The findings of the re-licensure survey, conducted 8/23/21 to 8/25/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first  revisit to the re-licensure survey of 08/25/21, conducted on 12/13/21 through 12/14/21, 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 second revisit to the re-licensure survey of 08/25/21, conducted on 01/25/22, 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 third re-visit to the re-licensure survey of 08/25/21, conducted 03/08/22, 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 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure all incidents and injuries of unknown cause were investigated to rule out abuse and reported to the local SPD when abuse was not reasonably ruled out for 1 of 2 sampled residents (#3) whose facility records were reviewed for incidents and injuries of unknown cause. Findings include, but are not limited to:

Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia.

During an interview with Resident 3 on 8/24/21 at 10:05 am, an approximately 2 inch by 1 inch yellow/green bruise was observed at the base of his/her right thumb. Resident 3 reported s/he was unaware of how s/he sustained the bruise.

Review of Resident 3's facility record revealed no documented evidence related to the bruise. Staff 2 (RN) reported during an interview on 8/25/21 at 12:45 pm that she was unaware the resident had a bruise and that it had not been investigated. Survey instructed the facility to report the injury of unknown cause to the local SPD. Fax confirmation of the report was provided prior to exit.

The need to investigate injuries of unknown cause to rule out abuse and to report to the local SPD when unable to reasonably rule out abuse was discussed with Staff 1 (ED) and Staff 2 on 8/25/21. They acknowledged the findings.

Actions to be taken to correct violation:

1) Incident and investigation was completed for resident. A report was faxed in to SPD on 8/25/21

2)

  A) facility staff to complete training on "Elder abuse Prevention, Investigation and Reporting" provided by Oregon Care Partners on their website oregoncarepartners.com. The facility shall provide completion certificate and employee roster to the Department when staff have completed the training.

  B) Skin sheets to be completed by care staff with each resident shower to identify resident skin changes/concerns.

  C) In-service to be completed with direct care staff regarding facility skin check process and incident reporting/documentation

3) The Oregon Care Partner Elder Abuse Training will be provided and completed for new facility staff and  annually.

4) The Executive Director  

2. Resident 1 was admitted to the facility in August 2018 with diagnoses including dementia and osteoarthritis.

The resident's service plan, dated 8/10/21, was not reflective of the resident's current care needs and did not provide clear direction to staff  in the following areas:

* Scoop plate;

* Meal assist;

* Ability to communicate; and

* Preference to sleep in and not eat breakfast.

The need to ensure resident service plans were reflective of current care needs and provided clear directions to staff was discussed with Staff  1 (ED) and Staff 2 (RN). They acknowledged the findings.

3. Resident 3 was admitted to the facility in July 2020.

Resident 3's 6/3/21 service plans and subsequent temporary service plans were not reflective of the resident's current status and care needs, did not provide clear direction to staff and was not followed in the following areas:

* Grooming;

* Bed mobility;

* Use of blankets and pillows for positioning in the recliner;

* Elevation of feet;

* Discontinued use of electric scooter;

* Signs and symptoms of depression;

* Resistance to bathing;

* Legs elevated when in chair;

* Weakness related to radial nerve palsy;

* Meal assist;

* Assist with remote control;

* Cup with handle and lid at chairside;

* Wrist brace; and

* Bed cane.

The need to ensure service plans were reflective of the resident's current care needs, provided clear direction to staff and were followed was discussed with Staff 1(ED) and Staff 2 (RN) on 8/25/21. 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, provided clear direction to staff regarding the delivery of services and were followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in April 2021 with diagnoses including chronic heart failure, chronic respiratory failure and morbid obesity.

Resident 2's current service plan, dated 8/10/21, lacked clear instructions to staff in the following areas:

* Side rails; and

* CPAP or Bi-PAP machine.

Interviews with Resident 2, Staff 7 (CG/MT) and Staff 2 (RN) on 8/24/21 indicated there was confusion about whether the resident used a CPAP or a bi-PAP machine.

