Nurses will review weekly MAR reports for accuracy, and the pharmacy Licensed Nurse will complete monthly medication training and cart audits.
4. The Director of Nursing will oversee the Licensed Nursing staff, Resident Care Coordinators, and medication techs for medication education, delegation, administration, errors, and accuracy.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to orders for 1 of 2 sampled residents (#7), who had documented medication and treatment refusals. Findings include, but are not limited to:
Resident 7 was admitted to the facility in 04/2021 with diagnoses including hidradenitis suppurativa (skin condition with lumps to groin and armpits which drain pus).
The resident's MAR and TAR, dated 07/01/23 through 07/26/23, were reviewed and revealed facility staff documented Resident 7 refused the following orders:
* Senna/Docusate (for bowel care) on two occasions;
* Cetaphil lotion (for hidradenitis suppurativa) on 20 occasions;
* Cosentyx (for hidradenitis suppurativa) on one occasion;
* Hibiclens (for hidradenitis suppurativa) on ten occasions;
* Lidocaine solution (for pain) on 20 occasions;
* Melatonin (for sleep) on seven occasions;
* Lidocaine injection ampule (for hidradenitis suppurativa) on 19 occasions;
* Miconazole powder (for yeast) on 19 occasions;
* Clindamycin phosphate (for skin lesions) on 28 occasions; and
* Silver sulfadiazine (for wounds) on 22 occasions.
On 07/28/23 at 10:09 am, Staff 9 (RCC) confirmed there was no documented evidence the facility notified Resident 7's physician of the refusals.
On 07/28/23, the need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator) and Staff 3 (Director of Nursing Services) on 07/28/23. They acknowledged the findings, and no additional documentation was provided.
1. The Director of Nursing, Resident Care Coordinators, Licensed Nursing staff, pharmacy staff, and medication techs reviewed the OARs related to the residents rights to refuse medications. Root cause analysis was completed to determine the cause for the medication ommission, errors, and parameters.
2. The Director of Nursing and Resident Care Coordinators faxed each residents ordering providers requesting parameters for medication refusals. The admission intake paperwork and the physician visit paperwork were updated to reflect medication refusal parameters.
3.The Director of Nursing, Licensed Nursing staff, and Resident Care Coordinator will evaluate the parameter reporting as indicated by the residents ordering provider and every 90-days.
4. The Director of Nursing will oversee the routine completion by the Licensed Nurses and the Resident Care Coordinators who will oversee all of the parameter notifcations and refusals on a routine basis.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure pre-service orientation training had been completed for 3 of 4 newly-hired staff (#s 12, 17 and 19). Findings include, but are not limited to:
Staff training records were reviewed on 03/15/23.
1. Staff 12 (Direct Care Specialist/CG) was hired on 11/04/22. The Staff training records lacked documented evidence of completing pre-service orientation training, prior to beginning job responsibilities, in the following areas:
* Infectious Disease Prevention.
2. Staff 17 (Housekeeping) was hired on 01/12/23. The Staff training records lacked documented evidence of completing pre-service orientation training, prior to beginning job responsibilities, in the following areas:
* Abuse reporting requirements;
* Infectious Disease Prevention; and
* Written job description.
3. Staff 19 (Direct Care Specialist/CG) was hired on 01/13/23. The Staff training records lacked documented evidence of completing pre-service orientation training, prior to beginning job responsibilities, in the following areas:
* Fire safety and emergency procedures.
The training program and requirements were discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 4 (RN), Staff 5 (RCC) and Staff 20 (Training and Compliance Coordinator) on 03/15/23 and 03/16/23. They acknowledged the findings.
C 370 OAR 411-054-0070 (3-4) Staffing Rqmts and
SS= E Training: Cargeiver Rqmts
1. New Hire Orientation and pre-service orientation training and onboarding is being evaluated and a revised process is being implemented. A full audit of all recent hires is also being conducted as well as a root cause analysis of the systems and processes has been completed. Any missed items will be communicated and completed by 5/15/23.
