The findings of the re-licensure survey, conducted 03/14/22 through 03/16/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
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 survey to the re-licensure survey of 03/16/22, conducted 07/05/22 through 07/07/22, 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 Division 57 for Memory Care Communities.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCCMemory 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 revisit to the re-licensure survey of 03/16/22, conducted on 09/19/22 through 09/20/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCCMemory 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
Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:
During the relicensure survey, conducted 03/14/22 through 03/16/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.
Refer to deficiencies in the report.
OR-411-0025 C-150 Facility Operation
* Please see Plan of Correction in it's completeness
* Executive Director will meet with each Department on a scheduled weekly meeting with and agenda to review all of the areas.
* Executive Director will have weekly full Department Head Meetings.
* This will be evaluated weekly.
* Executive Director and Department Heads will assure compliance with QA
Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. This is a repeat citation. Findings include, but are not limited to:
During the first re-visit survey conducted on 07/05/22 through 07/07/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.
Refer to deficiencies in the report.
OR 411-054-0025
*Please refer to the entire POC for all open deficiencies.
*An interdisciplinary team stand up meeting is held no less than 5 days per week to review compliance, operations, quality, clinical services, and staff training/needs. After the interdisciplinary team meeting, a break out clinical drill down meeting occurs to cross check all required components based on changes of condition and high risk clinical areas including, but not limited to medication and treatment orders changes, alert charting, on and off site provider visits and coordination of care, delegation needs, staff training, accident and incident reporting, APS or regulatory visit concerns, family or resident concerns, quality control efforts, infection control, skin management, nutritional/weight gains/losses, pain management needs, weekly clinical audits, etc..
Additionally, the Executive Director has established a 1:1 time with each department manager to discuss the specific needs of each department.
*This system is reviewed and executed daily and weekly.
*The Executive Director is responsible to ensure this system is corrected.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:
During the survey, conducted 03/14/22 through 03/16/22, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.
Staff 1 (ED) was interviewed on 03/15/22 at 2:30 pm. During the interview he confirmed the facility had failed to conduct ongoing quality improvement programs.
Refer to deficiencies in the report.
OR-411-0025 C-156 Facility Quality Improvement
* Re-establishing the Pacifica Quality Assurance program that was not in use at time of survey.
*All areas identified in QA Audit will be corrected in a timely manner and/or documentation will be evident of efforts put into placeto correct immediately
*Audits will be performed according to QA scheduled as follows:
O-Kitchen will be audited weekly
O-Healt h Services will be audited weekly, daily clinical
O-Fire/Life Safety Environmental weely review
O-Staff Training will be reviewed weekly
O-Move in Evaluation will evaluated weekly
* Executive Director will be reviewing with Dept. Heads daily/weekly to assure compliance
Based on observation, interview and record review, it was determined the facility failed to conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. This is a repeat citation. Findings included, but are not limited to:
During the survey, conducted 07/05/22 through 07/07/22, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.
Staff 1 (ED) and Staff 4 (Regional Director) were interviewed on 07/07/22. During the interview Staff 1 confirmed the facility was in process of conducting some quality improvement audits related to environment, medication review and the kitchen; however, facility staff had not completed quality improvement audits in all areas, which included resident services.
Refer to deficiencies in the report.
OR 411-0025 C-156 Facility Quality Improvement
*Our community has reviewed and adopted the Pacifica Quality Assurance program. This policy has been reviewed with the Admin/RN consultant to ensure all drill down audits specific to Oregon are reflective. Specifically, the Executive Director will be conducting audits and making improvements based on the current priorities outlined in this survey as step 1.
*Our QA program includes components that are to be reviewed daily, weekly, monthly, quarterly, and annually. We are working on implementing the daily QA audits which involve a drill down on change of condition, incident and accident reporting, and medication and treatment. These drill downs are conducted after the morning stand up meeting with the Administrator, and the clinical team. One time weekly an extended meeting will take place to include a drill down on all residents being monitored for active skin issues, nutritional/weight loss or gains, and residents who are on weekly monitoring for significant change of condition.
* Pacifica Divisional Nurse Director and consultant will be completing extensive training with the Executive Director and the Community RN on all aspects of the QA program.
* Audits are continuinly being performed according to QA scheduled as follows:
- Kitchen audited weekly
- Health Services is audited weekly, daily, clinical
- Fire/Life Safety Environmental weekly review
- Staff Training will be reviewed weekly
- Evaluation and Service Planning will be weekly
*Executive Director will be responsible to ensure the QA program is executed and regularly implemented with the Department Heads to assure compliance.
There are no detail notes for this visit.
Based on observation and interview, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to:
Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.
Upon entering the facility for the survey on 07/05/22 at 9:15 am, administrative staff and direct care staff were observed not wearing face masks.
During the remainder of the survey, 07/05/22 through 07/07/22, administrative, kitchen and direct care staff were observed on several occasions having their masks pulled down so as not to cover their nose and, in some cases, not covering their mouth and nose. These staff were in offices or the medication room with the doors open, and residents were observed to be able to enter the rooms freely.
The need to ensure staff fully and consistently complied with masking requirements was discussed with Staff 1 (ED) and Staff 18 (RN) during the exit meeting on 07/07/22. No further information was provided.
C-160 OAR 411-054-0025 (4) Reasonable Precautions
* An All Staff Meeting was held on 7/25/22 to discuss face mask wearing protocol as a team. Additionally we discussed where PPE Masks and Inventory are kept to ensure staff are provided with sufficient supplies.
* A Daily walk through will be completed to review for compliance by RCC/RN/ED. Any staff member not wearing his/her masks will be counseled on the mask mandate and expectations.
*The Executive Director will be responsible to ensure that masks will be worn at all times.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#s 1 and 5) were treated with dignity and respect related to being provided treatment and insulin injection performance in a common area during lunch hours. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in August 2021 with diagnoses including dementia.
During the acuity interview on 03/14/22, it was reported that Resident 5 received insulin injections from staff.
During an observation on 03/14/22 at 12:08 pm, Resident 5 was having lunch, sitting at a table with three other residents in the dining room. Staff 5 (Personal Care Assistant (PCA)/MT) was observed to bring insulin and blood sugar check supplies into the dining room. Staff 5 collected a small amount of blood from the resident's finger, informed the resident of the blood sugar result, and administered insulin to the resident's left upper arm at the table in the dining room in front of other residents, and while those residents at the table were having lunch.
The lack of privacy related to collecting blood from the resident and administering an insulin injection during lunch hours was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
2. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.
During the acuity interview on 03/14/22, it was reported that Resident 1 had a wound to the forehead.
During an observation on 03/14/22 at 12:45 pm, Resident 1 was sitting in the dining room at a table with three other residents with a loose, soiled bandage on his/her forehead. The dining room was full of residents waiting to be served lunch.
Staff 5 (PCA/MT) was observed to bring wound care supplies into the dining room and changed the dressing to Resident 1's forehead, while in the dining room with multiple residents.
The lack of privacy provided during wound care was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.
OR-411-0027 C-200 Resident Rights and Protection
*In-Service was completed on 3/25/22 all staff training
* New Hires will be presented during orientation as is in the new employee handbook.
*Facility Nurse/RCC will monitor for privacy during any and all resident care provided including medication administration.
*This will be discussed weekly with Dept Heads to assure all is completed
*Business Office Manager will monitor for compliance during QA review.
There are no detail notes for this visit.
2. Resident 2 was admitted to the facility in December 2020 with diagnoses including dementia.
An incident report and progress notes reviewed from 10/02/21 through 03/11/22 noted the following:
*On 10/02/21, Resident 2 was placed on alert charting for grabbing another resident's breasts;
*On 11/30/21, Resident 2 was noted to throw a resident out of his/her wheelchair;
*On 12/03/21, the resident had placed his/her hands down another resident's shirt; and
*An incident report dated 12/12/21 noted Resident 2 grabbed a resident and "threw" him/her to the ground.
There was no documented evidence the facility reported the resident to resident altercations.
Resident 2 was observed during the survey on 03/14/22 and 03/15/22 to be sitting in the common areas of the facility or engaged in an activity.
The failure to report inappropriate touching and resident to resident altercations as abuse or suspected abuse was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22 at 2:07 pm. The incidents were reported to the local SPD office per request of the surveyor. Confirmation the incidents had been reported was received on 03/15/22.
Based on observation, interview and record review, it was determined the facility failed to ensure incidents including unwitnessed injury falls, resident to resident altercations and sexual behaviors were thoroughly investigated to rule out abuse or neglect and reported to the local SPD office as appropriate for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.
Review of incident reports and progress notes from 12/14/21 thru 03/14/22 showed the following:
* An incident report dated 12/21/21 identified that Resident 1 had an unwitnessed fall and sustained a laceration under the left eye with swelling and bruising.
* A progress note dated 03/09/22 identified the resident had an unwitnessed fall from the wheel chair and sustained a laceration to the left side of the forehead and a skin tear to the left wrist.
There were no investigations completed to rule out abuse or neglect for the falls with injury. The incidents were not reported to the local SPD office.
The need to ensure resident incidents were promptly investigated to rule out abuse or neglect was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff acknowledged the findings.
The facility was asked to report the incidents from 12/21/21 and 03/09/22 to their local SPD office and a confirmation was provided prior to exit.
OR-411-0054-0028 C-231 Abuse Reporting and Investigation
* Any resident identified in survey sampling was sent on to APS.
* All staff In-service completed on 3/35/33
* All staff completed 2.5Hr Abuse Training Course
* Incident reports are having increased added investigation page for thoroughness.
* IR will be completed by first responder and given to RN/RCC/ED for investigation to be completed to rule out abuse/neglect if possible.
* The IR will be discussed daily in clinical meeting and service plans will be updated with interventions if needed.
*ED/RN/RCC will monitor weekly for compliance
3. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain.
A hospice visit note dated 06/13/22 was transcribed by a facility staff into the resident's progress notes on 06/14/22. It read in part, "I saw bruise on [his/her] back."
On 06/14/22, Staff 18 (RN) documented in a progress note, "RN reviewed [hospice] note and observed area to back/side in which a bruise is reported."
The bruise represented an injury of unknown cause for which the facility was required to report to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse/neglect.
