The findings of the relicensure survey, conducted 01/31/22 through 02/02/22, 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 first re-visit to the re-licensure survey of 02/02/22, conducted 05/11/22 through 05/12/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of the resident's current status for 2 of 3 sampled residents (#s 2 and 6) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2021. The quarterly evaluation, dated 11/01/21, was reviewed and staff were interviewed. The following inaccuracies were identified:

* Call light ability;

* Risk of weight loss;

* Where the resident took his/her meals; and

* Transfer assistance needed.

2. Resident 6 was admitted to the facility in 02/2009. The quarterly evaluation, dated 11/30/21 was reviewed, observations of the resident's unit were made during the resident interview and staff were interviewed. The following inaccuracies were identified:

* Transportation assistance needed;

* ER visits in the past month;

* Where the resident ate his/her meals;

* Mobility device;

* Mood; and

* Behaviors.

The need to ensure quarterly evaluations were reflective of the resident's current status was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) 02/02/22. They acknowledged the findings.

In reference to OAR 411-054-0034 (2-4) Resident Move-in and Eval: Res Evaluation

1. A review and audit of resident #2 & #6 evaluation accruacy has been completed. Any inaccuacies that were indentified have been updated to ensure they are reflective of residents needs and status.

2. A full audit of resident evaluations to be completed. Resident evaluations to be updated to reflect current resident needs and status. Systems to be implemented to include a larger evaluation team to be used to include care staff to ensure that evaluations are reflective of residents more current and consistent needs.  

3. This will be evaluated with each residents evaluation to ensure we capture the most up to date and accurate information.

4. This will be moniroted by the ED, HSD, AHSD and RCC.

2. Resident 1 was admitted to the facility in 07/2021 with diagnoses including signs and symptoms involving the circulatory and respiratory system and presence of a cardiac pacemaker.

Observations of Resident 1, interviews with staff, review of the 01/30/22 service plan and review of the Service Plan Addendums (SPAs) during the survey revealed the following was not reflective of the resident's needs, lacked clear direction and/or was not followed by staff:

* Use of oxygen including setting and instruction; and

* Fall risks status and interventions.

The need for the service plan to be reflective of the resident's needs, provided clear direction and was followed by staff was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 06/2021. The resident's service plan was reviewed and staff were interviewed. The service plan was not accurate or did not provide clear caregiving instruction in the following areas:

* The service plan directed staff to be aware of allergies and reactions, but there was no information listed of what the resident's allergic reactions were;

* Non-drug interventions for pain; and

* Assistance needed with grooming and hygiene.

4. Resident 6 was admitted to the facility in 02/2009. The resident's service plan and task sheet (used by the staff to assist in caring for the resident) were reviewed, observations were made in the resident's unit and Resident 6 and staff were interviewed. The service plan was not accurate or did not provide clear caregiving instruction in the following areas:

* Medications the resident self-administers;

* Interventions for shower refusals;

* Mood and behavior including effective interventions of how to approach the resident, tone of voice, how to gain trust, what to be observant of, how to react if the resident becomes verbally abusive;

* Sleep walking; and

* Incontinent products used by the resident and interventions for excess use.

The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) 02/02/22. They acknowledged the findings.

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 lacked clear direction to staff regarding the delivery of services for 4 of 4 sampled residents (#s 1, 2, 3 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2019 with diagnoses including multiple sclerosis and restless leg syndrome.

The resident's service plan dated 12/01/21 and Service Plan Addendums (SPAs) were reviewed during the survey and revealed the service plan lacked clear direction to staff in the following areas:

* Use of quarter length side rails and the risks and precautions related to the use of side rails; and

* Behaviors and interventions related to alcohol use.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

In reference to OAR 411-054-0036 (1-4) Service Plan: General

1. A review and audit of resident #1,2,3,6 service plan accuracy has been completed. Any inaccuracies identified have been updated to ensure they are reflective of resident needs and status.

2. A full audit of resident care plans to be completed and updated to reflect current resident needs and status. The care planning process to be updated to include a larger collaberative process to ensure care plans are reflective of the most accurate needs by ensuring care staff are documenting daily deviations in care.