2. We have just implemented a new HRIS system, Paylocity. We are working on the training and reporting module and will be incorporating some automation and improvements in the onboarding process to create better visibility, accountability, and collaboration between HR and departmental leaders prior to any resident care or interactions. We have developed a new framework for onboarding cohort groups twice a month to better track and streamline training completion and compliance. This will ensure that all pre-service requirements are met.
3. The documented and demonstrated competencies will be evaluated upon each onboarding, and monthly by the Training interdisciplinary focus group.
4. Director, People & Culture in collaboration with the Director of Nursing Services,Training & Compliance Coordinator, and the Administrator.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 12 and 19) completed all required training within 30 days of hire. Findings include, but are not limited to:
Staff training records were reviewed on 03/15/23.
1. Staff 12 (Direct Care Specialist/MT) hired 11/04/22, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* Medication pass and treatments.
2. Staff 19 (Direct Care Specialist/CG) hired 12/06/22, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* Abdominal thrust training.
The requirement to demonstrate competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 4 (RN), Staff 5 (RCC) and Staff 20 (Training and Compliance Coordinator) on 03/15/23 and 03/16/23. They acknowledged the findings.
C 372 OAR 411-054-0070 (6) (9) Training within 30
SS=E days: Direct Care Staff
1. New Hire Orientation and Training within 30-days orientation training and onboarding is being evaluated and a revised process is being implemented. A full audit of all recent hires is also being conducted as well as a root cause analysis of the systems and processes has been completed. Any missed items will be communicated and completed by 5/15/23.
2. As part of the revised onboarding process, a new competencies chart will be utilized to give full visibility to the Director of Nursing Services and Administration to ensure no employee is scheduled for shift work until all training requirements are completed. Beyond our tracking spreadsheets, tracking of competencies will also be documented in our new HRIS as we implement the new module. Notifications will be initiated when an employee is not compliant to all applicable parties.
3. The documented and demonstrated competencies will be evaluated upon each onboarding, and monthly by the Training interdisciplinary focus group.
4. Director, People & Culture in collaboration with the Director of Nursing Services,Training & Compliance Coordinator, and the Administrator.
Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled newly hired direct care staff (#19) completed all required training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:
Staff training records were reviewed on 07/26/23 and 07/27/23.
Staff 19 (Direct Care/MT/CG), hired 05/16/23, lacked documented evidence of demonstrated competency in all required areas within 30 days of hire including:
* Medication pass and treatments; and
* General food safety, serving, and sanitation.
The survey team requested a plan to ensure Staff 19 was trained in the medication pass and treatments prior to continuing MT duties. This plan was received and approved on 07/28/23 at 11:40 am.
The need to ensure newly hired direct care staff demonstrated competency in all required training topics within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Nursing Services) on 07/28/23. They acknowledged the findings.
1 New Hire Orientation and Training was evaluated by the leadership team and root cause analysis was completed. It was determined that the current systems and processes in place did not support interdisciplinary communication regarding the completion and compliance of the 30-day training requirements and significant delays in the implementation of the HRIS system impeded automated tracking and notifications.
2. Multiple orientation changes were implemented to allow new staff to complete all required pre-service and 30-day training requirements within a scheduled 5 day orientation training period. At the end of orientation training, completion is assessed by the Training and Compliance Coordinator. If new hires have not completed all required trainings, an overflow training schedule will be created by the Training and Compliance Coordinator allowing 5 additional days to complete required classes. T&C Coordinator will work in collaboration with the scheduling manager for each employee to advise whether the new hire is on an overflow schedule and an anticipated date to begin training on the floor. Staff will not be trained on the floor until T&C Coordinator and scheduling manager determine that employee is compliant. The Director of Nursing in coordiation with the T&C Coordinator will ensure the completion and compliance of all medication and treatment education for all medication technicians prior to being scheduled. An in-service dementia training plan was added to the Relias course list to renew annually after the pre-service training is completed. An alternative training plan was created in the event that there are delays accessing the OregonCarePartners website.