On 8/25/21 the need to ensure service plans were reflective of residents'  current needs and status and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Action taken to correct violation.

1) Resident 1, 2 & 3 service plans updated to reflect current needs and status including specific areas identified to be lacking directions. Counseling with RN on services plan deficencies.

2)Regional Nurse created Service Plan checklist/instructions to be utilized by RN, ED and RCC for service planning purposes. In person and ZOOM SP training by Regional Nurse with LN, RCC and ED.

3) All resident service plans will be reviewed by the ED, RN and RCC for each new admission, then quartely and with any change of condition prior to service plan team meeting. This will be a triple check process for SPs. SP training will be offered with any key staff changes and as needed.

4) The Executive Director

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 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1, 2 and 3'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) and Staff 2 (RN) on 8/24/21 and 8/25/21. They acknowledged the findings.

1) Resident 1, 2, & 3 will have assessments and SPs updated to reflect current status and needs. Subsequently, each resident and their representative will be requested to participate in a care conference with the facility Service Planning Team for further review and collaboration.

2)Implementation of Service Planning Team with ED, RCC, LN, Activities Director, Dietary Manager and  Resident/Resident Representative. Care Conference form to be created in PCC and utilized for all SP Team meetings.

3) A quarterly audit will be completed to ensure facility is completing SP team meetings.

4)Regional Nurse and/or Executive Director

2. Resident 1 was admitted to the facility in August 2018 with diagnoses including dementia. Resident 1 was identified during the acuity interview on 8/23/21 with a history of falls.

A review of progress notes, facility incident reports and service plans from 5/25/21 through 8/23/21 identified Resident 1 had the following short-term changes of condition related to non-injury falls:

* 6/4/21 Resident 1 was found on the floor with his/her head on the floor between the bed and dresser. The interim service plan provided instructions to decrease clutter in the room.   

* 7/5/21 The resident had an unwitnessed fall and was found next to the bed. The interim service plan provided instructions to assist with ADLs as needed, continue frequent checks and encourage a family member to acquire a hospital bed;

* 7/23/21  The resident was found on the bedroom floor. There were no new fall interventions implemented nor were previous interventions reviewed to determine if they were in place; and

* 8/8/21 The resident was found on the bedroom floor. Interim service plan instructed staff to place a rolled up blanket under the sheet along the edge of the bed.

There was no documented evidence the facility investigated the falls to include identifying causal factors, the service-planned interventions were not reviewed to determine if in place and whether they continued to be effective to help minimize the reoccurrence of falls.

Observations and interviews with staff on 8/23/21 and 8/24/21 confirmed Resident 1 needed full assist for all ADL cares.  The Resident was observed to ambulate with one person assist using a walker.  The resident was primarily non-verbal, unable to effectively communicate his/her needs.  

The need to ensure the facility had a system in place to investigate and evaluate fall incidents, patterns of falls, determine actions or interventions needed for short-term changes of condition and review the interventions for effectiveness was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/24/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate residents who experienced significant changes of condition, document findings, update the service plan and refer to the nurse for 1 of 2 sampled residents (#3) who experienced significant changes of condition.  The facility failed to determine what actions or interventions were needed, communicate information to staff on all shifts, monitor effectiveness of interventions and document weekly through resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced short-term changes of condition.  Resident 3 had repeated falls with injury.  Findings include but are not limited to:

1. Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia and monoplegia of left arm (paralysis).

A.  Resident 3's current service plan dated 6/3/21 noted the resident had a history of falls, was at risk for falls and required assistance with ADLs and mobility.  Fall prevention interventions included:

* Check routinely and during safety rounds;

* Put electric scooter where s/he cannot trip over it;

* Added 7/9/21: "Ensure resident wears non-slip footwear at all times"; and

* Transfer to his/her strong side.