There was no documented evidence the facility immediately investigated the injury and concluded it was not the result of abuse, nor did the facility report the injury to the local office as suspected abuse.
The need to ensure injuries of unknown cause were investigated immediately with documentation of how abuse was reasonably ruled out or, if abuse could not be ruled out, the injury was reported to the local office, was reviewed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 on 07/07/22. They acknowledged the findings.
The surveyor requested the facility report the injury of unknown cause to the local Department office. Confirmation the incident was reported was received on 07/07/22 at 3:07 pm.
Based on interview and record review, it was determined the facility failed to ensure resident to resident altercations were immediately reported to the local SPD office for 2 of 2 sampled residents (#s 6 and 10), and failed to immediately investigate an injury of unknown cause, and document the injury was not the result of abuse or neglect, or report the injury to the local SPD office as suspected abuse for 1 of 1 sampled resident (#7). This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in 02/2018 with diagnoses including Alzheimer's disease. During the acuity interview on 07/05/22 it was reported Resident 6 was involved in a resident-to-resident altercation.
Progress notes and incident reports indicated between 04/30/22 and 07/05/22, Resident 6 had two documented incidents of resident-to-resident altercations on 05/13/22 and 05/21/22.
The altercations represented incidents of abuse or suspected abuse that required reporting to local SPD office. There was no documented evidence the facility reported the incidents or took measures necessary to protect residents and prevent the reoccurrence of abuse.
The need to immediately report altercations to the local SPD office was reviewed with Staff 1 (ED) and Staff 4 (Regional Director) on 07/06/22 and 07/07/22.
The surveyor requested the facility self-report the resident altercations to local SPD office as suspected abuse. Verification was received prior to survey exit.
2. Resident 10 was admitted to the facility in 02/2020 with diagnosis of dementia. During the acuity interview on 07/05/22 it was reported Resident 10 was involved in a resident-to-resident altercation.
Progress notes and incident reports indicated between 04/30/22 and 07/05/22, Resident 10 had two documented incidents of resident-to-resident altercations on 04/28/22 and 05/13/22.
The altercations represented incidents of abuse or suspected abuse that required reporting to local SPD office. There was no documented evidence the facility reported the incidents or took measures necessary to protect residents and prevent the reoccurrence of abuse.
The need to immediately report resident altercations to the local SPD office was reviewed with Staff 1 (ED) and Staff 4 (Regional Director) on 07/06/22 and 07/07/22.
The surveyor requested the facility self-report the resident altercations to local SPD office as suspected abuse. Verification was received prior to survey exit.
OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action
*Resident 6 - the PCP has been involved in the resident's plan of care to determine whether the resident would benefit from any pharmacological interventions related to increased agitation and paranoia. Additionally, non-pharmacological interventions have been outlined on the resident's service plan that include a more individualized approach to behavioral supports for staff to follow. The individual that was involved in the resident to resident altercation with resident #6 has also been reevaluated to ensure an appropriate plan of care is implemented.
* Resident #7- The resident injury identified during the survey was investigated to identify causative factors. It was determined that the resident had an injury fall. This incident has been investigated and interventions have been put in place to reduce the potential for recurrence.
*Resident #10- The PCP has been involved in the resident's plan of care to determine whether the resident would benefit from any pharmacological interventions related to increased behaviors involving other residents. Additionally, non-pharmacological interventions have been outlined on the resident's service plan that include a more individualized approach to behavioral supports for staff to follow. The individual that was involved in the resident to resident altercation with resident #10 has also been reevaluated to ensure an appropriate plan of care is implemented.
*A comprehensive training on the policy for when to complete incident and accident reports, the process for investigating, requirements for self reporting to APS, and the need to implement timely interventions post incident have been reviewed with the entire team.
Incident reports are reviewed daily in the morning stand up meeting to ensure all Department Managers are aware of any high risk situations. Additionally, a detailed drill down in the clinical team morning quality assurance meeting is conducted to ensure all required steps post occurrence are completed, including but not limited to updating the service plan.
Additional training has been provided to the Med. Techs on 7/20/22 with consultant Nurse describing proper investigation requirements and steps to take immediately post occurrence.
* IR's are discussed daily in clinical meeting and service plans are updated with interventions needed.
* RCC will complete first investigation
* RN will follow up with interventions if needed
* ED will investigate for any abuse and prompt APS notification.
*The Executive Director is responsible to ensure the system has been corrected.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:
The kitchen was toured on 03/14/22. The following areas were in need of cleaning and/or repair:
* Rolling food cart inside the walk in refrigerator storing prepared food had dried food debris on the metal frame;
* In the freezer, boxes of food were stored on the floor;
* The dry storage area had bags with cooking utensils stored on the floor;
* Shelving under the steam table that faced the oven had chipped laminate and exposed particle board in multiple areas;
* The wall behind the warewasher had missing sheet rock and exposed wood framing;
* Cupboards in the kitchenette area were chipped and gouged creating a non-cleanable surface;
* Chemicals were observed under the kitchenette sink that were accessible to residents;
* The shared wall between the warewasher and the dining room had a section of wall missing that exposed wood framing; and
* The warewashing machine rinse temperature was greater than 180 degrees for sanitizing dishes, however, there was no data plate that provided instruction to staff ensuring dishes were washed and sanitized according to manufacturers recommendations.
The areas in need of cleaning and/or repair were reviewed with Staff 7 (Dining Services Director) on 03/14/22 at 11:50 am. She acknowledged the findings.
OR-411-0054-0030 (1)(a) C-240 Resident Service Meals and Food Sanitation Rule
* All items in sampling corrected, repaired or removed
* Q/A audit will be performed weekly
* FSD/ED will have weekly one to one meeting reviewing QA results
* FSD will keep Executive Director informed of things that are needed to remain in compliance on a weekly basis
*ED will monitor weekly for compliance during QA monitoring
There are no detail notes for this visit.
3. Resident 4 was admitted to the facility in 2021 with diagnoses which included Alzheimer's dementia.
Observations, staff interviews and review of the record during the survey revealed s/he was incontinent of bowel and bladder, needed staff assistance with ADL care needs, and did not advocate for him/herself or request assistance.
The most recent quarterly evaluation, dated 01/10/22, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:
* Personality: including how the person coped with change or challenging situations;
* Mental Health: Effective non-drug interventions;
* Ability to use call system;
* Laundry; and
* Alcohol use.
On 03/15/22, the need to ensure Resident 4's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (ED). He acknowledged the findings. No other information was shared.
2. Resident 2 was admitted to the facility in 2020 with diagnoses including Alzheimer's Disease.
a. Progress notes reviewed from 10/04/21 through 03/11/22 noted the resident was involved in resident to resident altercations, had an increase in sexual behaviors, was on alert charting for aggressiveness and agitation towards peers and staff, and was being monitored for changes in behavioral medications.
The evaluation dated 10/25/21 noted the resident was "even tempered" and would become "upset and yell" at peers that were "too loud".
During interviews on 03/14/22 with Staff 5 (Personal Care Assistant (PCA)/MT), Staff 10 (PCA) and Staff 11 (PCA) they stated the following:
* Agitated easily;
* Would grab and touch female residents' breasts; and
* Pushed residents that were in his/her way.
Resident 2's evaluation was not reflective of the resident's sexual behaviors, increased aggression or agitation, or resident to resident altercations.
b. Resident 2's evaluation did not indicate who was involved in the evaluation process.
Resident 2's evaluation was discussed with Staff 1 (ED) on 03/15/22 at 3:45 pm. Staff 1 acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and failed to ensure quarterly evaluations were reflective, signed, and addressed all changes based on the resident's status for 2 of 3 sampled residents (#s 2 and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to:
1. Resident 3 moved into the facility in December 2021.
The new move-in evaluation failed to address the following elements:
* Physical health status including visits to health practitioner(s) ER, hospital or NF in the past year;
* Mental health issues including effective non-drug interventions;
* Ability to manage medications;
* Ability to use call system;
* Housework and laundry;
* Transportation;
* Fall risk or history;
* Emergency evacuation ability;
* Complex medication regimen;
* Recent losses; and
* Elopement risk or history.
The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. The findings were acknowledged.
OR-411-0054-0034 C-252 Resident Move-in and Evalutation General
*Residents in sampling were brought into compliance
* All new admitt evaluations will be reviewed by the service plan team and the family to assure that all of the new residents needs are met as well as the service plan reflects resident specific and is person centered.
* All Service plans and new admits will be completed on 30 day, 90 day and any change of conditions as well as any interventions that are needed due to a change in baseline.
* 30/90 day and change of conditions will be reviewed daily/weekly during clinic meetings.
*ED/RN/RCC will assure these are completed, current with any changes warranted.
There are no detail notes for this visit.
2. Resident 2 was admitted to the facility in 2020 with diagnoses including dementia.
Observations of the resident, interviews with staff, and review of the current service plan revealed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:
* Lack of bed in the resident's apartment and preference to sleep in recliner chairs; and
* Particular resident's that had been identified as involved in sexual behavior.
The service plan was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22 at 2:07 pm. No additional information was provided.
3. Resident 3 was admitted to the facility in December 2021 with a diagnosis of Type II diabetes and dementia.
Observations of the resident, interviews with staff, review of the service plan updated 02/14/22, Temporary Service Plans, and 01/01/22 thru 03/14/22 progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas:
* Transfer assistance;
* Incontinence and toileting needs and level of assistance required;
* Right eye treatment status;
* Right hip precaution;
* Use of glasses; and
* Falls and safety interventions.
The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status and provided clear direction to staff for 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.
The resident's service plan dated 12/02/21, progress notes from 12/14/21 through 03/14/22 and hospice notes were reviewed. Observations of the resident during survey and interviews with staff and family were completed. The service plan was not reflective and did not provide clear instruction to staff in the following areas:
* Two person transfers;
* Bed mobility;
* Dressing, grooming, hygiene and toileting;
* Ambulation and mobility;
* Assistive devices;
* History of falls;
* Fall matt on the floor next to bed;
* Perimeter mattress;
* Non-skid footwear;
* Meal assistance;
* Evacuation ability;
* Pain;
* Skin conditions;
* Pressure reducing cushion in wheel chair; and
* Hospice Services.