3. This to be evaluated at the daily HS team review meeting.

4. This to be monitored by ED, HSD, AHSD, RCC   

Based on interview and record review, it was determined the facility failed ensure changes of condition were evaluated, referred to the facility RN when appropriate, monitored through resolution, and interventions identified and implemented for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) reviewed for changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including signs and symptoms involving the circulatory and respiratory system and presence of a cardiac pacemaker.

The resident's clinical records, dated 11/08/21 through 01/31/22, indicated the following:

a. Staff documented in a progress note on 12/20/21 that the resident had a fall and stated, " ...bruising noted to right knee with minor swelling and bruising noted to right ankle ..."

There was no documented evidence the resident's short-term change of condition related to the skin was monitored and progress documented weekly through resolution.

On 02/02/22, the failure to provide on-going monitoring for Resident 1's skin injuries was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN). They acknowledged the findings.

b. Review of the facility progress notes, incident reports and Service Plan Addendums (SPAs) during the survey revealed Resident 1 had a fall on 11/16/21, 12/20/21 and 01/06/22. The facility implemented auto generated SPAs, which were reflective of the same interventions for each fall.

There was no documented evidence the facility thoroughly reviewed the incident to determine the circumstance of the fall and development of interventions to minimize further falls.

The need to ensure short term changes were evaluated, specific resident interventions determined and documented was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 04/2021 with diagnoses including diabetes.

Resident 5's weight record was reviewed during the survey and revealed the following:

* 10/2021 - 231 pounds;

* 12/2021 - 246.8 pounds; and

* 01/2022 - 251.1 pounds.

From 10/2021 to 12/2021, Resident 5 had gained 15.8 pounds or 6.83 % of his/her body weight and gained an additional 4.3 pounds from 12/2021 to 01/2022, which represented a change of condition.   

There was no documented evidence the facility thoroughly reviewed the weight changes and determined if action or intervention was required.  

The need to ensure short term changes were evaluated, specific resident interventions determined and documented was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 06/2021 with diagnoses including abnormal weight loss. The resident's weight record was reviewed during the survey and revealed the following:

* 07/2021 - 162.3 pounds;

* 08/2021 - 162 pounds;

* 10/2021 - 152.1 pounds;

* 11/2021 - 108.5 pounds;

* 12/2021 - 106.5 pounds; and

* 01/2022 - 108.2 pounds.

From 10/2021 to 01/2022, Resident 2 had lost 54.1 pounds, or 33.33% of his/her body weight. This represented a severe change of condition in weight.

There was no documented evidence the facility thoroughly reviewed the weight changes and developed interventions to address the weight loss.

Refer to: C280, example 1.

5. Resident 6 was admitted to the facility in 02/2009. The resident's weight record was reviewed during the survey and revealed the following:

* 11/2021 - 187 pounds;

* 12/2021 - 177.8 pounds; and

* 01/2022 - 179 pounds.

From 11/2021 to 12/2021, Resident 6 had lost 9.2 pounds, or 4.91% of his/her body weight. This represented a change of condition in weight.

There was no documented evidence the facility thoroughly reviewed the weight changes and developed interventions to address the weight loss.

The need to ensure short term changes were evaluated, and resident specific interventions were determined and documented was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 05/2019 with diagnoses which included multiple sclerosis, restless leg syndrome and a history of falls.

Resident 3's progress notes, reviewed from 12/16/21 through 1/13/22, Service Plan Addendums (SPAs) and weight record revealed the following changes of condition:

a. Resident 3's weight record documented the following:

* 07/2021- 185.3 pounds;

* 10/2021 - 133.7 pounds;

* 11/2021 - 169.5 pounds; and

* 12/2021 - 169.0 pounds.

From 07/02/21 and 10/21/21, Resident 3 lost 51.6 pounds or 27.84% total body weight, within 3 months. This represented a change of condition in weight.

