The findings of the re-licensure survey conducted 05/02/22 through 05/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the first re-visit to the re-licensure survey of 05/04/22, conducted 08/03/22 through 08/04/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the second re-visit to the re-licensure survey on 05/04/22, conducted 12/14/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observation of the kitchen on 05/02/22 at 9:30 am, revealed an accumulation of food spills, splatters, loose food debris, dirt, dust and garbage on or underneath the following:
* Wall behind the handwashing sinks;
* Microwave interior and exterior;
* Fire extinguisher and the wall surrounding the fire extinguisher;
* Shelves in food preparation area;
* Floors, ceiling tiles and walls near the food preparation area;
* Metal racks in food preparation area;
* Commercial stand mixer and the paddle attachment;
* Blades and cages of portable and fixed fans;
* Fabric blinds;
* Stove vent;
* Top, sides and handles of convection oven;
* Knobs, handles, sides, fronts, and insides of ovens;
* Sides, baskets, and handle of fryer;
* Floor underneath ovens and fryer;
* Steam table face and knobs;
* Top and sides of steam table;
* Floor drain under the steam table;
* Shelving and drawers below steam table;
* Toaster;
* Sides, doors, handles, and inside surfaces of standing refrigerators;
* Floor and counter of drink service area;
* Plastic serving carts;
* Utensil holder;
* Floor and walls surrounding the three compartment sink;
* Floor, walls, pipes and containers underneath warewashing machine; and
* Ceiling vents and ceiling surrounding them.
Cupboard shelves and drawers under the steam table had exposed wood edges rendering the surfaces uncleanable. The commercial stand mixer had chipped paint increasing risk of cross-contamination. Gouged areas were visible on the entrance/exit door. The middle oven had a missing cover near the floor which exposed electrical wiring.
During an interview with Staff 3 (Dietary Manager) on 05/02/22 at 10:22 am, it was stated the kitchen cleaning schedule was marked completed 04/01/22 through 04/04/22 with no further acknowledgement of cleaning for the remainder of the month. Staff 3 was asked to begin cleaning and repairs immediately.
The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) and Staff 3 on 05/02/22 at 10:52 am. They acknowledged the areas that needed to be cleaned and repaired.
The areas that still required cleaning and repair were observed and reviewed with Staff 1 and Staff 3 on 05/03/22 at 9:04 am. They acknowledged the findings. Staff 3 then provided an updated cleaning schedule, the initial training provided, and an upcoming in-service by 11:07 am the same day.
1.) On 5/2/22 the Dietary Manager and Administrator immediately took steps to begin repairs and deep cleaning process. The following actions have been taken to correct the rule violation for each example:
-Accumulation of food spills, splatters, loose food debris, dirt, dust, and garbage were cleaned from:
Wall behind handwashing sink. Microwave interior and exterior. Shelves in food prep area. Floors, ceiling, and walls near food prep area. Metal racks in food prep area. Commercial stand mixer. Blades and cages on fans. Stove vent. Top, sides and handles of convection oven. Knobs, handles, sides, fronts of insides of ovens. Sides, baskets, and handle of fryer. Floor underneath ovens and fryer. Steam table face, knobs, top, and sides. Floor drain under the steam table. Shelving and drawers below steam table. Toaster. Sides, doors, handles, and inside surfaces of standing refrigerators. Floor and counter of drink service area. Plastic service carts. Utensil holder. Floor and walls surrounding the 3-compartment sink. Floor, walls, pipes and containers underneath warewashing machine. And Ceiling vents and ceiling surrounding them.
-Fabric blinds were removed.
-The exposed wood edges on cupboard shelves and drawers under the steam table were repaired along with the gouged areas on the entrance and exit doors.
-The commercial stand mixer has been removed from use and is awaiting new paint coating as labor and supply chain shortages allow.
2.) To prevent this violation from occurring again, the Dietary Manager or designee will in-service dietary kitchen staff on cleaning procedures and implement daily cleaning protocols and assigned tasks to kitchen personnel including check-off task list to ensure thorough cleaning/repair.
3. The area needing correction will be evaluated weekly by dietary manager or designee for four weeks, and quarterly thereafter.
4. The Dietary Manager or designee will be responsible to see that corrections are complete and monitored.
There are no detail notes for this visit.
2. Resident 2 was admitted to the facility in 07/2020 with diagnoses including hypertension and diabetes.
The current service plan/evaluation dated 03/24/22 noted the resident had multiple areas of eczema and dry skin and had a pressure ulcer to the coccyx.
Review of progress notes between 02/01/22 and 04/29/22 noted the resident received HH services related to wound care and treatment to Resident 2's bilateral lower extremities.
Resident 2 was observed during the survey to have black compression stockings and velcro wraps secured around the compression stocking on both lower legs.
During an interview with Staff 2 (RN) on 05/03/22 at approximately 2:00 pm, Staff 2 stated the resident had a pressure ulcer to his/her coccyx that had healed and had stasis ulcers to his/her bilateral lower extremities that were treated and monitored by home health.
Resident 2's evaluation was not reflective of the resident's current skin status.
Resident 2's evaluation was discussed with Staff 1 (Administrator) on 05/04/22 at 12:05 pm. No additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure resident's initial evaluations were updated and modified as needed during the 30 days following move-in for 1 of 1 sampled resident (# 4) and failed to ensure quarterly evaluations were reflective of resident's physical health status for 1 of 5 sampled resident (# 2). Findings include, but are not limited to:
1. Resident 2 was admitted to the facility on 02/22/22.
The facility lacked documented evidence the resident's initial evaluation was updated with changes as appropriate within the 30 days following move-in.
On 05/04/22 the need to ensure resident's evaluations were updated within 30 days of move in was discussed with Staff 1 (Administrator). She acknowledged the findings.
1.) - Resident 4's addendum to move-in evaluation was completed, service plan has been updated to reflect the skin changes that occurred in the 30-days and since initial move-in evaluation was completed.
- Resident 2's: LN assessment has been updated, the service plan was updated to reflect the resident's current skin status.
100% of residents who moved in in last 90 days have been audited, updated Move-in evaluation addendums have been done, as indicated along with updates to resident Service plans.
100% residents with current active skin isues have been completed, assessment completed as indicated and updates to servcie plans have been completed as indicated.
2. To prevent this violation from occurring again, Move-in evalutation addendums will be completed, as inidicated during the 30 days from move-in. The addendum evaluation, will include a summary of any changes and updated will be made to service plan.
3. In addition to the 100% audit of all new move-in in the past 90-days detailed above, Service Plans will continue to be audited by Administrator, or designee, weekly for residents with Service plan meetings for 90 days and quarterly thereafter.
4. The Admnistrator will be responsible to ensure corrections are completed/monitored.
Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 7 and 10) who were recently admitted to the facility and whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 7 moved into the facility in 07/2022.
The move-in evaluation failed to address the following areas:
* Interests, hobbies, social, leisure activities;
* Physical health status including list of current diagnoses and vital signs if indicated by diagnoses, health problems or medications;
* Mental health issues including history of treatment;
* List of treatments including type, frequency and level of assistance needed;
* Complex medication regimen; and
* Unsuccessful prior placement.