3. All training is set for automated renewal based on date of hire or prior completion through the online learning system, Relias. Staff and managers receive automated weekly updates on any staff education requirements that have upcoming or overdue deadlines. The Training and Compliance Coordinator will work in collaboration with the scheduling managers on a weekly basis to ensure ongoing compliance.
4. The Training & Compliance Coordinator will work in collaboration with each scheduling manager and the Administrator to ensure ongoing compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to dementia care, was completed for 2 of 4 long-term staff (#s 7 and 8) whose training records were reviewed. Findings include, but are not limited to:
Staff training records were reviewed on 03/15/23.
Staff 7 (Director Care Specialist/CG) was hired 05/2018 and Staff 8 (Director Care Specialist/CG) was hired 06/2020.
1. Staff 7 failed to have documented evidence of completing 12 hours of annual in-service training including six hours of annual in-service training related to the care of the dementia resident, between 05/2021 and 05/2022.
2. Staff 8 failed to have documented evidence of completing 12 hours of annual in-service training on topics related to the provision of care in a CBC setting, between 06/2021 and 06/2022.
The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 4 (RN), Staff 5 (RCC) and Staff 20 (Training and Compliance Coordinator) on 03/15/23 and 03/16/23. They acknowledged the findings.
C 374 OAR 411-054-0070 (5-7) Annual Training and
SS=E and Other Requirements
1. Annual training and onboarding is being evaluated and a revised process is being implemented. A full audit of all employees training is being conducted as well as a root cause analysis of the systems and processes has been completed. Any missed items will be communicated and completed by 5/15/23.
2. Tracking for employee annual trainings will be entered in our new Paylocity HRIS system initiating notifications to all applicable parties when the trainings are coming due. We will also initiate a new tracking process that encourages collaboration of departmental leadership and accountability.
3. The annual training requirements will be evaluated routinely by the Training & Compliance Coordinator and monthly by the Training interdisciplinary focus group.
4. Director, People & Culture in collaboration with the Director of Nursing Services,Training & Compliance Coordinator, and the Administrator.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months and failed to conduct and document fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:
On 03/13/23, fire drill and fire/life safety training records for the previous six months were requested.
1. Review of the documentation provided identified the following:
* No fire and life safety instruction was provided to staff.
2. Fire drill documentation lacked the following required information:
* Problems encountered, comments relating to residents who resisted or failed to participate in the drill;
* Evacuation time-period needed; and
* Number of occupants evacuated.
On 03/15/23 and 03/16/23, the need to ensure the facility provided and documented fire and life safety instruction every other month and documented fire drills according to the OFC was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 4 (RN), Staff 5 (RCC) and Staff 15 (Environmental Services Manager). They acknowledged the findings.
C 420 OAR 411-054-0090 (1-2) Fire and Life Safety
SS=F Safety: Safety
1. The Fire and Life Safety training and forms following the Oregon Fire Code (OFC) has been evaluated and a revised process and forms are being implemented. A full audit of all employees training is being conducted as well as a root cause analysis of the systems and processes has been completed. Any missed items will be communicated and completed by 5/15/23.
2. The Fire and Life Safety training will be included in our onboarding, routine, and annual trainings and a competency based training will be implemented. All training will be tracked in our Paylocity HRIS system to allow for improved visiability, notifications, and reporting.
3. The Fire and Life Safety training requirements will be evaluated routinely by the Environmental Services Manager and monthly by the Training & Compliance Coordinator.
4. Environmental Services Manager, Director, People & Culture in collaboration,Training & Compliance Coordinator, and the Administrator.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training annually. Findings include, but are not limited to:
Fire and life safety records were requested during the survey on 3/13/23.
There was no documented evidence of annual fire and life safety training provided to residents.
The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 4 (RN), Staff 5 (RCC) and Staff 15 (Environmental Services Manager). They acknowledged the findings. No further information was provided.