There was no documented evidence the facility thoroughly reviewed the weight changes, developed and implemented interventions to address the weight changes, communicated the interventions to staff, and referred the weight changes to the facility RN, when appropriate.

b. The following short term changes of condition were not communicated to staff and were not monitored at least weekly through resolution:

* 12/21/21 Resident reports a twisted ankle that hurts; and

* 12/23/21 MT observed a bruise on the bottom of the left foot.

The need to ensure the facility communicated changes of condition to staff,  monitored the changes in condition with weekly progress noted until resolution and referred changes of condition to the facility RN when appropriate, was reviewed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

Refer to: C280, example 2.

In reference to OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1.Chart review was completed for residents # 1,2,3,5,6 to identify any system breakdown and areas of improvement.

2. All resident charts to be reviewed to identify any change of condition not previously addressed. Staff inservice to be completed with focus on documentation and identiying change of condition.

3. All chart notes to be reviewed daily during HS chart review meeting.

4. to be monitored by HSD, AHSD, RCC and ED to identify   

Based on observation, interview and record review, it was determined the facility failed to conduct a significant change of condition assessment including findings, resident status, and interventions made as a result for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of condition related to weight loss. Findings include, but are not limited to:  

1. Resident 2 was admitted to the facility in 06/2021 with diagnosis including abnormal weight loss.

The resident's weight records dated 07/02/21 through 02/02/22, and progress notes dated 11/01/21 through 01/26/22, were reviewed, the resident was observed and staff were interviewed. The following was identified:  

* Between 10/02/21 and 11/22/21, Resident 2 lost 35.7 pounds, or 23.47% total body weight, in a little over one month; and

* Between 07/02/21 and 12/16/21, Resident 2 lost 55.8 pounds, or 34.38% total body weight, within six months.

This constituted a severe weight loss for Resident 2 which required an RN assessment.  

On 01/31/22, the surveyor requested the facility obtain a current weight. Resident 2's weight was noted at 108.2 (wheelchair), which was within the range of weights obtained between 11/02/21 and 12/16/21.

On 02/02/22 at 1:18 pm, Resident 2 was observed sleeping in his/her recliner. The resident appeared to fit in their clothing well and looked like the picture the facility took for their records in 07/2021.

On 02/02/22 at 1:28 pm, Staff 10 (CG) reported Resident 2 ate 100% of breakfast and lunch consistently. He confirmed he has not seen any evidence of weight loss while caring for the resident.

There was no documented evidence the facility RN conducted an assessment of the weight loss which included documentation of findings, resident status and interventions made as a result of this assessment.

The need to ensure severe weight loss was assessed and documented by the facility RN was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Multiple Sclerosis.

Progress notes dated 12/16/21 through 01/13/22, service plan dated 12/01/21, Service Plan Addendums (SPAs) and weight records were reviewed during the survey. The following was identified:

* Between 07/02/21 and 10/21/21, Resident 3 lost 51.6 pounds or 27.84% total body weight, within 3 months.

This weight loss represented a significant change of condition for Resident 3 for which an RN assessment was required.

On 01/31/22, the surveyor requested the facility obtain a current weight. Resident 3's weight was noted at 169.3 (standing), which appeared to stabilize since the 10/21/21 weight loss.

There was no documented evidence the facility RN conducted an assessment of the weight loss which included documentation of findings, resident status and interventions made as a result of this assessment. The resident's service plan was not updated and there was no evidence weight loss interventions were developed and implemented.

The need to ensure significant changes of condition were assessed and documented by the facility RN, and changes were made to the resident's service plan based on the findings of the assessment, was reviewed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

In reference to OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

1. Chart review for Residents # 2 and 3 completed. Resident #2 placed on weekly weights for monitoring. Resident #3 weight has been consistent.

2. A weight audit was completed for all residents any weight concerns have been addressed. Staff in-service with focus on weight documentation, weighing residents with ambulation devices and standards set for automatic re-weigh threshold.