The need to ensure move-in evaluations included all required elements was discussed on 08/04/22 at 10:00 a.m. with Staff 2 (RN) and Staff 19 (Administrator). They acknowledged the findings.
2. Resident 10 moved into the facility in 07/2022.
The move-in evaluation failed to address the following areas:
* Physical health status including list of current diagnoses and vital signs if indicated by diagnoses, health problems or medications;
* Mental health status including effective non-drug interventions;
* Unsuccessful prior placement; and
* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting and room temperature.
The need to ensure move-in evaluations included all required elements was discussed on 08/04/22 with Staff 19 (Administrator). She acknowledged the findings.
1.) Resident 7- addendum to move-in evaluation was completed, updated to reflect required elements of OAR 411-54-0034.
Resident 10- addendum to move-in evaluation was completed, updated to reflect required elements of OAR 411-54-0034.
2.) Pursuant to OAR 411-054-0034, the facility will ensure that new move-in evaluations address all required elements as referenced for sampled residents (#s 7 & 10.)
100% review of residents with PRN orders will be completed; updates done as indicated.
3.) Move in Evaluations will be audited by Administrator or designee prior to, upon move-in and weekly throughout initial 30 days from move in, to ensure compliance with OAR 411-054-0034, weekly x 90 days to ensure ongoing compliance.
4.) The Administrator will be responsible to ensure corrections are completed/monitored and addendums added as needed to ensure a person-centered Service Plan is available to staff.
There are no detail notes for this visit.
4. Resident 1 was admitted to the facility in 06/2019 with diagnoses including osteoarthritis.
Observations of the resident and interviews with staff on 05/02/22 and 05/03/22 and review of the current service plan dated 03/15/22 revealed Resident 1's service plan was not reflective of or failed to provide clear direction related to provision of care in the following areas:
*Evacuation status;
*Use of an assistive device on the bed; and
*Status of skin including a healed wound to the right lower extremity and a skin tear to the right top of hand.
Resident 1's service plan was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 05/03/22 at 2:00 pm. Staff acknowledged the findings.
2. Resident 5 was admitted in 09/2019 with diagnoses including Alzheimer's.
The 11/22/21 service plan was reviewed, a "cardex" document that was updated with any changes the care staff used, 04/01/22 through 05/02/22 MARs and TARs were reviewed and staff were interviewed. The service plan was not reflective of the resident's current status or lacked clear caregiving instruction in the following areas:
* Participation in bingo;
* Full assistance with all ADLs;
* Interventions used to encourage showers;
* Reminders for going to bed;
* Non-drug interventions related to wandering;
* Where the resident preferred to dine;
* Interventions to promote eating meals;
* Self-directing PRN medications;
* Ability to communicate needs and wants;
* Interventions to get the resident up from bed; and
* Staff to anticipate all needs.
The need to ensure resident's service plans were reflective of their current status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.
3. Resident 6 was admitted in 02/2014 with diagnoses including anxiety and bi-polar disorder.
The 02/10/22 service plan was reviewed, a "cardex" document that was updated with any changes the care staff use, 04/01/22 through 05/02/22 MARs and TARs were reviewed and staff were interviewed. The service plan was not reflective of the resident's current status or lacked clear caregiving instruction in the following areas:
* Spouse involvement;
* Safety checks;
* Non-drug interventions for anxiety;
* Signs and symptoms of the resident feeling anxious;
* Where the resident prefers to dine;
* Non-drug interventions for pain including a lower extremity wrap and compression gloves;
* The need to keep the water filled in an oxygen concentrator; and
* Portable oxygen tank use.
The need to ensure resident's service plans were reflective of their current status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. 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' needs and provided clear direction to caregiving staff regarding the delivery of services for 4 of 6 sampled residents (#s 1, 2, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in 07/2020 with diagnoses including Type 2 Diabetes, stasis wounds on legs and insomnia.
Resident 2's evaluation and service plan dated 03/24/22 were reviewed during the survey and revealed the service plan was not reflective of the resident's current needs, and did not provide clear direction to staff regarding the delivery of services in the following areas:
* Pressure ulcers;
* Catheter care;
* Signs and symptoms of dehydration;
* Behaviors;
* Frequency of home health visits; and
* Refusals of care.
The need to ensure service plans were reflective of the resident's needs and included clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator) on 05/04/22 at 12:45 pm. She acknowledged the findings.
1.)
-Resident 1's service plan has been updated to reflect individual needs including evacuation status, use of assistive device on the bed, and status of current skin concerns.
- Resident 2's service plan has been updated to reflect individual needs including pressure ulcers, signs and symptoms of dehydration, behaviors, frequentcy of home health visits, and refusals of care
- Resident 5's service plan has been updated to reflect individual needs including participation in BINGO, full ADL assistance level, interventions used to encourage showers, reminders for going to bed, non-drug interventions related to wandering, where the resident prefers to dine, interventions to promote eating meals, self-directing PRN medication, ability to communicate needs and wants, interventions to get the resident up from bed, and staff to anticipate all needs.
- Resident 6's service plan has been updated to reflect individual needs including spouse, safety checks, non-drug interventions for anxiety, signs and symptoms of the resident feeling anxious, where the resident prefers to dine, non-drug interventions for pain such as wraps and compression gloves, need for staff to fill oxygen concentrator with water, and portable oxygen tank use.
2. To prevent this violation from occurring again, the service plan will be updated in real-time as resident status and needs change, which will be monitored ongoing as part of the facility 24-hour stand-up process.
3. Service Plans will be audited by Administrator or designee weekly after residents with Service plan meetings for 90 days and quarterly thereafter.
4. The Admnistrator will be responsible to ensure corrections are completed/monitored.
2. Resident 7 was admitted to the facility in 07/2022. The resident's current service plan, dated 07/28/22, was reviewed and was not reflective of the resident's current status and care needs and failed to provide clear instruction in the following areas:
* Use of mobility devices; and
* Outside mental health service status.
The need to ensure the service plan provided clear and accurate information was discussed with Staff 2 (RN) and Staff 19 (Administrator) on 08/04/22. 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' needs, provided clear direction to caregiving staff regarding the delivery of services, and were followed for 2 of 4 sampled residents (#s 7 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 10 was admitted to the facility in 07/2022 with diagnoses including Bi-polar, anxiety and dementia.
Resident 10's evaluation and service plan dated 07/26/22 were reviewed during the survey. Observations of the resident and interviews with staff revealed the service plan was not reflective of the resident's current needs, did not provide clear direction to staff and was not followed in the following areas:
* Cognition including short-term memory loss;
* Behaviors; and
* Assistance with CPAP was not implemented and followed by staff.
The need to ensure service plans were reflective of the residents' needs, provided clear direction to staff regarding the delivery of services and were followed was discussed with Staff 19 (Administrator) on 08/04/22. She acknowledged the findings.
1.) Resident 10's Service Plan has been updated to reflect individual needs including cognition, short-term memory loss and behaviors to provide clear and accurate information to the staff about the resident.