The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director). The staff acknowledged the findings.
OR-411-0054-0036 (1-4) C-260 Service Plan General
* All Staff Inservice completed 3/25/22
* Residents in sampling updated service plans
* Service Planning Team will review upcoming service plans with front line staff
*Part or all Service Planning Team will meet weekly/daily to review upcoming Service Plans including notes from the front line staff that are coming due and discuss any changes or updates to be added.
* These Service Plans once updated will be reviewed by family, POA and resident when possible and changes will be implemented ASAP
*At least 2 members of the community Service Planning Team will be present for the review with the family/POA/resident.
*Q.A. checks by Executive Director monthly to assure compliance.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of the resident's needs and provided clear direction regarding the delivery of services, for 2 of 4 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident service plans and Temporary Service Plans were reviewed, residents were observed, and residents and staff were interviewed to obtain information about the residents' current status and care that was needed and being provided by staff. The following deficiencies were identified:
1. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services. The resident's record indicated a history of falls, and that s/he needed additional assistance with some ADLs following a fall on 07/06/22.
The resident's current service plan was not reflective or followed in the following areas:
* The resident now required full assistance with dressing rather than standby assistance as noted in the service plan;
* The resident was no longer independent with transfers and ambulation and unable to safely ambulate using his/her 4-wheeled walker as noted in the service plan;
* New interventions provided by hospice dated 06/07/22 were not added to the resident's service plan and implemented; and
* The flow rate on the resident's oxygen concentrator was not set at the correct setting.
The need to ensure service plans were reviewed and updated as necessary when a resident's care needs changed was reviewed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
2. Resident 8 was admitted to the MCC in 02/2022 with diagnoses including vascular dementia. During the acuity interview on 07/05/22, Resident 8 was identified as having a hip fracture, weight loss, and received hospice care.
Observations of the resident, interviews with staff on 07/05/22 through 07/07/22, and a review of the current service plan dated 04/19/22 indicated the service plan was not reflective of the resident's care needs and lacked clear instructions to staff in the following areas:
* Hip fracture and postoperative hip precautions;
* Recent hospital stay;
* Puree diet and thickened liquids;
* Full assist for food and fluid intake;
* Full assistance with all ADLs;
* Two-three person assist with repositioning and providing incontinence care while in bed;
* Hospice services and schedule;
* Pain areas and treatment;
* Weight loss and interventions; and
* Falls and current interventions.
The need to ensure service plans were reflective, updated, and provided clear instructions to staff was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
OAR 411-054-0036 (1-4) Service Plan: General
*Resident #7's service plan has been updated to reflect her current needs. These include, but are not limited to the level of assistance the resident requires with dressing, ambulation, mobility aids, and oxygen use. Additionally the resident continues to receive hospice services and requires coordination of care with hospice to ensure recommendations are implemented into the plan of care timely.
*Resident 8 -passed away
* An All Staff Inservice was conducted on 7/25/22 to discuss service planning processes, including what to report to the ED/RN/RCC, and how to effectively communicate changes observed with residents that require a service plan update.
The service planning team will review upcoming service plans with front line staff prior to updating. Once updated, service plans will be reviewed with family, POA, and the resident when possible.
At least 2 members of the community Service Planning Team will contribute to the development of the service plan.
*During the daily clinical drill down meeting, all short term or potentially long term changes to a resident's service plan will be reviewed.
* The Executive Director will be responsible to ensure the system is in place and effective.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:
Resident 1, 2, 3 and 4's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.
The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) on 03/16/22. He acknowledged the findings.
OR-411-0054-0036 C-262 Service Planning Team
* All Staff Training completed on 3/25/22 addressing Service Planning and Procedures
* Service Planning Team will consist of the RN/RCC/ED and family members, POA and residents
*Part or all of the Service Planning Team will meet weekly/daily to review upcoming Service Plans that are coming due and discuss any changes or updates to be added.
*These Service Plans once updated will be reviewed by family, POA and resident when possible and changes implemented ASAP.
* At least 2 members of the community Service Planning Team will be present for the review with the family/POA/resident.
* QA check will be completed by Executive Director monthly.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed ensure changes of condition were evaluated, monitored through resolution, and actions or interventions were identified and implemented for 2 of 4 sampled residents (#s 1 and 3) reviewed for changes of condition. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in December 2021 with diagnoses including dementia.
Review of the facility progress notes, dated 01/01/22 through 03/14/22, the resident's 02/14/22 service plan, temporary service plans and incident reports revealed Resident 3 had falls on 01/01/22 and 02/17/22.
There was no documented evidence the facility thoroughly reviewed the incidents to determine the circumstances of the fall and there was no documented evidence the facility developed interventions to minimize further falls.
The need to ensure short term changes were evaluated, and specific resident interventions determined and documented was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
2. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.
The resident's 12/02/21 service plan, 12/14/21 thru 3/14/22 progress notes, temporary service plans, incident reports and physician communications were reviewed. The resident experienced multiple short-term changes lacking evaluation, monitoring at least weekly to resolution, actions or interventions determined, documented and communicated to staff in the following areas:
* 12/14/21-Non-injury fall;
* 12/21/21-Fall with facial laceration, bruising and swelling;
* 01/29/22-Hospice admission;
* 02/22/22-Two non-injury falls; and
* 03/09/22-Fall with skin injuries to the forehead and left arm.
Staff 3 (Memory Care Director/LPN) reported on 03/15/22 that she had not monitored Resident 1's facial laceration, bruising and swelling from the 12/21/21 fall weekly to resolution.
The need to ensure short term changes of condition were evaluated, monitored at least weekly to resolution, actions or interventions determined, documented and communicated to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff acknowledged the findings.
OR-411-0054-0040 (1-2) C-270 Change of Conditioning and Monitoring
* Training to front line staff on what "Change of Condition" is and who to report to once this has been identified.
*RN/RCC will assure all documentation is in place and appropriate parties have been notified when necessary
* Daily/Weekly clinical meeting will take place with the RN/RCC/ED to discuss next steps, review service plan and make any further changes such as interventions when needed. They will also review chart notes and confirm alert charting is completed daily.
* ED/RN/RCC will review daily.
* Executive Director will monitor monthly for compliance.
4. Resident 9 was admitted to the facility in 2021 with diagnoses including vascular dementia.
On 07/06/22, the surveyor observed Resident 9 enter the medication room with a bloody right forearm. The resident appeared to have a five to six inch cut. Resident 9 stated "[dog] scratched me again." Staff 16 (MT) stated to the surveyor the blood came from a previous scratch that was scabbed over and reopened when the resident was playing with Staff 1's (ED) dog.
During an end of day meeting on 07/06/22 at 4:40 pm, Staff 1 said the dog belonged to him and he brought the dog to the facility most days. The surveyor requested an incident report, progress notes and any updated service plans related to the resident's skin injury.
Staff 1 provided the following documents:
* A late entry progress note dated 06/30/22 that noted Resident 9 had a five to six inch long scratch on his/her forearm; and
* An incident report completed on 07/06/22 that noted two injuries occurred, one on 06/30/22 and another on 07/05/22. The incident report noted the injuries were caused by the dog and that the dog's nails were trimmed on 07/05/22.
During an interview on 07/07/22 at 9:18 am, Staff 5 (PCA/MT) was not aware of the resident's skin injury and verified there was no documented evidence on the TAR which indicated the resident had received treatment on 06/30/22.
The surveyor and Staff 5 went to observe Resident 9 on 07/07/22 at 9:25 am. Resident 9 was observed to have three scratches on the right forearm approximately five to six inches in length. The scratches were scabbed and slightly reddened.
During an interview on 07/07/22 at 10:30 am, Staff 14 (Activity Director) stated the dog came into the facility daily. Staff 14 stated the dog was rambunctious and at times would get wild and jump up on people especially during activities that involved a ball toss.
Resident 9 experienced a change of condition on 06/30/22 related to a skin injury. At the time of the incident, there was no documented evidence the facility evaluated the resident to determine what actions or interventions were needed to help minimize future injuries, and implemented monitoring of the wound.
The facility developed a temporary service plan on 07/06/22 with instructions for monitoring the resident's wound and instructions for staff for monitoring the dog. In addition, a plan of correction addressing ways to minimize the dog's "rambunctious" play was outlined and dispersed to staff.
The facility's failure to respond to the change of condition was discussed with Staff 1 (ED) and Staff 4 (Regional Director). Staff acknowledged the findings.
3. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services. The resident's record indicated a history of falls.
The resident's record from 05/01/22 through 07/05/22 was reviewed including progress notes, hospice visit notes, the 06/2022 MAR/TAR, the current service plan dated 05/24/22, Temporary Service Plan (TSP) updates and incident reports. The facility failed to comply with rules related to changes of condition as follows:
a. A facility staff transcribed a hospice visit note into the resident's progress notes on 05/17/22. The note read in part, "patient was complaining about a stomach ache and pain in [his/her] chest. [RN case manager] and facility staff notified." The facility failed to determine and document what action or intervention was needed for the resident and failed to monitor and document on the status of the resident's condition until resolved.
b. On 05/27/22, a staff documented in a progress note that while assisting the resident with toileting, the staff observed blood in the stool. The facility failed to determine and document what action or intervention was needed for the resident and failed to monitor and document on the status of the resident's condition until resolved.
c. The resident had a fall on 06/07/22 where s/he sustained a skin tear to the right wrist and complained of severe back pain, and a fall on 06/29/22 where s/he sustained pain and redness to the top of the head an a "tear" on the back. The TSPs that were written lacked resident-specific information about the falls and injuries, lacked clear instructions for monitoring the injuries, and lacked a review of the service-planned mobility needs and fall interventions for effectiveness. There was no documented monitoring of the injuries, and the facility failed to develop and implement any new interventions to try to prevent further falls.
d. Between 06/13/22 and 06/16/22 (four days), the resident was not administered two medications prescribed for heart disease/congestive heart failure - amlodipine and furosemide. The facility failed to monitor the resident for any negative effects of not receiving the medications.