3. This will be reviewed daily during HS chart review meeting.

4. This will be monitored by HSD, AHSD, RCC and ED

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed staff. Findings include, but are not limited to:

Delegation records for Resident 5, reviewed on 02/02/22, indicated the facility RN failed to complete the process of delegation and document all required components of delegation in accordance with the OSBN Administrative Rules, including:

* Documentation as to how the RN determined the resident's condition was stable and predictable, given Resident 5 was hospitalized during the time period of the assessment.

* Transfer delegation was completed on 07/27/21. There was no documented evidence the incoming RN reviewed Resident 5's condition, teaching plan, competence of the staff, written instructions and plan for supervision as outlined by the outgoing RN.

* Staff 3's (MT/RCC) initial delegation was completed on 09/15/21 and re-evaluation of the delegation task was completed 12/16/21, more than 90 days from initial delegation. The delegating RN failed to re-evaluate the insulin administration task within 60 days from the initial date of delegation.

* Staff 13 (MT) was delegated on 07/09/21 and and was to be re-evaluated in 90 days or before 10/07/21. The re-evaluation of skills was completed on 11/13/21, 37 days after the 90 day period.  

The requirements for delegation were reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

In reference to OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

1. Audit of delegation documentation completed.

2. Procedures put into place to account for residents who are out of building at time of delegation expiration and for PRN staff who are not working at time of delegation expiration. RN to complete Oregon Delegation course.

3. This will be monitored on a monthly basis.

4. This will be monitored by ED and HSD.  

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system for 3 of 5 sampled residents (#s 1, 3 and 6). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including hyperlipidemia, hypothyroidism, cardiac arrhythmia, and signs and symptoms involving the circulatory and respiratory system and presence of a cardiac pacemaker.

Resident 1's most recent signed physician orders, 01/2022 MAR and the resident's clinical record were reviewed during the survey and revealed the following:

* Resident returned to the facility on 01/27/22; and

* The resident was enrolled to hospice services on 01/27/22.

The reconciliation of the MAR and the most recent signed physician orders revealed the following medications were not administered to the resident on 01/28/22 without documentation of why or having a signed physician order to discontinue:

* Lasix (for heart disease and fluid retention) 20 mg daily;

* Synthroid (for hypothyroidism) 150 mcg daily;

* Carvedilol (for high blood pressure) 3.125 mg twice daily;

* Eliquis (for the reduction of blood clotting) 2.5 mg twice daily; and

* MiraLAX (for constipation) 17gm daily.

On 02/02/22 at 10:27 am, the findings were reviewed with Staff 1 (Administrator) and Staff 19 (LPN). They acknowledged the findings. No further information was provided.

2.  Resident 3 was admitted to the facility in 05/2019 with diagnoses including multiple sclerosis. The resident's 01/2022 MAR was reviewed.

There was no documented evidence of a signed physician's order in the resident's medical chart.

At the request of the surveyor, the facility obtained a current copy of the signed orders during the survey.

Refer to: C303, example 1.

3. Resident 6 was admitted to the facility in 02/2009. The resident's 01/2022 MAR was reviewed.

There was no documented evidence of a signed physician's order in the resident's medical chart.

At the request of the surveyor, the facility obtained a current copy of the signed orders during the survey.

Refer to: C303, example 5.

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

C282: Delegation;

C303: System: Medication and Treatment Orders;

C305: System: Resident Right to Refuse;

C310: System: Medication Administration;

C325: System: Self Administration of Medication; and

C330: System: PRN Psychotropic Medications.

In reference to OAR 411-054-0055 (1)(a) Systems: Medications and Treatments.

1. Physical orders were obtained for all residents. 3-way MAR audit was completed.

2. Procedure put into place in regards to obtaining physician orders timely. Routine 3-way MAR audits to be completed monthly. Staff in-service to be completed regarding MAR documentation, order processing and re-education on new pharmacy procedures.

3. This is to be monitored daily during HS chart review meeting.

4. This is to be monitored by ED, HSD, AHSD and RCC

2. Resident 1 was admitted to the facility in 07/2021 with diagnoses including cardiac arrhythmia and had a cardiac pacemaker.

Resident 1 had a physician's order, dated 01/28/22, to apply Lidocaine patch daily.