Resident 7's Service Plan has been updated to reflect individual needs including use of mobility devices and outside mental health service status to provide clear and accurate information to the staff about the resident.
100% of residents who moved-in in last 90 will be audited; updated move-in evaluation addendums will be done as indicated, along with updates to resident Service Plans, as indicated.
2.) To maintain compliance with OAR 411-054-0036, the facility will ensure that resident Service Plans will be reflective of resident needs and clear directions for care giving staff.
3.) Service Plans will be audited by Administrator or designee prior to, upon move-in, and weekly throughout initial 30 days from move in, to ensure compliance with OAR 411-054-0036 for 4 weeks and then monthly x 90 days.
4.) The Administrator will be responsible to ensure corrections are completed/monitored and addendums added as needed to ensure a Person-Centered Service Plan is available to staff.
There are no detail notes for this visit.
3. Resident 1 was admitted to the facility in 06/2019 with diagnoses including osteoarthritis.
Progress notes dated 03/10/22 revealed "...new rash between breasts..." and another note on 03/21/22 noted "...rash...is really red."
There was no documented evidence the facility determined what action or intervention was needed nor was there evidence the area was monitored through resolution.
During an interview with Resident 1 on 05/03/22 s/he stated the rash on his/her chest was no longer there.
Resident 1's short term change of condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/03/22 at 2:00 pm. Staff 2 verified there was no other documentation regarding the rash to the resident's chest.
4. Resident 2 was admitted to the facility in 07/2020 with diagnoses including diabetes and hypertension.
The 04/01/22 through 04/30/22 MAR was reviewed and noted the resident received an antibiotic for seven days related to cellulitis.
There was no documented evidence noting signs and symptoms the resident was experiencing requiring antibiotic treatment, no action or interventions for staff to implement and there was no evidence the resident was monitored through resolution.
Resident 2's change of condition related to antibiotic treatment was discussed with Staff 1 (Administrator) on 05/04/22 at 12:05 pm. No additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure short term changes were reviewed to determine and document what action or intervention was needed for the resident and those changes were monitored through resolution for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) who experienced short term changes of condition. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 09/2019 with diagnoses including Alzheimer's.
Interview with staff during the survey indicated the resident required staff assistance with all ADLs. Progress notes dated 02/01/22 through 04/26/22 were reviewed and indicated the following:
* 02/03/22 - The resident was "coming across as forgetting how to swallow" medications;
* 02/18/22 - Increased confusion;
* 02/19/22 - Poor appetite;
* 02/22/22 - Wandering into other resident's rooms;
* 02/25/22 - Red right eye; and
* 03/15/22 - Hallucinations.
There was no documented evidence the facility determined actions or interventions needed for these changes of condition and that the changes of condition were monitored through resolution.
The need to ensure short term changes were reviewed to determine and document what action or intervention was needed for the resident and the changes were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 02/2014 with diagnoses including anxiety and bi-polar disorder.
Progress notes dated 02/03/22 through 05/02/22 were reviewed and indicated the following:
* 02/03/22 - Pain with urination which documentation showed had not resolved through 03/29/22;
* 02/06/22 - Increased drowsiness and an increase usage of the call system;
* 02/09/22 - Urine analysis was collected; and
* 04/27/22 - "Wound care treatments being done on toes bi-laterally."
There was no documented evidence the facility determined actions or interventions needed for these changes of condition and that the changes of condition were monitored through resolution.
The need to ensure short term changes were reviewed to determine and document what action or intervention was needed for the resident and the changes were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.
5. Resident 3 was admitted to the facility in 02/2018 and was noted to experience skin breakdown.
The resident's 02/01/22 through 05/02/22 progress notes were reviewed and revealed the resident experienced the following changes of condition:
* 02/08/22 - " ...[Left lower extremity] with several scabbed areas where resident reports s/he has been scratching."; and
* 02/16/22 - "I've witnessed resident habitually picking at sores on his/her left arm with a pair of tweezers."
There was no documented evidence the facility determined and documented interventions to deter the resident from scratching him/herself and monitored the changes of condition with progress noted at least weekly through resolution.
On 05/04/22 the need to ensure interventions were determined and documented for Resident 3's changes in condition and the conditions monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.
6. Resident 4 was admitted to the facility in 02/2022 with diagnoses including altered mental status and chronic obstructive pulmonary disease.
The resident's 02/22/22 through 05/04/22 progress notes were reviewed and revealed the resident experienced the following changes of condition:
* 02/24/22 - Decrease in oxygen saturation, weakness and confusion;
* 02/28/22 - Return from hospital; and
* 03/01/22 - Complaints of thrush in mouth.
There was no documented evidence the facility monitored the changes of condition with progress noted at least weekly through resolution.
On 05/04/22 the need to ensure Resident 4's changes in condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.
1. Resident 1, 2, 3, 4, 5, and 6 were reviewed to ensure there were no current temporary changes in condition requiring monitoring with progress notes.
2. To prevent this violation from occurring again, residents with temporary change in condition will be placed on Alert. Med Techs and Caregivers have been in-serviced by LN on Alert charting and change of condition protocols. While the resident is on alert, a LN will complete an initial assessment and then weekly, as indicated by policy, for on-going monitoring to determine resolution prior to discontinuing alert charting.
3. Residents placed on alert charting will be audited weekly for four weeks and quarterly thereafter by a LN. Alert charting is monitored ongoing M-F, as part of the facility stand-up process, to ensure compliance.
4. The RN or designee will be responsible to ensure ongoing compliance and corrections are complete and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and signed physician orders were documented in the resident's facility record for all medications the facility was responsible to administer for 2 of 6 sampled residents (#s 3 and 6) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 6 moved into the facility in 02/2014 with diagnoses including bipolar disorder. Physician orders and 04/01/22 through 05/02/22 MARs were reviewed.
a. Resident 6 had a signed physician order for the facility to administer 81 mgs of aspirin (for heart health) daily. This medication was not on the resident's MAR and was confirmed by Staff 2 (RN) on 05/03/22 at 2:13 pm it was not being administered.
b. There was no documented evidence the facility had signed physician orders for the following medications:
* Quetiapine 400 mgs (for manic depression); and
* Robitussin, PRN (for cough).
c. There was no documentation if the resident was administered quetiapine on 04/28/22 and 04/29/22. There was also no documentation of administration for scheduled Tylenol on 04/29/22 and 04/30/22.
The need to ensure physician orders were carried out as prescribed and signed orders were in the resident's facility record was reviewed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 2018 with diagnoses including diabetes mellitus. The resident's 04/01/22 through 05/02/22 MARs and 02/01/22 physician's orders were reviewed.
a. The following medications were present in the resident's MARs but were not listed in the current physician's orders:
* Acetaminophen (for pain);
* Benefiber Powder (for bowel care);
* Budesonide (for asthma)
* Benzonatate (for cough);
* Furosemide (for edema);
* Guaifenesin (for cough);
* Methyl cream (for skin infection);
* Nitroglycerin (for heart pain);
* Nystatin (for skin infection);
* Polyethylene glycol (for bowel care); and
* Spriva (for asthma).
b. The 02/01/22 physician's orders contained an order for novolog insulin pen (for diabetes), sliding scale. The parameters for the sliding scale were not included in the order.