The need for the facility to develop a system for identifying and communicating about changes of condition, reviewing existing interventions for effectiveness, and ensuring clear instructions regarding interventions and monitoring were documented and communicated to staff following a change of condition was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented, and communicated to staff, and the residents' conditions, including the effectiveness of interventions, were monitored weekly through resolution for 4 of 4 sampled residents (#s 6, 7, 8 and 9) who had documented changes of condition. Resident 8 had repeated injury and non-injury falls. Resident 6 had repeated resident to resident altercations. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the MCC in 02/2022 with diagnoses including vascular dementia. During the survey, s/he was identified with a history of falls, and a recent fall resulting in a right hip fracture.
A review of Resident 8's 04/19/22 service plan provided the following interventions:
* Staff to escort the resident to meals and activities;
* Staff to remind the resident to ask for assistance with transfers; and
* When the resident was in bed, the staff were to ensure the bed was at the lowest position.
Observations of Resident 8 throughout the survey confirmed the resident was bed bound, was a two-three person assist for repositioning and incontinence care, and was dependent on staff for all ADLs.
a. On 05/21/22, the resident had a fall and injured his/her nose. The resident was placed on alert charting for the injury, and the injury to the nose was documented as resolved on 05/31/22. However, the follow up investigation failed to document if service-planned interventions were being followed at the time of the fall, were effective, or if new interventions were needed following the fall.
b. On 05/25/22, staff documented that the resident had an unwitnessed non-injury fall. There was no documented evidence the facility investigated the fall, determined if new interventions needed to be developed and communicated the information to staff, and documented monitoring of the resident's condition at least weekly until resolved.
c. On 06/23/22, staff documented that the resident was found on the floor on his/her knees. The incident report completed on 06/23/22 noted an "apparent injury, small mark on [his/her] right ribs." The resident was placed on alert charting, and a Temporary Service Plan (TSP) noted the resident had a "small red mark on the right ribs" and instructed staff to report "any complaints of pain, any complaints of discomfort, and any observed discoloration." There was no documented evidence the facility determined if service-planned interventions were followed at the time of the fall, were effective, or if new interventions were needed following the fall. On 06/24/22, staff documented the resident had an x-ray in the facility which showed a subcapital fracture of the right hip.
d. On 06/25/22, staff documented that the resident had a non-injury fall. The follow up investigation failed to document if service-planned interventions were being followed at the time of the fall, were effective, or if new interventions were needed following the fall.
The resident was hospitalized on 06/25/22 for hip surgery. The facility's failure to evaluate Resident 8's fall risk, develop interventions to prevent falls, and monitor interventions for effectiveness resulted in a fall with a hip fracture.
On 07/01/22, the resident returned to the facility.
e. On 07/03/22, the resident was found wrapped in his/her blankets on the floor between the window and the bed. The incident report noted "frequent checks" as the follow-up action. The resident was put on alert charting, and a TSP instructed staff to monitor and report any complaints of pain, discomfort, observation of discoloration, and shortness of breath to the nurse. However, the facility failed to ensure the TSP instructed staff to provide frequent checks.
f. On 07/04/22, the resident was found on the floor next to his/her bed, with the resident's head at the end of the bed and feet towards the head of the bed. The incident report documented "Frequent checks every thirty minutes/one hour" as the follow-up action. The resident was put on alert charting, and a TSP instructed staff to monitor and report any complaints of pain, discomfort, observed discoloration, and swelling or redness to the nurse. However, the facility failed to ensure the TSP instructed staff to provide frequent checks every thirty minutes/one hour.
The failure of the facility to evaluate the resident, review previous fall interventions to ensure they were added to the service plan and were implemented, monitor fall interventions for effectiveness, or develop new interventions to try to prevent future falls or injuries placed the resident at risk for continued falls and/or injuries.
The need to ensure the facility thoroughly investigated the circumstances for falls, determine if service planned interventions were implemented, were effective or if new interventions were needed, and failure to monitor and document on the resident's condition at least weekly until resolved was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 02/2018 with diagnoses including Alzheimer's disease.
Review of the facility progress notes, dated 05/10/22 through 06/30/22, the current service plan, temporary service plans and incident reports identified Resident 6 had resident to resident altercations on 05/13/22 and 05/21/22.
The current service plan lacked interventions to address resident to resident altercations and there were no other documents that communicated further interventions or monitoring instructions for staff following each altercation. The resident continued to be involved in physical altercations with other residents.
The need to ensure incidents were evaluated, and specific resident interventions determined and documented was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
Refer to Z 165, example 1.
OR-411-0054-0040 (1-2) C-270 Change of Conditioning and Monitoring.
* Resident #6 - Collaboration of care with the PCP and family regarding medication management services for the resident have occurred. A reassessment of the resident will be conducted by the RN to ensure all pharmacological and/or non-pharmacological supports implemented into the plan of care are effective. The service plan will be reflective of any changes to the plan of care.
* Resident #7 - A reassessment of the resident's fall risk and current interventions in place to reduce the recurrence of future incidents and injuries will be completed. The service plan will be reflective of any changes to the plan of care.
* Resident #8 - passed away
* Resident #9 - A reassessment of the resident's skin status has been conducted to ensure all skin tears have healed. Additionally, the resident's risk for skin breakdown has been updated on the resident's service plan.
* A comprehensive retraining on what types of changes of condition need to be reported and protocols for monitoring condition changes until resolution has been completed.
The RN/RCC will assure all documentation is in place and appropriate parties have been notified when necessary. Residents who experience a significant change of condition will be placed on alert charting and will move to at a minimum weekly monitoring by the facility RN until a new baseline has been established and/or the condition resolves. A significant change of condition log will be utilized to ensure all parties clearly know who is on Significant Change Monitoring by the RN.
A Daily clinical drill down meeting is conducted with the clinical team to discuss changes of condition and appropriate follow-up measures including documentation on monitoring, interventions, and service planning. Should an incident rise to a safety concern, a safety plan will be developed and implemented for all staff to review as needed.
A daily audit of alert charting has been implemented to identify any omissions in the record.
The Executive Director and RN are responsible to ensure this system is corrected.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN completed a significant change of condition assessment based on the condition of the resident, developed interventions and updated the service plan for 1 of 1 sampled resident (#1) who had a significant change of condition which included a decline in ADLs and mobility. Findings include, but are not limited to:
Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia.
During the acuity interview on 03/14/22, it was revealed Resident 1 was a two person transfer, had experienced a decline in mobility and required an increase in ADL assistance.
The service plan, dated 12/02/21, identified the resident as independent with transfers, ambulation and one person assist with toileting, dressing, grooming and showering.
On 03/14/22 at 11:50 am, the resident was observed in a high back wheel chair in the dining room. Staff provided cues and some assist with intake of the meal. After the meal, staff provided full assist with mobility in the wheelchair. On 03/15/22 at 09:55 am Resident 1 was observed during a transfer from wheelchair to bed with a full two person assist.
Staff 10 (Personal Care Assistant (PCA)) reported on 03/14/22 at 1:00 pm that the resident was independent with transfers and ambulation until approximately a month ago. She stated Resident 1 needed a two person total assist with transfers, mobility in a wheelchair and with all ADL cares.
The resident's need for increased assistance with transfers, changes in mobility and ADL's in multiple areas, constituted a significant change of condition. There was no RN assessment completed.
The need for an RN assessment which included development of interventions, documentation of findings and updating of the service plan was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff acknowledged the findings.
OR-411-0054-0034 C-280 Resident Health Services
* RN will be notified immediately when there is a change of condition, the RN will have change of condition assessment completed within 24hrs.
* RN/RCC will review daily during clinical if a member of the team is not in the community then will join via phone or zoom.
*This will be reviewed daily by the RCC/RN/Ed
* RCC/RN/ED will monitor for compliance
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed and documented for 1 of 1 sampled resident (#8) who experienced a significant change of condition related to weight loss. This is a repeat citation. Findings include, but are not limited to:
Resident 8 was admitted to the MCC in 02/2022 with diagnoses including a history of stroke and vascular dementia.
The resident's 04/19/22 current service plan, 05/01/22 through 07/04/22 charting notes, and weight documentation were reviewed during the survey and identified the following weights:
* 05/01/22; 160 pounds; and
* 06/01/22; 151 pounds.
Between 05/01/22 and 06/01/22, Resident 8 lost nine pounds or 5.62% total body weight in one month. This weight loss represented a significant change of condition for Resident 8, which required an RN assessment.
There was no documented evidence an RN assessment was completed for Resident 8's significant weight loss. In an interview on 07/06/22, Staff 18 (RN) confirmed there was no RN assessment.
During the survey the resident was observed to receive nutritional supplements, specially prepared meals and was assisted with eating. The resident was unable to be weighed during the survey.
The need to ensure an RN assessment was completed related to significant changes in condition and included the required components of documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 on 07/07/22. They acknowledged the findings.
OR-411-0054-0034 C-280 Resident Health Services
* Resident #8 passed.
A comprehensive retraining on what types of changes of condition need to be reported and protocols for monitoring condition changes until resolution has been conducted. Specifically, residents who are at risk for weight loss/weight gain and/or are actively experiencing weight loss or gain are to be reported to the community RN.
Staff have been re-trained on what types of risks associated with weight loss should be reported including, meal refusals, appetite changes, changes to the fit of clothing, teeth pain, denture fit/slips, etc..
Staff have been re-trained on what type of risks associated with weight gain should be reported including, decreased mobility, regularly requesting second helpings, snacks, sweets, hoarding of foods, medication changes, swelling, etc..
A comprehensive weight tracking system for monitoring resident's weight occurs routinely on a monthly basis unless the resident has been identified as at risk for weight loss/gain. Residents who experience a 5% in 30 days, 7.5% in 90 days, and/or 10% or greater in 6 months are placed on significant change of condition monitoring for the RN to assess, develop a plan, implement interventions, and update the service plan as deemed appropriate. Residents who experience a significant change of condition related to weight loss or weight gain will be monitored at a minimum of weekly by the facility RN until a new baseline has been established and/or the condition resolves. A significant change of condition log will be utilized to ensure all parties clearly know who is on Significant Change Monitoring by the RN.
During the daily clinical drill down meeting, the clinical team will discuss weight changes and appropriate follow-up measures including documentation on monitoring, interventions, and service planning.