Resident 1's 01/2022 MAR revealed there was no indication the order was transcribed.

On 02/02/22, the physician orders and current MARs were reviewed with Staff 1 (Administrator), Staff 2 (Regional RN) and Staff 19 (LPN). They acknowledged the findings.

3. Resident 5 was admitted to the facility in 04/2021 with diagnoses including hypertension (high blood pressure).

Resident 5 had a physician's order to administer Metoprolol 150 mg daily for hypertension and hold for blood pressure less than 100 or heart rate less than 50 per minute, which was also reflected on the MAR.

Resident 5's 01/2022 MAR revealed seven occasions there was no documented evidence the facility was taking the resident's blood pressure and heart rate prior to administering the medication to determine if the mediation needed to be held.

On 02/02/22, the physician orders and current MAR were reviewed with Staff 1 (Administrator), Staff 2 (Regional RN) and Staff 19 (LPN). They acknowledged the findings.

4. Resident 2 was admitted to the facility in 06/2021 with diagnoses including macular degeneration and glaucoma. The resident's 01/2022 MAR and physician orders were reviewed. The below medications were not administered per physician's orders on the following dates:

* 01/02/22 - GenTeal Tears (for dry eye) was not administered as the medication had not been received;

* 01/03/22 - Brimonidine tartrate solution (for glaucoma), cyclosporine emulsion (for glaucoma), dorzolamide HCI-timolol mal solution (for glaucoma), erythromycin ointment (for dry eye), and systane solution (for dry eye) were not administered as the resident was sleeping;

* 01/07/22 - GenTeal Tears was not administered as the resident was sleeping;

* 01/21/22 - GenTeal Tears and diclo gel (for pain management) was not administered as the resident was sleeping; and

* 01/30/22 - Artificial eye ointment (for dry eye) was not administered as the medication had not been received.

5. Resident 6 was admitted to the facility in 02/2009. The resident's 01/2022 MAR, physician orders and service plan were reviewed. The resident's room was observed and the resident and staff were interviewed.

a. There was no documented evidence of signed physician's orders in the resident's medical chart.

b. Resident 6 had an order for levothyroxine with the parameters specifying to administer the medication "30 minutes before first meal and medications." The MAR reflected staff was to administer the medication at midnight.

An interview with Staff 9 (MT) on 02/01/22 at 10:04 am confirmed the resident went to sleep late and woke up between 9:30 am and 12:00 pm.

The need to ensure physician's orders were followed as prescribed and current signed physician's orders were available in the resident's chart for all medications and treatments administered by the facility was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose physician orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Multiple Sclerosis. The resident's 01/2022 MAR and physician's orders were reviewed.

There was no documented evidence of a signed physician's order in the resident's medical chart for the following medications and treatments:

* Amlodipine (for hypertension);

* Docusate Sodium (for bowel care);

* Gabapentin 1.5 tablets (for pain);

* Gabapentin 1 tablet (for pain);

* Lisinopril (for hypertension);

* Rosuvastatin Calcium (for hyperlipidemia);

* Vitamin D3 (supplement);

* Carbamazepine (for nerve pain);

* Baclofen (for skin);

* PRN Tylenol (for pain);

* PRN Albuteral (for shortness of breath);

* PRN Ibuprofen (for pain);

* PRN Lidocaine Cream (for pain);

* PRN Lidocaine Ointment (for pain);

* PRN Nicotine Patch (for smoking cessation);

* PRN Polyethylene Glycol powder (for bowel care); and

* PRN Voltran Gel (for pain).

On 01/31/22, Staff 1 (Administrator) and Staff 2 (Regional RN), reported they were sending faxes out to physician's to obtain signed orders but were having difficulty getting the physician's to send signed orders back.

The need to ensure current signed physician's orders were available in the resident's chart for all medications and treatments administered by the facility was discussed on 02/02/22, with Staff 1 and Staff 2. They acknowledged the findings.

In reference to OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders.