Review of the 04/01/22 through 05/02/22 MAR noted the resident received sliding scale insulin three times daily. In an 05/04/22 interview with Staff 2 (RN), he confirmed the facility was unable to produce a physician's order for the novolog insulin pen.
The need to ensure signed physician's orders were complete and in place for all medications administered was discussed with Staff 1 (Administrator) and Staff 2 on 05/04/22. They acknowledged the findings.
1. Resident 3 and Resident 6 May MAR and TAR were immediately reviewed. Any medications for which a current signed order was not in-house, original eSpcript obtained from pharmacy if unavailable, order was put on hold and updated order or d/c was requested from provider.
- Resident #3 parameters for insulin have been obtained.
- Identified ommissions have been communicated to provider and added to resident MAR.
- 100% audit of residents to be completed to verify that all pharmacy orders on MAR have valid provider order as part of resident chart, all orders with necessary parameters are included as part of the order.
2. To prevent this violation from occurring again, Medication Technicians have been inserviced on facility policy regarding order confirmation process, administration and documentation of Medications and treatments, per physician orders. Including appropriate process for when a medication/treatment cannot be administered.
- Marquis RN consultant to inservice RN HSD and LPN on medication confirmation process and retention of provider valid orders with resident records.
3. LN or designee will audit weekly for four weeks and quarterly thereafter for any Medication and/or treatment omissions.
4. The RN will be responsible to ensure the correction is complete and monitored.
There are no detail notes for this visit.
3. Resident 5 was admitted to the facility in 09/2019 with diagnoses including major depressive disorder and Alzheimer's.
The resident's 04/01/22 through 05/02/22 MARs and physician orders were reviewed and revealed refusals of the following prescribed orders on 04/19/22:
* Bupropion (for depression);
* Calcium plus vitamin D (for supplement);
* Donepezil (for Alzheimer's);
* Fluoxetine (for major depression);
* Glucos/Chond (for supplement);
* Lisinopril (for hypertension);
* Multivitamin (for supplement);
* Vitamin D (for supplement); and
* Acetaminophen (for pain).
There was no documented evidence the facility notified the physician of Resident 5's refusals of medications. Staff 2 (RN) confirmed the facility had not notified the physician of the refusals on 05/03/22 at 2:13 pm.
The need to ensure the physician is notified when a resident refuses to consent to orders was discussed with Staff 1 (Administrator) and Staff 2 on 05/04/22. They acknowledged the findings.
4. Resident 6 was admitted to the facility in 02/2014 with diagnoses including heart disease and edema.
The resident's 04/01/22 through 05/02/22 MARs, TARs and physician orders were reviewed and revealed multiple refusals of the following prescribed orders:
* Polyethylene Glycol (for bowel care);
* Anoro Ellipta (for chronic bronchitis);
* Selenium Sulfide Lotion (for dandruff); and
* Compression stockings (for edema).
There was no documented evidence the facility notified the physician of Resident 6's refusals of medications. Staff 2 (RN) confirmed the facility had not notified the physician of the refusals on 05/03/22 at 2:13 pm.
The need to ensure the physician is notified when a resident refuses to consent to orders was discussed with Staff 1 (Administrator) and Staff 2 on 05/04/22. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 2018 and was noted to experience skin breakdown. The resident's 04/01/22 through 05/02/22 MARs/TARs were reviewed and revealed the resident refused the following treatments:
* Ketoconazole shampoo (for dandruff) was refused nine times;
* Barrier cream (for skin integrity) was refused 56 times;
* Diclofenac sodium (for pain) was refused 53 times;
* Fluticasone (for allergies) was refused two times;
* Mupirocin (for skin antibiotic) was refused 39 times;
* Nystatin (for skin integrity) was refused 58 times; and
* Methyl cream (for muscle pain) was refused 58 times.
There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders.
The need to ensure the facility notified the prescriber of treatment refusals was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 4 of 4 sampled residents (#s 2, 3, 4 and 6) whose records were reviewed, and had documented medication and treatment refusals. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility 07/2020 with diagnoses including Type 2 Diabetes, stasis wounds on legs and insomnia.
Review of the 04/01/22 through 05/02/22 MARs/TARs during the survey revealed multiple medication and treatment refusals of the following prescribed orders:
* Triamcinolone ointment (for leg dressings);
* Selenium Sulfide 1% shampoo (for seborrhea);
* CBG check once a day for Diabetes Type 2;
* Polyethylene Glycol 3350 powder (daily for constipation);
* Miconazole 2% powder (for skin irritation);
* Barrier cream to coccyx (for skin irritation);
* Eucerin Cream (for dry skin); and
* Lidocaine jelly 2% GEL 5ML apply to a specific site (for pain).
There was no documented evidence the facility notified the physician of Resident 2's refusals of medications and treatments.
The need to ensure notification of the physician when a resident refused to consent to orders was discussed with Staff 1 (Administrator) on 05/04/22 at 12:45 pm. She acknowledged the findings.
1. Resident 2, 3, 4, and 6 physician has been updated regarding resident refusals of medications, orders updated as indicated.
- Communication was immediately made to all Med Tech and Med Assist staff educating them on the requirement and procedure of provider notification for resident refusals.
2. To prevent this violation from occurring again, Medication Technicians and Med Assists have been inserviced on regulation and facility policy resident refusals, including appropriate process for when a medication/treatment is refused by a resident.
3. LN or designee will audit weekly for four weeks and quarterly thereafter for any Medication and/or treatment refusals to ensure communication was sent to provider per provider instruction.
4. The RN will be responsible to see ensure the correction is complete and monitored.
There are no detail notes for this visit.
2. Resident 1 was admitted to the facility in 06/2019 with diagnoses including osteoarthritis.
Review of the 04/01/22 through 05/02/22 MARs noted the following as needed medications:
*Hydrocodone (narcotic pain medication) as needed for pain; and
*Sportscreme (topical pain medication) every six hours as needed for pain.
There were no resident specific parameters related to which medication to administer for pain or the frequency that the Hydrocodone could be administered. The resident did not receive either medication during the time frame reviewed.
Resident specific parameters for as needed medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/03/22 at 2:00 pm. No additional information was provided.
4. Resident 6 was admitted to the facility in 09/2014 with diagnoses including anxiety.
a. Resident 6 receives a scheduled dose of Anoro ellipta, an inhaler prescribed for chronic bronchitis. Staff documented, "Other/See nurse notes" on the following dates:
* 04/01/22 through 04/08/22;
* 04/12/22 through 04/21/22;
* 04/25/22 through 04/28/22; and
* 05/02/22.
In an interview on 05/03/22 at 2:13 pm, Staff 2 (RN) confirmed there was no documentation that could explain why staff referred to "Other/See nurse note."
b. Resident 6 had an order that s/he could administer over the counter eye drops, which was also reflected on the resident's MARs. There were staff initials indicating they had administered the eye drops.