A monthly audit of weights will be conducted as part of the QA program in place.
The Executive Director and RN are responsible to ensure this system is corrected.
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 Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#5) 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 03/14/22, Resident 5 was identified to be administered insulin injections by non-licensed staff.
Resident 5's MARs, reviewed from 02/01/22 through 03/16/22, revealed insulin had been given by Staff 5 (Personal Care Assistant (PCA)/MT) on multiple occasions.
The initial delegation for Staff 5, completed 12/24/21, lacked documentation in the following areas:
* The skills and ability of the unlicensed person;
* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; and
* How frequently the unlicensed person should be supervised and re-evaluated, including rationale for the frequency based on the competency of the caregiver.
Additionally, there was no documentation that Staff 2 (RN) re-evaluated Staff 5 within 60 days of the initial delegation.
The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 03/16/22. He acknowledged the findings. No further information was provided.
OR-411-054-0034 C-282 RN Delegation and Teaching
* Med Tech training was completed 3/15/22, reviewing the medication Orientation Training
* Any new delegations/task RN is notified and the one on one training is provided by RN as needed and documented
* This will be discussed daly in your clinical meeting
*RCC/RN will monitor daily to assure all tasks are completed in a private setting
* ED/RCC/RN will review with each candidate or delegation to monitor for compliance
Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 4 of 4 sampled residents (#s 9, 11, 12 and 13) reviewed for the delegation of insulin injections by unlicensed staff. This is a repeat citation. Findings include, but are not limited to:
Residents 9, 11, 12 and 13 were identified as having insulin-dependent diabetes and were administered insulin injections by non-licensed staff.
On 07/06/22, the facility's RN delegation records were reviewed and revealed the following:
The previous facility delegating RN transferred delegation of the residents to Staff 18 (RN) on 06/14/22.
The transferred delegations were accepted missing the following required documentation:
* Rational for frequency of reassessment of the resident;
* Rational that task could be safely delegated to unlicensed staff; and
* Rational for the frequency at which staff would be reevaluated.
Staff 18 completed initial delegations for Residents 9, 11, 12 and 13 with five care staff. The delegations were missing the following required documentation:
* Nursing assessment and condition of the client to determine the client's condition was stable and predictable;
* Rational for frequency of reassessment of the resident;
* Rational that task could be safely delegated to unlicensed staff; and
* Rational for the frequency at which staff would be reevaluated.
The new delegations also included the staff would be reevaluated in 90-days instead of the required 60-days for initial delegations.
On 07/07/22, the need to ensure RN delegation was completed and maintained as required by OSBN Division 47 Administrative rule was discussed with Staff 1 (Executive Director) and Staff 18. They acknowledged the findings.
OR-411-054-0034 C-282 RN Delegation and Teaching
Resident #9, #11, #12, & #13 have been reassessed by the community RN to ensure there is documented evidence on the rationale for frequency of reassessment of the resident related related to a delegated service, rationale that the task could be safely delegated to unlicensed staff; and the rationale for the frequency at which staff will be reevaluated.
Additionally, an updated RN assessment and condition
of the client has been conducted to determine whether the client is stable and predictable to be delegated. The RN will include the frequency of reassessment
of the resident and rationale that the nursing task could be safely delegated to unlicensed staff. A competency has been completed for each staff member being delegated and rationale for the frequency at which staff will be reassessed.
A delegation tracking system will be created and utilized to ensure delegations are completed timely and do not exceed the minimum time frames outlined in Division 47 of the Oregon Nurse Practice Act. The Community RN will complete the didactic reading materials on delegation in CBC in Oregon and complete the competency test.
The Community RN is responsible to ensure this system is in place per Oregon State Board of Nursing Scope and Standards. The Executive Director will consult with corporate RN and/or the appointed consultant will assist with QA to verify all components.
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 3 sampled resident (#3) who received outside provider services. Findings include, but are not limited to:
Resident 3 was admitted to the facility 12/2021 after right hip surgery.
During the acuity interview on 03/14/22, Resident 3 was identified to receive HH services.
The resident's progress notes dated 01/01/22 through 03/14/22, 02/14/22 service plan, Temporary Service Plans and HH visit notes dated 01/15/22 through 03/01/22 were reviewed and revealed the following:
* 01/25/22 HH OT recommendation - "Please check in with [the resident] about hip pain...seems to have increased pain with ambulation and transfers." Resident could "benefit from ice pack application to hip."; and
* 02/03/22 HH PT recommendation - "Will notify surgeon of ongoing pain...Please remember [his/her] hip precautions: no bending more than 90 [degrees], no crossing legs, no rotating... keep foot pointed out".
There was no documented evidence these recommendations were communicated to staff nor implemented.
On 03/14/22, Staff 2 (RN) confirmed the Home Health recommendations were not passed on to the staff or implemented for the provision of care for Resident 3's right hip care instruction and pain.
The need to ensure ongoing coordination of care with outside providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
OR-411-054-0034 C-290 On-site and Off Site Health Services
* All staff training completed 3/25/22
*HH or Outside Agency notes will be transferred onto TSP and documented
*RN/RCC will confirm these are in place same day as recommendations are made
*ED will review to cofirm if there are any updates needed
*ED/RN/RCC will monitor for compliance
Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers to ensure staff were informed of new interventions, and that the service plan was adjusted, if necessary, for 1 of 1 sampled resident (#7) for whom hospice left instructions for the facility. This is a repeat citation. Findings include, but are not limited to:
Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident's record indicated a history of falls. The resident was receiving hospice services.
a. The record indicated Resident 7 had a fall on 06/07/22 in his/her room and sustained a skin tear to the right wrist and complained of back pain. A hospice nurse visited later on 06/07/22, evaluated the resident and left the following written instructions for the facility:
* Increase morphine orders to be faxed;
* Keep bed at lowest position;
* Keep wheelchair and walker out of reach when resident was in bed;
* Encourage use of call light;
* Every-hour checks; and
* Toileting every four hours.
A facility staff transcribed the hospice visit note into the resident's progress notes on 06/08/22. However, there was no documented evidence the facility added the interventions to Resident 7's service plan and informed staff of the new interventions.
b. A facility staff transcribed a hospice visit note into the resident's progress notes on 05/17/22. The note read in part, "patient was complaining about a stomach ache and pain in [his/her] chest. [RN case manager] and facility staff notified."
There was no documented evidence the facility coordinated care with the outside provider which included an evaluation of the resident to determine if the service plan needed to be adjusted and staff informed of any new interventions.
The need to ensure the facility had a system to ensure outside provider notes were reviewed and new instructions were added to the resident's service plan and implemented, was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
OR 411-054-0034 C-290 On-Site and Off Site Health Services
* Resident #7 has been reassessed by the community RN to include documented evidence of coordination of care with hospice services. The resident's service plan and medications have been updated to reflect the current plan ordered by the hospice doctor and appointed nurse.
*A comprehensive training has been completed with ALL staff to review policy on coordinating care with on and off site providers. Specifically, a compilation of ancillary staff that may be involved in the resident's care was reviewed including, but not limited to clinic visits with PCP/NP/Providers, PT, OT, ST, Home Health Nursing, Wound Clinic, Dialysis, Palliative Care, Hospice Care, Drug/Alcohol Rehab, etc.,
Documented evidence of the visit must be requested and received for residents that require coordination of care services. The resident's record will include how the visit went and whether there are any needs or interventions to be implemented into the plan of care by the facility.
All interventions deemed to be appropriate for implementation into the resident's plan of care will be completed timely.
Residents receiving on and off site visits are discussed in the daily clinical drill down meeting to ensure visit notes are received, reviewed, and implemented into the resident's service plan for staff to follow.
* The ED/RN/RCC are responsible to ensure the system is completed.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, for 2 of 4 sampled residents (#s 7 and 8) whose physician orders were reviewed. Findings include, but are not limited to:
1. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services.
Resident 7's most recent signed physician orders were reviewed and compared to the 06/2022 MAR/TAR. The following orders were not followed:
* Amlodipine qd (for heart disease) and furosemide qd (for congestive heart failure) were not administered for four days (06/13/22 through 06/16/22) because the facility failed to obtain refills through hospice.
* Ibuprofen BID (for pain) was not administered on 06/20/22 and potassium chloride qd (for congestive heart failure) was not administered on 06/23/22 because the facility failed to obtain refills through hospice.
* On 06/11/22 and 06/16/22, PRN lorazepam was given for shortness of breath without having first administered PRN morphine with ineffective results per the physician orders dated 06/06/22.
* On 06/07/22, 06/08/22 and 06/17/22, PRN morphine was given for pain without having first administered PRN ibuprofen with ineffective results per the administration instructions.
* During the survey, Resident 7's oxygen concentrator flow rate was observed to be set at 1.75 liters per minute, not three liters per minute as prescribed.
The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
2. Resident 8 was admitted to the MCC on 02/2022 with diagnoses including vascular dementia, stroke, high blood pressure and constipation.
Resident 8 had the following PRN bowel medications:
* Senna two tablets (17.2 mg) give first if no bowel movement in three days;
* Bisacodyl suppository (10 mg) give second if no bowel movement in three days and the Senna was ineffective.
The resident's 06/01/22 through 07/05/22 bowel monitoring records showed the following:
* Bowel monitoring on the 06/2022 TAR indicated Resident 8 did not have a bowel movement from 06/12/22 through 06/17/22, when the facility administered PRN Senna. The PRN Senna was not administered to the resident on the third day of not having a bowel movement, as prescribed;
* The TAR indicated the resident did not have a bowel movement until 06/19/22, two days after PRN Senna was administered; and
* There was no documented evidence the resident was administered the PRN Bisacodyl suppository when the Senna was ineffective.
The need to ensure medication and treatment orders the facility was responsible to administer were carried out as prescribed was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
OAR 411-054-9955 (1)(f-h) Systems: Treatment Orders
Resident #7's medication and treatment orders have been reconciled to ensure the medication administration record matches the resident's PCP orders. Additionally, all medication and treatment specific instructions with parameters have been updated on the Medication Administration Record (MAR).
Resident #8 passed.