1. Resident #3 physican orders obtained. Resident #1 MAR reviewed and now reflect indications on all medications. Resident #1 MAR updated to reflect resident's vitals. Resident #2 physician orders updated to reflect resident eye drops to only be administed during waking hours. Clarification made that Resident #6 prefers her levothyroxine to be administed at midnight and approval obtained from PCP that midnight is an acceptable administration time.

2. Procedure put into place in regards to obtaining physician orders timely. Routine 3-way MAR audits to be completed monthly. Staff in-service to be completed regarding MAR documentation, order processing and re-education on new pharmacy procedures.

3. This is to be monitored daily during HS chart review meeting.

4. This is to be monitored by ED, HSD, AHSD and RCC

2. Resident 5 was admitted to the facility in 04/2021 with diagnoses including diabetes.

Resident 5's 01/2022 MAR was reviewed during the survey and revealed the following:

* Staff documented Resident 5 refused a treatment, Clindamycin gel for infection, 11 occasions; and

* Staff documented Resident 5 refused a treatment, Clotrimazole-Betamethasone cream twice daily for skin care, on 34 occasions.

There was no documented evidence the facility notified Resident 5's physician of the refusals.

The need to ensure the facility notified physicians or practitioners of treatment refusals was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 2 and 5) who had documented medication and treatment refusals. Findings include, but are not limited to:

Resident 2's 01/2022 MAR, progress notes and medical chart were reviewed and the following medications were noted as "spit out" or "refused:"

* Ascorbic acid (supplement);

* B complex vitamin (supplement); and

* Diclo Gel (for pain management).

There was no documented evidence the facility notified the prescriber each time the resident refused to consent to the orders.  

The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.  

In reference to OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse.

1. Audit completed, all physicians have been notified of any refusels or medications not administered.

2. Staff in-service to be completed to include resident right to refuse and procedures relating to resident refusel.

3. To be monitored daily during chart review meeting.

4. This to be evaluated by HSD, ED, AHSD and RCC.

2. Resident 5 was admitted to the facility in 07/2021. The resident's 01/2022 MAR was reviewed during the survey and revealed the following treatment lacked indication of location/area for treatment:

* Tacrolimus ointment twice daily; and

* Hibiciens Liquid 4 % as needed for skin care.

The need for resident specific parameters and clear administrative instruction to unlicensed staff was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure  MARs were complete and accurate for 2 of 5 sampled residents (#s 2 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2021. The resident's 01/2022 MAR was reviewed and the following medications were missing a reason for use:

* Latanoprost solution;

* Brimonidine tartrate solution;

* Dorzolamide solution; and

* Carboxymethylcellulose solution.

The need to ensure MARs were accurate and all medications had documentation of the reason for use was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

In reference to OAR 411-054-0055 (2) Systems: Medication Administration

1.Resident #2 indication for use has been updated on the MAR. Resident #5 indication for use has been updated on the MAR. 3-way MAR audit completed to include indication for use on all medications.

2. Routine 3-way MAR audits to be completed monthly. Staff in-service to be completed regarding MAR documentation, order processing and re-education on new pharmacy procedures.

3. This is to be monitored daily during HS chart review meeting.

4. This is to be monitored by ED, HSD, AHSD and RCC

2. Resident 5's 01/2022 MAR indicated and staff documented the resident self-administered Clobetasol Pro cream twice daily for wound care.

There was no documented evidence the facility had a physician's written order of approval for the resident to self-administer the treatment. There was also no documented evidence Resident 5's ability to safely self-administer the treatment was evaluated.

The failure to obtain physician's orders and to complete the evaluation of the resident's ability to self-administer medications and treatment was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. No further information was received.

3. Resident 6 was admitted to the facility in 02/2009. The 01/2022 MAR, physician orders dated 01/31/22 and self medication evaluation dated 11/30/21 were reviewed. The resident's unit was observed while s/he was interviewed.

The physician order specified the resident was not to self administer any medications with the exception of "APAP and creams." The MAR and self medication evaluation reflected the resident self administered triamcinolone acetonide aerosol (for allergies).