On 05/04/22 at 10:33 am, Staff 17 who also works as a "Med Assist," verified staff administer the eye drops and confirmed the resident doesn't self administer any treatments.
c. Documentation revealed Resident 6 refused to have compression stockings donned in the morning on 04/05/22, 04/06/22 and 04/28/22. Staff signed in the evening that they doffed the compression stockings on the same dates the resident refused.
d. Sodium chloride solution (for nasal dryness) has another name which is Deep Sea nasal spray. There was a duplicate order for the PRN administration of this medication. Also, the Deep Sea nasal spray did not have clear parameters to direct unlicensed staff to administer either one to two sprays in each nostril.
The need to ensure resident's MARs were accurate and include resident specific parameters was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.
Resident 3 was admitted to the facility in 02/2018 with diagnoses including hypertension.
The resident's 04/01/22 through 05/02/22 MARs were reviewed, and the following deficiencies were identified:
An order for Benefiber, one teaspoon in four to six ounces of liquid daily PRN included the following instructions: "may increase dosage to achieve one soft bowel movement." The instructions lacked resident specific parameters on what the dosage should be increased to.
An order for Amlodipide, five mg tabs included the following instructions: "take an additional two and one half mg if blood pressure is still high two hours after scheduled dose and re-check blood pressure in four hours." The instructions lacked resident specific parameters for the resident's blood pressure and what should occur when the resident's blood pressure was still elevated after four hours.
The requirement to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.
2. Resident 4 was admitted to the facility on 02/2022 with diagnoses including chronic obstructive pulmonary disease.
The resident's 04/01/2022 through 05/02/22 MARs were reviewed, and the following deficiencies were identified:
The resident had an order for a Symbicort inhaler, inhale one to two puffs into the lungs twice a day. There were no resident specific parameters regarding when to administer one puff vs two puffs or if the resident could self direct the treatments.
The need to ensure medication records, for each medication the facility was responsible for administering, included the correct dosage and any resident specific parameters was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 6) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility 07/2020 with diagnoses including: Type 2 Diabetes, stasis wounds on legs and insomnia.
Review of the 04/01/22 through 05/02/22 MARs revealed the following:
a. The order for Triamcinolone 0.1% ointment 15GM, apply a thin layer 2 times per week to legs with wound care and dressing changes, lacked clear parameters for what two days to administer the medication and who was responsible to administer it.
b. For the administration of Triamcinolone 0.1% ointment 15GM, facility staff documented resident refusals of the medication everyday during the month of 04/2022 when the order read to apply twice weekly.
The need to ensure MARs were accurate and included clear parameters for administration of the medications was discussed with Staff 1 (Administrator) on 05/04/22 at 12:45 pm. She acknowledged the findings.
1. Action taken to obtain resident specific parameters and reason for use to Resident 1, 2, 3, 4, 5, 6 MAR's. Resident #2 is mis-identified in this citation, the example under the citation is actually resident #6. Resident #6 orders, specific parameters have been obtained.
2. To prevent this violation from occurring again, all new orders will have specific parameters, as indicated, reason for use included with each medication/treatment, as indicated. In addition, all current residents will have orders reviewed for clarification, resident specific parameters put in place and reason for use indicated.
3. LN will in-service RSC and Med Tech on medications that need parameters and protocol for obtaining those parameters. Inservice will also included the facility policy for Resident centered medications and the time frames assigned for administration for those medications, as reflected in EMAR.
LN, or designee, will review weekly for four weeks and quarterly thereafter all new medication orders to ensure parameters are in place, as indicated.
4. The LN will be responsible to ensure corrections are complete and monitored.
2. Resident 7 was admitted to the facility in 07/2022 with diagnoses including pain in left shoulder and generalized anxiety disorder.
The resident's 07/28/22 through 08/03/22 MARs were reviewed and the following deficiencies were identified:
a. Review of the MARs noted the following as needed medications:
* Acetaminophen 650 mg every four hours as needed for pain; and
* Ibuprofen 400 mg every four hours as needed for pain.
There were no resident-specific parameters related to which medication to administer first for pain. The resident did not receive either medication during the time frame reviewed.
b. Review of the MARs noted the following as needed medications:
* Lorazepam (medication to treat anxiety) 1 mg twice daily as needed.
There were no resident-specific parameters related to how the resident demonstrated signs and symptoms of anxiety. The resident did not receive the medication during the time frame reviewed.
c. Review of the MARs noted the following as needed medications:
* Polyethylene Glycol 17 gm powder every day as needed for constipation.
There were no resident-specific parameters including when to administer the medication. The resident did not receive the medication during the time frame reviewed.
Resident-specific parameters for as-needed medications was discussed with Staff 2 (RN) and Staff 19 (Administrator) on 08/04/22 at 10:00 am. They acknowledged the findings.
3. Resident 8 was admitted to the facility in 05/2016 with diagnoses including hemiplegia and hemiparesis following cerebral infarction.
The resident's 07/01/22 through 08/03/22 MARs were reviewed, and the following deficiencies were identified:
a. Review of the MARs noted the following as needed medications:
* Tylenol 325 mg tablets, take 1-2 tablets every six hours as needed for pain.
There were no resident-specific parameters including when staff should administer 1 tablet versus 2 tablets for pain. The resident did not receive the medication during the time frame reviewed.
b. Review of the MARs noted the following as needed medications:
* Milk of Magnesia as needed for constipation; and
* Miralax powder as needed for constipation.
There were no resident-specific parameters related to which medication to administer first for constipation. The resident did not receive either medication during the time frame reviewed.
Resident-specific parameters for as-needed medications was discussed with Staff 2 (RN) and Staff 19 (Administrator) on 08/04/22 at 10:00 a.m. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 3 of 4 sampled residents (#s 7, 8 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 10 was admitted to the facility in 07/2022 with diagnoses including dementia.
Review of the 07/26/22 through 08/03/22 MARs noted the following as needed medications:
*Tylenol 325 mg tablet, take 2 tablets every four hours as needed for pain; and
*Tylenol 500 mg tablets, take 1-2 every six hours as needed for pain.
There were no resident-specific parameters related to which medication to administer first, no clear instructions for the type or location of the pain and no indication for when to administer 1 tablet verses 2 tablets. The resident did not receive either medication during the time frame reviewed.
During an interview with Staff 2 (RN) on 08/04/22, he reported Resident 10 could "self-direct PRN's." The MAR lacked clear instructions regarding the resident's ability to self-direct PRN medications.
Resident-specific parameters and clear instructions for unlicensed staff was discussed with Staff 19 (Administrator) and Staff 2 on 08/04/22. They acknowledged the findings.
1.) Action taken by facility RN to obtain resident specific parameters and reason for use of PRN for sampled residents (#7, 8 & 10) and incorporated into the MAR's.
Resident #10- OT evaluation for cognitition has been requested. Pending cognitive evaluation, resident specific parameters and clear instructions for use of PRN pain medication Tylenol 325mg and Tylenol 500mg will be added to MAR.