*A comprehensive medication and treatment reconciliation will be completed for all residents to ensure all orders are accurate on the MAR and accessible in the record.
Medication and treatment orders will be reconciled at a minimum of every 90 days moving forward. This includes a comprehensive chart review, cart audit, and physician order signatures.
The medication techs were inserviced on the policy and protocols on how to process orders via the triple check system.
Step 1: First check- initial receiving medication tech processes all new orders to ensure no delay of treatment. Staff will contact the community nurse for direction as needed. All new orders received or order changes will be transcribed into the MAR, and the previous medication (if med changed) will be discontinued.
Second check- oncoming medication tech verifies all first check orders were processed accurately, appropriate directions and parameters for staff to follow were put in place.
Third check- nursing to be the final check. The final verification of processing will be to ensure all components are in place and to make updates as indicated.
Step 2: The Administrator or Designee will complete weekly and monthly medication administration audits to ensure any concerns with medication discrepancy, omission, as needed effectiveness and parameters are followed timely.
Areas of focus for auditing will include verifying each Residents MAR is reflective of most recent Physician Order information including but not limited to: resident specific reasons for administering PRN pain medications, parameters for use of all PRN medications including topical medications, and directions for staff to administer PRN psychoactive medications. Review will also include ensuring all medications and treatments are being given per MD order.
Step 3: The Executive Director or Designee will add all providers / practitioners required resident notifications for daily weights or vitals out of parameters to the acuity report to self-audit and ensure providers / practitioners notifications are done timely.
Step 4: The Executive Director or Designee will audit the medication administration record on a daily, weekly and monthly basis. All orders will be reconciled quarterly prior to physician orders being sent to the providers for review.
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 1 of 3 sampled residents (# 14) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 14 was admitted to the facility in 04/2021 with diagnoses including dementia.
Resident 14's MARs and current physician orders, dated 09/01/22 through 09/19/22, were reviewed and revealed the following:
* Memantine 5 mg was ordered on 08/31/22 to be administered once a day for seven days, then was to increase to twice daily for dementia.
The Memantine was administered once a day as ordered for seven days and then discontinued on 09/07/22. There was no order to discontinue the medication. The resident did not receive the Memantine as ordered on 23 occasions.
Resident 14's MARs and orders were reviewed with Staff 18 (RN) on 09/19/22, and Staff 25 (Executive Director) on 09/20/22. They acknowledged staff failed to ensure the order was carried out as prescribed. Administration of the medication was resumed on 09/19/22 at 8:00 pm.
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 1 of 1 sampled resident (#4) who had documented medication and treatment refusals. Findings include, but are not limited to:
Resident 4's MARs were reviewed for the time period of 02/01/22 through 03/15/22.
Staff documented Resident 4 refused:
* Tylenol (for pain) on six occasions;
* Docusate sodium (stool softener) on four occasions;
* Risperidone (for mood) on four occasions;
* Morphine (for pain) on one occasion; and
* Sertraline (antidepressant) on three occasions
There was no documented evidence the facility notified Resident 4's physician/practitioner of the refusals.
Staff 16 (MT) was interviewed on 03/15/22 at 1:10 pm. During the interview, she confirmed the lack of documentation that staff had notified Resident 4's physician/practitioner of medication refusals.
The need to inform Resident 4's physician/practitioner of medication refusals was discussed with Staff 1 (ED) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.
OR-411-054-0034 C-305 Systems Resident Right to Refuse
* Med Tech will send fax to physician by end of each shift of any resident refusals.
* Resident will be placed on alert charting for choosing to refuse to take medications.
*Daily will be discussed in clinical meeting
*ED/RN/RCC will monitor for compliance
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications, for 3 of 4 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 4 was admitted to the facility in 2021 with diagnoses which included Alzheimer's and edema.
Resident 4 had an order for compression stockings for edema. Staff were instructed to "apply compression stockings to lower extremities in the morning before resident gets out of bed ..."
Review of the MAR, from 03/01/22 - 03/15/22 revealed that on 03/15/22 at 8:00 am, Staff 16 (MT) initialed that the resident's compression stockings had been applied.
Multiple observations of the resident on 03/15/22 revealed s/he was not wearing compression stockings.
In an interview with Staff 5 (Personal Care Assistant (PCA)/MT) on 03/15/22, she said PCAs applied the stockings, not the MTs. She added that the stockings had not been donned that morning because the family was washing them.
Staff 16 was interviewed on 03/15/22 at 1:10 pm. She was unaware that the resident was not wearing the stockings. She reviewed the MAR and confirmed she initialed that the stockings had been applied without verifying it.
The need to ensure an accurate MAR was discussed with Staff 1 (ED) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.
2. Resident 3 was admitted to the facility in 2021 with diagnoses including type II diabetes.
Resident 3 had a physician order to administer Trulicity (a medication to treat type II diabetes) injection weekly.
Resident 3's 03/01/22 through 03/14/22 MAR revealed the following:
* 03/04/22 - there was no staff signature noting administration of the injection as scheduled; and
* 03/11/22 - Staff 17 (PCA/MT) signed on the MAR that she administered the Trulicity injection when Staff 3 (Memory Care Director/LPN) administered the injection.
The need to ensure an accurate MAR was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/15/22. They acknowledged the findings.
3. Resident 1 was admitted to the facility in February 2021 with a diagnosis of dementia.
Resident 1's 02/01/22 thru 03/14/22 MAR was reviewed and identified the following PRN pain medications ordered:
* Acetaminophen oral every six hours as needed for pain and for fever; and
* Morphine Sulfate oral every two hours as needed for pain or shortness of breath.
The MAR gave no direction to staff on which medication to use first for the resident's pain.
The need to ensure MARs included clear direction to staff for medication administration was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.
OAR 411-054-0034 C-310 Medication Administration
*In-Service All Medication Tech. meeting scheduled April 26th.
*Health Services Director will review monthly prior to cycle fill.
*Parameters will be reviewed no less than monthly to also include new resident and medication changes.
*Monthly or as needed the RN/RCC will review
*QA checks will occur with RCC during weekly medication review checks
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident-specific parameters, staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications, direct care staff administering the medications had knowledge of common side effects and when to contact a health professional regarding side effects, and all direct care staff had knowledge of non-pharmacological interventions for 2 of 2 sampled residents (#s 1 and 4) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:
1. Resident 4 moved into the facility in 2021 and had diagnoses which included Alzheimer's dementia.
Review of the resident's service plan, physician orders, and 02/01/22 through 03/15/22 MAR revealed the following:
Resident 4 was prescribed lorazepam 0.5 mg (anti-anxiety medication) one tablet every two hours PRN for anxiety.
The facility failed to ensure the resident's MAR and clinical record included the following required information:
* Resident-specific parameters regarding how Resident 4 expressed anxiety;
* Common side effects;
* When to contact a health professional regarding side effects; and
* Staff administered the PRN lorazepam on 11 occasions without documentation that non-pharmacological interventions were attempted prior to administration of the medication.
Additionally, the record lacked documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 4.
During an interview with Staff 16 (MT) on 03/15/22 at 1:10 pm, she reviewed the resident's record and confirmed staff had not documented that non-pharmacological interventions had been attempted prior to administering the medication.
The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (ED) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.
2. Resident 1 moved into the facility in February 2021 and had diagnoses which included dementia.
Review of the resident's physician orders, and 02/01/22 thru 03/10/22 MAR revealed the following:
Resident 1 was prescribed the following PRN psychotropic medications:
Lorazepam 0.5 mg (anti-anxiety medication) every two hours PRN for anxiety/shortness of breath; and
Haloperidol 0.5 mg (anti-psychotic medication) 0.5 mg every hour PRN for agitation/delirium.
The facility failed to ensure the MAR included the following required information:
* Resident-specific parameters regarding how Resident 1 expressed anxiety, agitation or delirium;
* Non-pharmacological interventions to be attempted prior to considering the administration of the medication;
* Common side effects; and
* When to contact a health professional regarding side effects.
The need to ensure the required information for PRN psychotropic medications was documented in the MAR was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. The staff acknowledged the findings.
OR-411-054-0034 C-330 Psychotropic Medication
*Medication Tech. all staff training will be held 4/26/22 discussing that Non-Pharmaceutical intervention for residents.
*Documentation will take place as well as a alert charting documenting the result of the non-pharmaceutical intervention.
*This will be monitored by the RN/RCC daily
*Q.A. will be completed by RN monthly to assure compliance.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed including a thorough review by an RN, PT or OT prior to use and documentation of less restrictive alternatives prior to use for 1 of 1 sampled resident (#1) who had a perimeter mattress on the bed. Findings include, but are not limited to:
Resident 1 was admitted to the facility in February 2021.
On 03/14/22 at 1:00 pm, Resident 1's bed was observed to have a perimeter mattress (a mattress with raised edges).
Staff 10 (Personal Care Assistant (PCA)) stated the perimeter mattress was to prevent Resident 1 from getting up because s/he had a history of falls from the bed.
There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use.
The lack of assessment for use of a perimeter mattress was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.
OAR 411-054-0060 C-340 Restraints and Supportive Devices
* RN will assess for any supportive devices for potential restraint devices.
*Any restraint ssistive devices will be approved by the Executive Director before implementation.
*This will be discussed during daily clinical meetings
*ED/RCC/RN will verify for compliance
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired direct care staff (#10) completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to:
Staff training records were reviewed on 03/15/22 with Staff 8 (Business Office Manager). There was no documented evidence Staff 10 (Personal Care Assistant (PCA)), hired 02/04/22, had completed the required training in abdominal thrust and First Aid.
The need to ensure staff have completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 8 and Staff 1 (ED) on 03/15/22. They acknowledged the findings.
OAR 411-054-0070 C-372 Training within 30 days: Direct Care Staff
* Any staff who failed to get Training is completing/completed training immediately.
* BOM will assure that all required trainings are completed within 30 days of hire.
* BOM will work with RCC/RN to assure all aspects of training is completed
* The Matrix will be updated weekly to assure all training is completed and in compliance.