In an interview with Resident 6 on 02/01/22 at 10:14 am, an observation was made of two nasal spray containers located on the resident's shelf by his/her bed. When asked if s/he administered their own nasal spray, the resident confirmed s/he did.

The need to ensure resident's had physician's orders to self administer medications was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 02/02/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate a residents' ability to safely self-administer medication and failed to have physician or other legally recognized practitioner's written order of approval for self- administration of medication for 3 of 4 sampled resident (#s 3, 5 and 6) who self-administered medications.  Findings include, but are not limited to:

1. Resident 3 was admitted to the facility 05/2019 with diagnoses including multiple sclerosis.

The resident's record confirmed s/he was self-administering some medications and treatments. There was no documented evidence the facility had physician's orders for the resident to self-administer the following medications and treatments:

* PRN Albuterol (for shortness of breath);

* PRN Tylenol (for pain);

* PRN Ibuprofen (for pain);

* PRN Lidocaine Cream (for pain);

* PRN Lidocaine Ointment (for pain); and

* PRN Voltaren Gel (for pain).

The need to ensure signed physician orders were available in the residents' chart for all medications and treatments the resident self-administered was discussed with Staff 1 (Administrator) and Staff 2 (Regional RN) on 01/31/22. They acknowledged the findings.

In reference to OAR 411-054-0055 (5) Systems: Self-Administration of Meds

1. Resident #3 physician orders were obtained and include self administration orders. Resident #5 Clobetasol cream is administed by community. Resident #6 orders were obtained with clarification of self administration orders regarding PRN medications.

2.Routine 3-way MAR audits to be completed monthly. Audit of all self medications orders has been completed.

3. This is to be monitored daily during HS chart review meeting.

4. This is to be monitored by ED, HSD, AHSD and RCC  

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 1) who was administered PRN psychoactive medication. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2021 with diagnoses including cardiac arrhythmia.

Resident 1's 01/2022 MAR, 01/28/22 signed physician orders and clinical records were reviewed during the survey and revealed the following:

* Resident 1 had orders for PRN Ativan for "anxiety or restlessness";

* The PRN Ativan was administered to the resident on 01/28/22, 01/29/22 and 01/30/22;

* There was no documented evidence medical parameters had been identified for the administration of the PRN medication;

* There was no listing of non-drug interventions on the MAR; and

* There was no documented evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.

On 02/02/22, Resident 1's record was reviewed with Staff 1 (Administrator) and Staff 2 (Regional RN). They acknowledged the findings.

In reference to OAR 411-054-0055 (6) Systems: Psychotropic Medication

1. Resident #1 MAR updated to reflect non pharmicological interventions.

2. 3-way MAR audit completed. MAR system updated to reflect if non- phamicological interventions have been attempted prior to administration.

3. This to be monitored monthly during 3-way MAR audit.

4. This to be evaluated by HSD, AHSD and ED

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required areas was completed prior to beginning job duties for 3 of 3 newly hired staff (#s 8, 14 and 15). Findings include, but are not limited to:

The facility training records were reviewed with Staff 4 (Office Manager) on 01/31/2022 at 1:00 pm and revealed the following:

*  Staff 8 (CG), Staff 14 (MT) and Staff 15 (MT), hired on 12/16/21, 11/22/21 and 12/10/21 respectively, lacked documented evidence of pre-service orientation in standard precautions for infection control and fire safety and emergency procedures.

*  Staff 14 lacked documented evidence of completion of required pre-service dementia training.  

The need to ensure newly hired staff completed pre-service training in all required areas was discussed with Staff 1 (Administrator) and Staff 4 during the survey. They acknowledged the findings.

In reference to OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

1. Staff members 8, 14 and 15 have completed pre-service orientation in standard precautions for infection control and fire and life safety procedures. Staff member 14 has completed pre-service dementia training.