Resident #7 - Resident specific parameters for use of PRN pain medication Acetaminophen 650mg and Ibuprofen 400mg added to MAR. Clear instructions regarding "self-direct PRN's" added to MAR for resident. Resident specific parameters for PRN Lorazepam has been updated to routine. Directions on what staff should identify as signs for need to offer PRN added to MAR. Resident is able to express needs and request PRN(s) appropriately. Resident specific parameters for use of PRN Polyethylene Glycol 17gm added to MAR.
Resident #8- Resident specific parameters for us of PRN Tylenol 325mg added to MAR. Directions on what staff should identify as signs for need to offer PRN added to MAR. Resident specific parameters for use of which PRN Milk of Magnesia or Miralax should be offered added to MAR.
2.) All PRN orders will have resident specific parameters as indicated in physician orders if resident is unable to self-direct PRN use. PRN Self-direction order will be included within physician orders and included on resident Service Plan.
100% review of all residents with PRN orders, will be completed. Updates will be done, as indicated.
3.) Facility Nurse will in-service Resident Service Coordinator and Medication Techs on medications that need parameters and protocol for obtaining those parameters.
Facility Nurse will conduct audit of all new PRN orders weekly x 4 weeks and then monthly x 90 days to ensure on-going complaince.
4.) Facility RN and Administrator will be responsible to ensure corrections are complete and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#4), who received psychotropic medications. Findings include but are not limited to:
Resident 4 was admitted to the facility in 02/2022 with diagnoses including anxiety.
The resident's 04/01/22 through 05/02/22 MARs were reviewed and the following was noted:
Resident 4 was prescribed Hydroxyzine 50 mg every five hours as needed for anxiety.
Records indicated Hydroxyzine was administered on 04/22/22, 04/28/22 and 05/02/22.
The facility lacked documented evidence non-pharmacological interventions were attempted and ruled ineffective prior to administration of Hydroxyzine.
During an interview on 05/04/22, Staff 10 (MA) confirmed the facility had not documented when non-pharmacological interventions were attempted and ineffective prior to administering the Hydroxyzine for Resident 4.
The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.
1.) Resident 4 has Physician order active since 4/28/22 stating s/he can self-direct all PRN medications, facility recognizes that for the dose on 4/22 documentation lacked the evidence of non-pharmacological interventions prior to Hydroxyzine PRN was administered.
To correct this violation, Med techs have been in-serviced on the requirement to document non-pharmacological interventions attempted prior to administration of psychotropic PRN for residents who cannot self-direct their use.
2.) To prevent this violation from happening again, all residents with orders for PRN psychotropic medications will have resident-specific, non-pharmacological interventions included in their Service Plan/Kardex for staff to reference. Residents who can self-direct their use of PRN psychotropic medications will be clearly noted in the MAR.
3. LN or designee will audit weekly for four weeks and quarterly thereafter for use and documentation of non-pharmacological interventions prior to administration of PRN psychotropic medications for residents who are unable to self-direct.
4. The RN will be responsible to see ensure the correction is complete and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing care to residents for 2 of 3 newly hired direct care staff (#s 11 and 16) whose training records were reviewed. Findings include, but are not limited to:
Staff training records were reviewed on 05/04/22.
Staff 11 (CG), hired 03/05/22, and Staff 16 (CG), hired 03/23/22, lacked documented evidence pre-service dementia training was completed prior to performing job duties.
The need for all direct care staff to complete the required pre-service dementia training prior to providing care to residents was reviewed with Staff 1 (Administrator) and Staff 4 (Staffing Coordinator) on 05/04/22. They acknowledged the findings.
1. The following actions have been taken to correct this violation:
- Staff 11, and 16 have completed an approved pre-service dementia training.
- ALF Staffing Coordinator and RSC to complete audit of all current staff files for required elements of pre-service dementia training.
- Staffing Coordinator and HR Director will ensure ALF direct care staff completed an approved pre-service dementia training.
2. To prevent any future deficient practices, the following actions will be taken:
- Administrator has in-serviced staffing and HR on the requirements for pre-service dementia training, training resources and tracking of completion.
- All new employees will be required to complete an approved pre-service dementia training before their first day providing direct patient care to residents
3. Staffing Coordinator, HR Director, or designee, will review employee file compliance on a weekly basis for 90 days, then quarterly after. HR Director will conduct new hire file audit within 30 days of hire date. Findings will be reported to ALF Staffing Coordinator and ALF Administrator.
4.HR Director will be responsible to see that corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired staff (#s 20 and 22) had documentation of completed pre-service orientation and 1 of 2 sampled newly-hired direct care staff (# 20) had completed pre-service dementia training prior to performing any job duties. This is a repeat citation. Findings include, but are not limited to:.
Staff training records were reviewed on 08/03/22.
1. Staff 20 (MT), hired 08/01/22, and Staff 22 (CG), hired 07/15/22, lacked documented evidence pre-service orientation training in all required areas was completed prior to performing any job duties, including:
* Infectious Disease Prevention; and
* Written job description.
2. Staff 20 lacked documented evidence pre-service dementia training was completed prior to performing job duties.
The need for all newly-hired staff to complete the required pre-service orientation and pre-service dementia training prior to providing care to residents was reviewed with Staff 9 (MT/Resident Care Coordinator) and Staff 19 (Administrator) on 08/03/22. They acknowledged the findings.
1.) All new hires will complete a Pre-Service Orientation at the facility, conducted by the facility HR Director or designee and will complete an approved Pre-service Dementia Care Training for Direct Staff & Infection Prevention and Control for Community-Based Care training through Oregoncarepartners.com. per OAR 411-054-0070.
Staff #20 has completed Pre-Service Dementia Care training & Infection Prevention and Control Training; signed job description in personnel file.
*Staff 22 is no longer an employee at the facility.
2.) HR Director and HR Assistant have been re-inserviced on requirements for Pre-Serivce orientation and job descriptions per facility policy.
3.) Administrator and HR Director to complete audit of all current staff files for required elements of Pre-service Dementia training & Infection Prevention and Control training.
Verification of new hire paperwork and required pre-service training will be done prior to any new staff being scheduled to work with residents
4.) HR Director and Administrator will ensure ALF direct-care staff have completed an approved Pre-service Dementia training and Pre-service Orientation.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired caregiving staff (#s 4, 11 and 16) had documented evidence of demonstrated satisfactory performance in all job duties within 30 days of hire and had abdominal thrust and First Aid training. Findings include, but are not limited to:
Staff training records were reviewed on 05/04/22. The following deficiencies were identified:
1. Staff 4 (MA), hired on 10/05/21, Staff 11 (CG), hired 03/05/22, and Staff 16 (CG), hired 03/23/22, lacked documented evidence of demonstrated competency in all required areas within 30 days of hire including:
* 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
* Other duties as applicable (Med pass, treatments).
2. Staff 4, 11 and 16 lacked documented evidence of abdominal thrust and First Aid training.
The need to ensure newly hired direct care staff had documentation of demonstrated competency and completed abdominal thrust and First Aid training within 30 days of hire was discussed with Staff 1 (Administrator) on 05/04/22. She acknowledged the lack of training documentation.