*Q.A. audit during BOM/ED will review weekly during one to one
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 ensure fire drills included all required documentation components. Findings include, but are not limited to:
Fire and life safety records for 10/2021 through 03/2022 were reviewed on 03/15/22 and revealed the following:
* The lack of fire and life safety training provided to staff on alternating months on different topics;
* The facility was not consistently relocating or evacuating residents during fire drills; and
* Fire drill documentation lacked the following required information;
- Escape route used;
- Evacuation time-period needed;
- Resident evacuation problems encountered; and
- Number of occupants evacuated.
The need to ensure staff received required fire and life safety training and fire drills included required components according to the Oregon Fire Code was reviewed with with Staff 1 (ED) and Staff 6 (Maintenance Director) on 03/16/22. They acknowledged the findings.
OAR 411-054-0090 C-420 Fire and Life Safety
* Fire and Life Safety Training completed at all staff 3/25/22
* Jan, March, May, July, Sept, Nov will be months of ongoing training for Fire Life and Safety during all staff meetings
*Alternate months will be drills along with on the spot training to review results
*Documentation will be reviewed with the ED immediately
*ED/MD will review weekly to assure compliance
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:
Fire and life safety records were requested during the survey. The following deficiencies were identified:
* Documentation that fire and life safety training was provided to residents within 24 hours of move-in; and
* Alternate exit routes were used during fire drills.
The need to ensure residents received fire and life safety training and that alternate exit routes were used during fire drills was discussed with Staff 1 (ED) and Staff 6 (Maintenance Director) on 03/16/22. They acknowledged the findings.
OAR 411-054-0090 C-422 Fire and Life Safety
* All staff training completed on 3/25/22
*Residents training evaluations will be completed on all new admissions.
*Resident training assessment for fire and life safety will be completed at each annual service plan meeting
* Alternate exit routes will be added to fire drill training with staff fire drills on alternate months
* Documentation will be reviewed with ED each month
* ED/MD will review monthly for compliance during QA
There are no detail notes for this visit.
Based on observation, 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 C303 and C513.
Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse. Findings include, but are not limited to:
On 03/14/22 a tour of the facility identified the following deficiencies:
* Six mattresses were stacked next to the dumpster, along with wood and metal debris; and
* Approximately two dozen sand bags, some broken open, were strewn near the tool shed, along with plastic tarps, pieces of wood, and tomato cages.
The exterior areas were reviewed with Staff 1 (ED) during a tour on 03/15/22. He acknowledged the findings.
OAR 411-054-0200 C-510 General Building Exterior
* Maintenance will weekly inspect property
* MD will review with ED findings from his walk through during weekly meeting
*ED will review findings of his QA walk through with the MD weekly.
* QA inspection will be evaluated monthly for compliance
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the environment was free from unpleasant odors, and was maintained clean and in good repair. Findings include, but are not limited to:
The facility was observed on 03/14/22 through 03/16/22. The following deficiencies were identified:
* Urine and stool odors in the hallways, laundry room, and bathrooms;
* Multiple urine-soaked briefs overflowing top of trash can in bathroom nearest private dining room;
* Open soiled laundry bag in laundry room, showing clothing soiled with brown matter;
* Scrapes and gouges in walls, doors, and door jambs in laundry room, rendering the surfaces uncleanable;
* Yellow, white and brown splatters in and around utility sink in laundry room;
* Dark brown matter smeared on the electrical outlet to the right of the television, and splatters and spills on the chairs and tables in the private dining room; and
* Food debris on the floor, and in cabinets and drawers of the kitchenette at the end of hallway, opposite Resident Room 18.
Those findings were shown to or reviewed with Staff 1 (ED) on 03/15/22 and 03/16/22. He acknowledged the findings.
OAR 411-054-0200 C-513 Doors, Walls, Elevators, Odors
*All Staff Training reguarding laundry and incontinent disposal
* Added essential oil atomizers in areas of building where air stagnation occurs.
* Laundry and Housekeeping will be held accountable to assure their areas are clean and odor free
* If Laundry or Housekeeping call off then a member of the management team will assure that the area is clean.
*PCA's will assure that all soiled laundry and trash are removed from the resident's rooms upon exiting the room
* Environmental Services will walk community at least 3 times daily to assure the community is odor free.
*Q.A will be completed weekly during Executive Directors environmental audit.
Based on observation and interview, it was determined the facility failed to ensure the environment was in good repair. This is a repeat citation. Findings include, but are not limited to:
Observations of the facility on 07/06/22 and 07/07/22 revealed the following:
* An approximate six by six inch area behind the warewashing machine in the kitchen had crumbling sheet rock and was not a cleanable surface;
* The tile flooring in the bathroom across from the nurses office had multiple chipped and broken areas that created a non-cleanable surface;
* An approximate three foot by three foot area in the flooring of the laundry room laminate was pealed off requiring repair; and
* An approximate two by two inch hole in the sheet rock behind a dryer in the laundry room created a non-cleanable surface.
The environmental areas were discussed and observed with Staff 1 (ED) and Staff 6 (Maintenance Director) during the survey. Staff acknowledged the findings.
OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors
*Bids for completion obtained through Environmental Director by 8/5/22 on all items reflected in survey
* All Items repaired or in good order by 8/26/22
* Weekly Q.A. with ED and Environmental Director to assure of progress towards compliance
* All Staff 7/25/22 - discussing open environmental items and reporting on Maintenance forms.
* Q.A. weekly audit completed Environmental Director
Due to the facility requesting an extension, the plan of correction date was extended to 09/30/22 for facility environmental areas. The facility remains out of compliance.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 150, C 156, C 200, C 231, C 240, C 372, C 420, C 422, C 510 and C 513.
OAR 411-057-0140(2) Z-142 Administration Compliance
Plan of Correction:
See C-150
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 150, C 156, C 160, C 231 and C 513.
OAR 411-057-0140(2) Z-142
Administration Compliance
Plan of Correction
See C-150; C-156; C-160; C-231 and C-513
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C513.
Based on interview and record review, it was determined the facility failed to ensure 7 of 8 sampled direct care staff (#s 5, 10, 11, 13, 17, 18, and 19) completed all required orientation, pre-service and competency training within the required timelines. Findings include, but are not limited to:
Training records were reviewed on 03/15/22 with Staff 8 (Business Office Manager). The following deficiencies were identified:
1. There was no documented evidence that Staff 10 (Personal Care Assistant (PCA)), hired 02/04/22, and Staff 11 (PCA), hired 02/24/22, completed pre-service orientation in the following areas:
* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Standard precautions for infection control; and
* Fire safety and emergency procedures.
2. Staff 5 (PCA/MT) was hired 01/06/21. There was no documented evidence that Staff 5, Staff 10, and Staff 11 completed the following pre-service training requirements within 30 days of hire:
* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;
* Techniques for understanding, communicating and responding to distressful behavioral symptoms;
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;
* Environmental factors that are important to a resident's well-being;
* Family support and the role the family may have in the care of the resident;
* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that required on-going assessment;
* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and
* Use of supportive devices with restraining qualities in memory care communities.
3 a. There was no documented evidence that Staff 5, Staff 10, and Staff 11 demonstrated competency in their job duties within 30 days of hire in the following areas:
* The role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition; and
* Conditions that require assessment, treatment, observation and reporting.
b. Staff 10 and Staff 11 did not have documented evidence of competency in the following area:
* General food safety, serving and sanitation.
c. Staff 5 did not have documented evidence of competency in the following area:
* Medication and treatment administration.
4. In addition, 4 of 5 remaining MTs (#s 13, 17, 18, and 19) did not have documented evidence of competency in medication and treatment administration. Staff 1 (ED) was requested to ensure training of MTs prior to scheduled shifts.
The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 and Staff 8 on 03/15/22. They acknowledged the findings.
OAR 411-057-0155(1-6) Z-155 Staff Training Requirements
Plan of Correction:
See C-372; C-200; C-231; C-260; C-270; C-282; C-340; C-420; C-422
Based on observation, interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 19, 22 and 24) completed all required orientation, pre-service dementia training and demonstrated competency in job duties within 30-days of hire and 3 of 3 direct care staff (#s 5, 13 and 24) completed training and demonstrated satisfactory performance in any duty assigned. This is a repeat citation. Findings include, but are not limited to:
Staff training records were reviewed on 07/06/22 and 07/07/22.
1. Staff 24 Personal Care Associate/Medication Technician (PCA/MT) was hired on 04/28/22.
a. Staff 24 lacked documented evidence of completing orientation training, prior to beginning job responsibilities, in the following areas:
* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Standard precautions for infection control;
* Fire safety and emergency procedures; and
* Written job description.
b. Staff 24 lacked documented evidence of competency demonstration within 30 days of hire related to the following training topics:
* Role of service plans in providing individualized care;
* 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;
* General food safety, serving and sanitation; and
* Medication administration training.
The surveyor requested documentation of training competencies for Staff 24 prior to her next scheduled shift. A plan to provide training for Staff 24 was received and accepted by the survey team on 07/07/22.
2. Staff 22 (PCA) was hired on 04/21/22.
a. Staff 22 lacked documented evidence of completing orientation training prior to beginning job responsibilities in the following areas:
* Resident rights and values of CBC care;
* Standard precautions for infection control; and
* Abuse reporting requirements.
b. Staff 22 lacked documented evidence of pre-service dementia training in the following areas:
* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communication and responses to distressful behavioral symptoms;
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach;
* Environmental Factors that are important to a resident's well-being;
* Family support an the role the family may have in the care of the resident; and
* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;
* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and
* Use of supportive devices with restraining qualities in memory care communities.
c. Staff 22 lacked documented evidence of competency demonstration within 30 days of hire related to the following training topics:
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.
3. Staff 19 (PCA/MT) was hired 02/01/22. During an interview on 07/06/22 at 4:40 pm, Staff 1 (ED) verified Staff 19 worked as a Resident Care Coordinator, caregiver and medication aide dependent on the needs of the facility.
Staff 19's training records lacked documented evidence of completing orientation training, pre-service dementia training and competency demonstrated within 30 days of hire.
The surveyor requested documentation of training competencies for Staff 19 prior to her next scheduled shift. A plan to provide training for Staff 19 was received and accepted by the survey team on 07/07/22.