2. Updates made to staff training tracking system and documentation of trainings has been put into place.

3. This is to be monitored weekly during BOM/ED meeting.

4. This is to be monitored by BOM, Staffing coordinator, RCC and ED.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 14 and 15) had demonstrated competency in all required areas within 30 days of hire and 2 of 3 staff (#s 8 and 15) completed abdominal thrust and First Aid training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 4 (Office Manager) on 01/31/22 at 1:00 pm and revealed the following:

* Staff 14 (MT) and Staff 15 (MT) hired on 11/22/21 and 12/10/21 respectively, lacked documented evidence of demonstration of competency in all required areas was completed within 30 days of hire.

* Staff 8 (CG), hired on 12/16/21 and Staff 15 lacked documented evidence of abdominal thrust and First Aid training.

The need to ensure staff had documentation of  demonstrated competency in all required areas within 30 days of hire and completed abdominal thrust and First Aid training was discussed with Staff 1 (Administrator) and Staff 4 during the survey. They acknowledged the findings.

In reference to OAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff

1. Staff member #14 and #15 have demonstrated and documentation made on competency of care giving in addition to administration of medications. Staff #8 completed and documentation obtained regarding first aid training with abdominal thrusts.

2.  Updates made to staff training tracking system and documentation of trainings has been put into place.

3. This is to be monitored weekly during BOM/ED meeting.

4. This is to be monitored by BOM, Staffing coordinator, RCC and ED.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 11, 17 and 18) completed the minimum required 12 hours of annual in-service training which included six hours of training on dementia care topics. Findings include, but are not limited to:

Annual facility training records were reviewed with Staff 3 (RCC) on 02/01/22 at 11:00 am and revealed the following:

Staff 11 (MT), Staff 17 (MT) and Staff 18 (CG),  hired on 01/19/20, 01/31/13 and 01/19/20 respectively, lacked documented evidence of 12 hours of annual training which included six hours of training on dementia care topics.

The need to ensure all direct care staff completed 12 hours of annual in-service training which included six  hours of training in dementia care topics was discussed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

In reference to OAR 411-054-0070 (6-7) Annual Training and Other Requirements

1. Staff members #11, 17 and 18 have completed 12 hours of training which included 6 hours of dementia training. All staff are completing 12 hours of training which include 6 hours of dementia training.

2. All staff to catch up on 12 hours of training, in addition to continuing with monthly tranings ongoing. Updates made to staff training tracking system and documentation of trainings has been put into place.

3. This is to be monitored weekly during BOM/ED meeting.

4. This is to be monitored by BOM, Staffing coordinator, RCC and ED.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff  was provided on alternating months from fire drills. Findings include, but are not limited to:

Fire drill and fire and life safety training records from 11/01/2021 to 01/31/22 were reviewed on 01/31/2022. There was no documented evidence the facility provided fire and life safety instruction to staff on alternating months from the fire drills.

The need to ensure the facility provided fire and life safety instruction to staff on alternating months from the fire drills was discussed with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

In reference to OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and Instruction.

1. Alternate month fire and life safety has been added to monthly staff trainings.

2. Community to contiue with monthly fire drills due to size of community, size of staff and resident population. Alternating month fire and life safety training to be added in addition to fire drills.

3. This is to be monitored monthly

4. This is to be evaluated by BSM, BOM and ED

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and located above the first floor. Findings include, but are not limited to:

The interior of the facility was toured with Staff 6 (Maintenance Assistant) on 01/31/2022 at 12:00 pm. The windows in rooms 218, 220, and 229, located above the first- floor level, had sill heights that measured lower than 36 inches. The windows opened to full capacity and lacked a locking mechanism to prevent accidental falls.

Staff 6 stated that windows above the first-floor level had not been checked and confirmed all the windows above the first level did not have a locking mechanism to prevent accidental falls.

The need to ensure windows above the first floor were designed to prevent accidental falls was discussed with Staff 1 (Administrator) and Staff 6 during the survey. They acknowledged the findings.

In reference to OAR 411-054-0300 (5) Resident Units.

1. Window locks placed on windows in apartments #128, 220 and 229.

2. Locks have been placed on all apartment windows on the 2nd floor.

3. This is to be monitored on a monthly basis.

4. This is to be monitored by BSM and ED