1. The following actions have been taken to correct this violation:
- ALF Staffing Coordinator and RSC to complete audit of all current staff files for required elements of training, 30 day job performance to include all areas identified in OAR including, First aid, and abdominal thrust.
- Staff 4, 11, and 16 have completed First aid and abdominal thrust training and 30 day competencies.
- Staffing Coordinator and HR Director will ensure ALF staff have completed First Aid and abdominal thrust training and 30 day job required areas of competency.
2. To prevent any future deficient practices, the following actions will be taken:
- Administrator has in-serviced staffing coordinator, HR director on requirements for First Aide, Abdominal thrust and 30 day competencies per policy and OAR.
- All new employees will be required to complete First Aide, Abdonminal Thrust training and required 30 day competencies, as outlined in OAR, within the first 30 days of hire.
3. Staffing Coordinator, HR Director, or designee, will review employee file compliance on a weekly basis for 90 days, then quarterly after. HR Director will conduct new hire file audit within 30 days of hire date. Findings will be reported to ALF Staffing Coordinator and ALF Administrator.
4.HR Director will be responsible to see that corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly-hired caregiving staff (# 23) had documented evidence of demonstrating satisfactory performance in all job duties within 30 days of hire, including abdominal thrust and First Aid training. This is a repeat citation. Findings include, but are not limited to:
Staff training records were reviewed on 08/03/22. The following deficiencies were identified:
Staff 23 (CG), hired on 06/06/22, lacked documented evidence of demonstrated competency in all required areas within 30 days of hire, including:
* 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
* First Aid and Abdominal thrust training.
The need to ensure newly-hired direct care staff had documentation of demonstrated competency and completed abdominal thrust and First Aid training within 30 days of hire was discussed with Staff 19 (Administrator) on 08/03/22. She acknowledged the lack of training documentation.
1.) Staff #23 has completed the 30 day performance checklist, including abdominal thrust and First Aid training. HR Director or designee to complete audit of all current staff files for required elements of training, 30 day job performance to include all areas
identified in OAR including, First aid, and Abdominal Thrust.
2.) All new employees will be required to complete First Aide, Abdonminal Thrust training and required 30-Day Competencies as outlined in OAR 411-054-0070 within the first 30 days of hire.
3.) Administrator and HR Director or designee, will review employee file for compliance on a weekly basis for 90 days, then quarterly after. HR Director will conduct new hire file audit within 30 days of hire date. Findings will be reported to Staffing Coordinator and Administrator.
4.) Administrator and HR Director will be responsible to see that corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 4 of 4 long-term staff (#s 5, 8, 14 and 15) whose training records were reviewed. Findings include, but are not limited to:
Facility training records were reviewed on 05/04/22 and revealed the following:
Training records for Staff 5 (MA), hired 09/05/19, Staff 8 (MA), hired 06/24/17, Staff 14 (CG), hired 03/23/20, and Staff 15 (CG), hired 06/23/20, failed to have documented evidence of completing 12 hours of required in-service training, including six hours relating to the care residents with dementia.
The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) on 05/04/22. They acknowledged the findings.
1. 100% audit of all Direct care staff have been completed to ensure all required annual inservicing prior to anniversary dates of their hire, including Dementia care training, has been completed, audit to include staff #5, #8, #14, #15.
- Administrator has inserviced Staffing and HR director on process tracking, requirements and facility policy/access to Oregon Care partners for required trainings.
2. To ensure this violation does not occur again, Maquis Piedmont ALF has implemented Oregon Care Partners approved trainings for annual in-service requirement that can be done both in-person or remotely if needed. Documentation will be maintained by facility.
All Direct care staff have been inserviced on access to Oregon Care partners and process for completion of inservice requirements.
3. Due to the monthly nature of this requirement, inservicing hours will be audited monthly by the ALF staffing coordinator, Administrator, or designee for 6-months and then quarterly thereafter.
4. The Staffing Director will be responsible to ensure corrections are complete and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:
Fire and life safety records for 11/2021 through 04/2022 were reviewed and lacked the following components:
* There was no documented evidence fire and life safety training was conducted on alternating months of fire drills; and
* There was no documentation of the problems encountered or comments relating to residents who resisted or failed to participate in the drills.
The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Administrator) on 05/04/22. She acknowledged the findings.
1. Fire and Life Safety Training in-service has been completed for all staff and will continue per regulation ongoing, to include any problems that occurred during training and residents who chose /or could not participate in the training.
2. To ensure the violation does not occur again, Fire and Life Safety Training will be included every other month during scheduled all-staff meetings. Documentation, to include any problems that occurred during training and residents who chose /or could not participate in the training.
- Maintenance director has been inserviced on the requirements for Fire and life safety instruction training requirements.
3. Administrator or designee will audit every month for 90 days to ensure compliance with Documentation addressing any problems that occurred during training and residents who chose /or could not participate in the training.
4. The Maintenance Director will be responsible to ensure corrections are complete and monitored.
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:
Fire and life safety records for 07/2022 were reviewed and lacked the following required components:
* Escape route used;
* Documentation of problems encountered or comments relating to residents who resisted or failed to participate in the drills; and
* Evidence alternate routes were used.
Additionally, the facility was not identifying residents who were unwilling to participate in fire drills, therefore there was no system in place to document changes that were made to ensure the evacuation standard was met.
The need to ensure the facility conducted fire drills per the OFC and documented all required components of the fire drill was discussed with Staff 19 (Administrator) on 08/03/22 at 3:32 p.m. She acknowledged the findings.
1.) Fire Drill form updated to reflect addition of 'escape route used' and 'evidence alternate escape routes used' during fire drills; problems encounters, if any, and residents that resisited or failed to participate during fire drill.During Fire & Life Safety Training the specific training topic will be identified and documented for staff in-services.
2.) The updated Fire Drill form will be used for each drill going forward, with the first drill using updated form being completed on 8/23/22.
3.) Fire Drills and Fire & Life in-services are conducted monthly.
4.) The Maintenance Director is responsible for conducting all Fire Drills and Fire & Life Safety in-services. The Administrator will ensure drills and in-services are conducted and are thourough and complete to maintain compliance with OAR.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:
On 05/03/22, Staff 1 (Administrator) was asked to explain the facility's process and to provide documentation for instructing residents in fire and life safety procedures upon admission and annually. Staff 1 was unable to provide a clear description of their process for training residents in fire and life safety procedures and was unable to provide any supporting documentation related to the completion of the required trainings.
The need to instruct residents upon move-in and annually in general fire safety procedures was discussed with Staff 1 on 05/04/22. She acknowledged the findings.
1.) To correct this violation, all current residents will receive education on facility fire safety procedures, evacuation methods, and responsibilities during fire drills.
2.) To ensure the violation does not happen again, Fire and Life Safety training will be provided to Resident within 24-hours of admission and annually thereafter. Documentation supporting this training will be maintained.