The facilities training program was reviewed and discussed with Staff 1 (ED), Staff 8 (Business Office Manager) and Staff 4 (Regional Director) during the survey. Staff verified the lack of documented training for Staff 19, 22 and 24.
4. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia, congestive heart failure and lower back pain. The resident was receiving hospice services.
The resident had signed physician orders dated 06/16/22 for continuous oxygen to be administered at a rate three liters per minute via nasal cannula. The resident used an oxygen concentrator when in his/her room and a portable oxygen machine when in common areas of the building.
On 07/05/22, 07/06/22 and 07/07/22, the oxygen flow rate on Resident 7's concentrator was observed to be set at 1.75 liters per minute. In separate interviews on 07/07/22, Staff 5 (Personal Care Assistant/MT), Staff 13 (Personal Care Assistant/MT) and Staff 24 (Personal Care Assistant/MT) were each asked if they knew how to read and set the flow rate on Resident 7's concentrator. All three staff stated they did not know how to read and set the flow rate and they had not been taught as part of their training.
The need to ensure staff were properly trained to perform their required job duties was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. Staff 18 acknowledged the findings and suggested arranging for a hospice provider to provide training for the staff.
OAR 411-057-0155 (1-6) Z-155
Staff Training Requirements
* Audit completed by B.O.M 7/18/22
* Staff given timelines toward completeness
* All New Staff completing all requirements before working in facility.
* Inservice with Med Tech's on 7/20/22 relating to Medications, Treatments, Alert Charting, Service Plans, O2, Outside Services, ISP's with RN Consultant
* All Staff 7/25/22
* Q.A. completed monthly by B.O.M.
* Review with E.D. monthly for compliance
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 305, C 310, C 330 and C 340.
OAR 411-057-0160(2b) Z-162 Compliance with Rules of Health Care
Plan of Correction:
See C-252; C-260; C-262; C-270; C-280; C-290; C-305; C-310; C-330; C-340
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 260, C 270, C 280, C 282, C 290 and C 303.
OAR 411-057-0160(2b) Z-162
Compliance with Rules of Health Care
Plan of Correction
See C-260, C-270, C-280, C-282, C-290 and C-303
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C303.
Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans for each resident was developed and included in service plans for 3 of 4 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:
Resident 2, 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.
The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) on 03/16/22. He acknowledged the findings.
OAR 411-057-0160(2)(c)(A)(B) Z-163 Nutrition and Hydration
* Service Planning Team will review each service plan for compliance
* Service plans will have nutrition and hydration plan for each individual
* ED/RCC/DFS/HealthWellness will audit for continual compliance for each new service plan
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose records were reviewed. Findings include, but are not limited to:
Resident 1, 2, 3 and 4's service plans were reviewed during survey. Each of the service plans lacked an individualized activity plan that included the following:
* Past and current interests;
* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Activities that could be used as behavioral interventions, if necessary.
There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities.
The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Regional Director) on 03/15/22. They acknowledged the findings.
OAR 411-057-0160(2d) Z-164 Activities
* Assessment forms sent out to families for resident interests, hobbies, past activities etc.
* Service plans will have individualized activity consistent with assessment form
* ED/RCC/Life Enrichment will audit for continual compliance for each new servcie plan
Based on interview and record review, it was determined the facility failed to develop individualized activity plans for 3 of 4 sampled residents (#s 6, 7 and 9) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 6, 7 and 9's records were reviewed during the survey.
There was no documented evidence the facility developed individualized activity plans based on activity evaluations which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.
On 07/07/22, the lack of an individualized activity plan was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN). They acknowledged the findings.
OAR 411-057-0160(2d) Activities
Z-164
*Resident #A6, #7, & #9 have been reevaluated on how and what staff should assist each resident related to activities. An individualized activity plan has been developed and is incorporated into the resident's service for all staff to follow including: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; Page 16 (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions.
*During the routine service plan review periods, the comprehensive activity plan will be reviewed and updated as applicable.
Staff have been inserviced on the purpose and meaning of the individualized activity plan and understand how to use them and protocol for providing feedback/updating the plan when appropriate.
The system is reviewed quarterly during the resident's routine service plan review cycle.
* The ED/Life Enrichment are responsible for maintaining this system.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the community, and include information and instructions for staff on the service plan for 2 of 2 sampled residents (#s 6 and 10) who had a documented history of challenging behaviors. Resident 6 and 10 continued to have resident to resident altercations with multiple peers. Findings include, but are not limited to:
1. Resident 6 resided in a MCC and was diagnosed with Alzheimer's disease. The resident's current service plan indicated s/he had a history of thinking items were stolen. The service plan instructed staff to assist with looking for the item and if not found, fill out an incident report to validate his/her concern. There was no further information regarding altercations or other behaviors noted.
Progress notes and incident reports indicated between 04/30/22 and 07/05/22, Resident 6 had two documented incidents of resident to resident altercations on 05/13/22 and 05/21/22. Both behaviors included intrusion into a common area bathroom when another resident was in the bathroom and intrusion into another resident room. Both incidents resulted in physical injury to Resident 6.
In an interview on 07/06/22, Staff 16 (Personal Care Assistant/MT) reported Resident 6 had a history of the following behaviors:
* Intrusive into other resident rooms or personal space;
* Paranoia that other residents or staff were stealing his/her belongings;
* Yelling at staff and residents;
* Cussing at staff and other residents (mostly staff);
* S/he could also become physical with staff and other residents;
* Resistive to care; and
* Hoarding things in his/her room and would become physical with staff if they tried to clean his/her room. Family members would intervene and assist by taking the resident out of the facility so staff could deep clean his/her room.
Interventions noted by Staff 16 included the following:
* Supervise when s/he was walking the hallways;
* Ensure other resident rooms were locked;
* Change caregivers and re-approach; and
* Call family if s/he refused care.
Staff 16 further acknowledged, "We just try to deal with [him/her], [s/he] is a real hand full, a real challenge."
In an interview with Staff 14 (Activity Director) on 07/05/22, the following behaviors were noted:
* Hoarding; and
* Noise and large groups were triggers for behavior.
Staff 14 added, "I wrote in [his/her] activity evaluation that daily 1:1 activities were preferred to ensure [s/he] doesn't become escalated near other residents."
The facility failed to evaluate Resident 6's behavior, add information about the behavior and resident to resident altercations to the service plan, and develop interventions for staff to protect themselves and residents from future altercations. The resident continued to engage in physical altercations with other residents.
The surveyor requested an individualized behavior plan on 07/07/22 that addressed Resident 6's behaviors. Survey received and accepted a behavior care plan on 07/12/22.
The need to evaluate Resident 6's behaviors, update the service plan and provide interventions for staff to attempt when the behavior occurred was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
2. Resident 10 was admitted to the MCC facility in 02/2020 with a diagnosis of dementia.
Progress notes and incident reports reviewed from 04/28/22 through 07/05/22 indicated Resident 10 had three physical altercations on 04/28/22, 05/13/22 and 05/15/22.
The resident's current service plan dated 04/19/22 indicated staff were to report any behavior or out of baseline behaviors to the MT/licensed nurse, provide 1 on 1 engagement and redirect. There was no further information regarding altercations, other behaviors, potential triggers for the behaviors, or further interventions noted.
During an interview with Staff 16 (Personal Care Assistant/MT) on 07/06/22, it was reported Resident 10 would become agitated and escalate if s/he heard another resident saying something disrespectful to female staff. "[His/her] response was usually yelling, getting out of [his/her] wheelchair and physically punching or hitting the other resident." If staff were unable to intervene it usually resulted in physical aggression towards others.
Staff 16 also reported Resident 10 was able to walk independently and only preferred to use the wheelchair. "[S/he] is actually pretty strong and when [s/he] becomes agitated [s/he] will get out of the wheelchair and approach the resident that is bothering [him/her] which usually resulted in a punch or swinging [to hit another resident]."
The facility failed to evaluate Resident 10's behavior, add information about the behavior and resident to resident altercations to the service plan, and develop interventions for staff to protect themselves and residents from future altercations. The resident continued to engage in physical altercations with other residents.
The surveyor requested an individualized behavior plan that addressed Resident 10's behaviors on 07/07/22. Survey received and accepted a behavior care plan on 07/07/22.
The need to evaluate Resident 10's behaviors, update the service plan and provide interventions for staff to attempt when the behavior occurred was discussed with Staff 1 (ED), Staff 4 (Regional Director) and Staff 18 (RN) on 07/07/22. They acknowledged the findings.
OAR 411-057-0160(e) Behavior
* Resident #6 & #10 have been reassessed by the community RN to identify underlying pathologies that contribute to verbal and physical behaviors in the community including, but not limited to: intrusive behaviors involving other residents, rooms, and/or personal space; paranoias that involve other residents or staff including what those paranoias are; verbal threats, tone, and tendency to elevate speech, physical threats and tendencies; resistive to care; hoarding, other, etc.. A comprehensive behavioral plan has been developed for resident #6 & #7. Additionally, Yamhill Behavioral Specialist provided an inservice training for staff on behaviors and dementia.
A behavioral evaluation will be conducted on all residents who have a known history or current behaviors to gather information to create an individualized behavioral plan.
Staff have been inserviced on the purpose and meaning of individualized behavioral plans and understand how to utilize them to care for the resident. Staff have been given instructions on how to provide feedback and/or to update the behavior plan when appropriate.
Residents with challenging behaviors are reviewed daily during the morning stand up meeting.
The system is reviewed quarterly during the resident's routine service plan review cycle and as needed for new or escalating behaviors.
* The ED/Life Enrichment are responsible for maintaining this system.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:
The MCC was toured on 03/15/22. Twenty-seven out of 40 residents lacked individual identification of their rooms that would assist in room recognition.
The need to ensure each resident room was individually identified for the resident was reviewed with Staff 1 (ED) on 03/15/22 during a walk-through of the facility. He acknowledged the findings.
OAR 411-057-0170(9) Z-176 Resident Rooms
* New signage purchase and installed for all resident doors for proper identification
* Pictures and individual identification will be encouraged with families for decorating individual doors and outside of door frame
* Life Enrichment will add to any doors or signs when family are absent
* ED/RCC/Life Enrichment will audit for continual compliance for each resident room
There are no detail notes for this visit.