C 422 OAR 411-054-009 (5) Fire and Life Safety:
SS= F Training for Residents
1.The leadership team evaluated the required Training for Residents and completed root cause analysis of the current systems and processes. The Environmental Services Manager will review all of the required OFC Fire and Life Safety training within 24-hours of resident admission, as needed and annually.
2. This task was not previously tracked. The Environmental Services Manager will hold the responsibilty to ensure ongoing compliance and the Training & Compliance Coordinator will spot audit.
3. The Fire and Life Safety training requirements will be evaluated routinely by the Environmental Services Manager and monthly by the Training & Compliance Coordinator.
4. Environmental Services Manager, Director, People & Culture in collaboration,Training & Compliance Coordinator, and the Administrator.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 270 and C 372.
1. The leadership team reviewed the previous Plan of Corrections (POC) and cross referenced the OARs and root caused the failure in the systems and processes. The leadership team developed a focused priority list to support the POC and continue to prioritize staff recruitment, retention, and education.
2. The leadership team negotiated with the Special Needs Contract Administrator to increase the Licensed Nursing staff FTEs. The contract now supports 5 FTE Licensed Nurses which will directly impact the follow through with the POC and ongoing sustanability of the systems and processes. The Licensed Nurses will case manage by floor for improved resident care coordination, oversight, and ongoing OAR and POC compliance. The leadership team developed a system of internal communication and tracking to ensure ongoing OAR compliance.
3. The ongoing compliance for all OARs will be evaulated as outlined in the POC.
4. The Administrator and Director of Nursing will provide direct oversight for the leadership team to ensure ongoing compliance.
There are no detail notes for this visit.
Based on observation and interview, the facility failed to take measures to prevent the entry of insects. Findings include, but are not limited to:
The facility was toured with Staff 2 (Assistant Administrator) and Staff 15 Environmental Services Manager) on 03/15/23.
Dirty dishes were left in bins in the halls of each floor. Multiple fruit flies were noted in common areas on each floor.
Fruit flies were noted in resident rooms on the 3rd and 4th floors.
Staff 2 and Staff 15 acknowledged the infestation of fruit flies.
C 610 OAR 411-054-0300 (3) (a-h) General Building
SS= F Exterior
1. Action was taken immediately after survey exited. The Nutritional Services Manager wiped down all surfaces with cleanser and purchased covered bus tub bins for each floor to minimize fruit flies. The Nutritional Services Manager is educating the dietary and direct care staff on the removal of dirty dishes and the ongoing cleaning schedule.
2. This task was not previously tracked, and staff were not educated to complete the task routinely. It has been added to the dietary teams cleaning task list to be spot auditied routinely by the Nutritional Services Manager. The direct care staff will also work in coordination with the dietary team to ensure all dirty dishes are promptly removed from resident rooms and common areas.
3. This will be routinely evaluated for quality assurance and audited on a daily basis.
4. Nutritional Services Manager, Dietary Staff, and Administrator will monitor and maintain accountability for completion of tasks
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean. Findings include, but are not limited to:
Observations of the facility on 03/15/23 revealed:
* Multiple cigarette butts on the balconies on 2nd, 3rd, and 4th floors;
* Litter and debris in all stairwells; and
* Spills, splatters, and debris in the busing areas on the 2nd, 3rd, and 4th floors.
The surveyor toured the facility with Staff 2 (Assistant Administrator) and Staff 15 (Environmental Services Manager) on 03/15/23. They acknowledged the findings.
C 613 OAR 411-054-0300 (4) (d-i) General Building:
SS= F Doors-Walls, Cleanable
1. Action was taken immediately after survey exited.The Environmental Services Manager and the housekeeping team promptly cleaned the courtyard, balconies, and stairwells. The leadership team completed root cause analysis on the systems and process and implemented a new cleaning schedule.
2. This task was not previously tracked, and staff were not educated to complete the task routinely. It has been added to the housekeeper's daily cleaning task list.
3. This will be routinely evaluated for quality assurance and audited on a daily basis.
4. The Environmental Services Manager and the Assistant Administrator will monitor and maintain accountability for completion of tasks.
There are no detail notes for this visit.