3.) ALF Administrator or designee will audit every month for 90-days, then quarterly thereafter to ensure compliance.
4.) ALF Administrator will be responsible to ensure corrections are completed/monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 252, C 260, C 310, C 370, C 372 and C 420.
The facility will ensure the re-licensure survey plan of correction os implemented and satisfies the department- refer to C252, C260, C310, C370, C372 & C420.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the common-use areas, entrance, and exit ways were made of hard, smooth material, were accessible, and maintained in good repair and the grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:
The exterior grounds were toured on 05/03/22 at 9:15 am. The following deficiencies were identified:
* There were drop-offs between two to nine inches from the pavement to the planting bed at the corners and along the edges of multiple pathways around the perimeter of the building. These drop-offs created potential tripping or fall hazards for residents.
* There were cigarette butts, soiled single-use gloves, and furniture surrounding the garbage can.
* There were utility sinks that were removed from the kitchen and stacked patio furniture stored behind the building.
On 05/04/22 at 12:19 pm, the surveyor discussed the need for pathways to be made of smooth material and the grounds to be kept orderly and free of litter and refuse with Staff 1 (Administrator) and Staff 13 (Campus Maintenance Director). They acknowledged the findings.
1. Action has been taken to correct the violation. This includes ordering gravel to fill four inch drop off which posed potential tripping hazard. Cleaning up litter such as gloves and cigarette butts. Furniture and utility sinks have be disposed of.
2. To prevent the violation from occuring again, the grounds will be toured/inspected weekly by the Maintanence Director or designee.
Maintanance Director was present during tour with Survey team on 5/3/22 and is clear on requirement to keep grounds orderly and free of refuse or litter.
3. Administrator or designee will audit grounds monthly for 90 days, then quarterly thereafter.
4. The Administrator and Maintenance Director will be responsible to ensure corrections are complete and monitored.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident clean and in good repair. Findings include, but are not limited to:
The interior of the building was toured on 05/02/22 at 12:19 pm. The following areas needed cleaning or repair:
* Multiple resident room doors had black scuff marks;
* Room 336 had a spill on the wall to the right of the door;
* Elevator frame on the third floor had chipped paint and loose weather stripping;
* Elevator car had torn laminate on the walls and debris in the lighting panels;
* Laundry room of the third floor had lint build-up surrounding the exhaust piping;
* Lights above the entrances to rooms 207, 300 and 332 were broken;
* Walls near rooms 204, 205, 207, 210, 211, 215, 217, 221, 225, 226, 231, 232, 233, 235, 237, 239, between 309 and 311, 313 and between 340 and 342 were gouged with exposed drywall;
* Handrail to the left of room 334 was jagged;
* Carpet in front of room 228 and in front of the stairway door near room 222 was frayed;
* Ceiling tiles in the activity room on the second floor had water stains;
* Table legs in the activity room were stained;
* The microwave in the activity room had food debris inside and staining in the cupboard below;
* Walls throughout the dining room had chipped paint;
* Table and chair legs in the dining room were stained and covered in dirt/food debris;
* Windowsills in the dining room had dead bugs and dirt/debris;
* Cabinet below the sink in the dining room had black and brown stains;
* Carpet near exit doors of the dining room was frayed; and
* Carpet near locked kitchen entrance was stained.
The need to keep interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety, and comfort of the resident clean and in good repair was discussed with Staff 1 (Administrator) and Staff 13 (Campus Maintenance Director) on 05/04/22 at 12:19 pm. They acknowledged the findings.
The following actions have been taken to correct the violation:
- Resident room doors have been cleaned or re-painted to remove black scuff marks.
- Spill on wall outside Apt. 336 has been cleaned.
- The elevator frame on 3rd floor has been repainted and smoke stripping replaced.
- Laminate in elevator has been repaired and debris in lighting panels cleaned.
- Lint build up in laundry rooms have been removed and cleaned.
- The lights above the following apartments have been replaced/repaired: 207, 300, 332.
- Walls near the following apartments have been repaired and/or painted: 204, 205, 207, 210, 211, 215, 217, 221, 225, 226, 231, 232, 233, 235, 237, 239, 309, 311, 313, 340, and 342.
- The handrail by Apt. 334 has been repaired.
- The carpet in front of apartment 228 and in front of the stairwell by apartment 222 has been repaired/replaced.
- Ceiling tiles in the activity room have been replaced.
- Table legs in the activity room have been wiped down of residue left from disinfectant spray.
- The microwave and cabinets in the activity room have been cleaned of debris and staining.
- Areas with chipped paint in the dining room have been repainted.
- Table legs in the dining room have been wiped down of the residue left from disinfectant spray.
- Windowsills in dining room have been cleaned thoroughly.
- Inside of cabinet in dining room has been cleaned of spilled coffee.
- Carpet near exit doors in dining room have been repaired/replaced.
- Stained carpet near kitchen service hallway entrance has been replaced.
2.)To prevent the violation from occuring again, the grounds will be toured/inspected monthly by the Maintanence Director, Housekeeping Supervisor, or designee.
Maintanance Director was present during tour with Survey team on 5/3/22 and is clear on requirement to keep all interior materials and equipment clean and in good repair.
3. The Administrator or designee will audit the interior building weekly for 90 days, then quarterly thereafter.
4. The Administrator and Maintenance Director will be responsible to ensure corrections are complete and monitored.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and to include a flushing rim clinical sink with a handheld rinsing device in the soiled linen area. Findings include, but are not limited to:
During a tour of the two community laundry rooms on 05/02/22 at 12:19 pm, it was observed that there was a single entrance and a single utility sink in each room.
In an interview with Staff 4 (Staffing Coordinator/MA) on 05/03/22 at 9:35 am, he stated that soiled linen was bagged, brought to the community laundry room, rinsed in the utility sink by a caregiver wearing gloves and then washed with laundry detergent in the residential washing machines.
In an interview with Staff 1 (Administrator) and Staff 13 (Campus Maintenance Director) on 05/04/22 at 12:19 pm, it was confirmed that the facility did not have access to a flushing rim clinical sink to rinse soiled linen.
The facility's failure to provide a one-way flow of soiled linen and to include a flushing rim clinical sink with a handheld rinsing device in the soiled linen area was reviewed with Staff 1 and Staff 13 on 05/04/22. They acknowledged these findings.
1.) A waiver was approved by facility Policy Analyst on May 17, 2022 based on the following justification:
A flushing rim clinical sink is not available in the ALF as it does not have a specific soiled linen room. There is a flushing rim clinical sink available in the attached PAR facility. Heavily soiled laundry requiring this level of cleaning would be placed in a covered barrel and walked to the PAR and down the service elevator for cleaning. 2) The laundry rooms at Marquis Piedmont ALF are meant for resident and staff use. There is one entry and the washers are closer to the door than the dryers. Laundry is done individually by resident and is immediately placed in the washer upon entry to the laundry room. It is then placed in the dryer and removed once completed. Laundry is then placed back in the individual laundry basket. No dirty laundry is stored in the laundry room at any time.
There are no detail notes for this visit.