Progress notes dated 5/23/21 through 8/20/21 revealed the following falls:   

* 5/30/21: Resident found uninjured on the floor next to his/her table.

* 7/9/21: Resident found uninjured on floor in apartment stating s/he tripped over his/her socks.

* 7/24/21: Resident fell backwards and hit his/her head on walker.  

* On 8/9/21, Resident 3 was heard yelling in his/her room and was found on the floor reporting that s/he had hit his/her head. The resident was transported to the ED by ambulance and returned the same day with diagnoses including right-sided radial nerve palsy, a neurological injury which impacted the resident's strength and functional use of his/her right arm for ADLs and mobility with a walker.

* 8/17/21: Resident 3 experienced a witnessed fall from toilet, hit his/her head and sustained a laceration to his/her forehead. The resident was transported to the emergency department where s/he received sutures to his/her forehead and was diagnosed with a small brain bleed.

* 8/20/21: Resident experienced a non-injury fall in his/her room where s/he was found on the floor.

During the survey, on 8/24/21, Resident 3 was observed being transported in the hallway in a wheelchair by a caregiver.

There was no documented evidence the facility had monitored the circumstances of each fall, evaluated if there was a pattern to the falls, if previously identified fall prevention interventions were in place at the time of the falls, whether the interventions were effective and did not consistently identify new fall prevention interventions. The resident continued to fall and sustained injuries.

B. On 8/9/21, Resident 3 fell and was diagnosed with right-sided radial nerve palsy, a neurological injury which impacted the resident's strength and functional use of his/her right arm for ADL and mobility.  During interviews with Staff 4 (RCC) and Staff 6 (CG), they stated the resident experienced a major decline in the ability to feed him/herself, toilet, groom, hold the walker and manipulate the television remote control after the injury. This constituted a significant change of condition.

There was no documented evidence the facility evaluated the resident, documented the findings, determined what actions an interventions were needed for the resident, communicated the actions and interventions to staff on all shifts and updated the service plan to include all pertinent information related to the resident's injury and decline in function.

C. On 8/17/21,  Resident 3 fell from the toilet, hit his/her head and sustained a laceration to the forehead. The resident was transported to the emergency department where s/he received sutures to the forehead and was diagnosed with a small brain bleed. Staff 4 and Staff 6 reported the resident was not able to walk after the injury.

There was no documented evidence the facility evaluated the resident, documented the findings or updated the service plan in all pertinent areas.  

D.  On 7/16/21, Resident 3 was sent to the emergency department of the local hospital for urinary retention. S/he returned the same day with a prescription for Flomax to be administered for 10 days. There was no documented evidence the facility monitored the resident for adverse reactions to the medications or whether it was effective.  

Resident 3's significant changes of condition and on going falls including referring  to the RN, determining what actions or interventions were needed, communicating information to staff on all shifts, monitoring effectiveness of interventions and documenting weekly progress through resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21.  Staff acknowledged the findings.

3. Resident 2 was admitted to the facility in April 2021 with diagnoses including chronic heart failure, chronic respiratory failure and morbid obesity.

Review of progress notes dated 5/23/21 through 8/23/21 revealed staff identified a "very dark red and peeling" area on the back of Resident 2's right leg on 7/31/21. There was no documented evidence this skin condition was monitored, with at least weekly documentation of progress, through resolution.

The need to monitor changes of condition and document progress at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.

1) Implementation of TSP in PCC by LN in a timely manner. Printed for staff to review and sign. Regional Nurse to provide review of systems for TSPs and 24 hours book with RN and the care team.

1a) Assessments and SPs to reflect resident 1, 2 & 3 current status and needs  to reflect change of condition to be completed by RN. RN counseled and re-trained on change of condition and documentation requirements.This alslo inlcudes weekly skin assesment and documentation.

2a) Train staff to identifying resident changes and when to report to LN or RCC for direction, action steps and documentation in PCC for ongoing monitoring. Implement use of Stop and Watch Forms.

2b) Reporting protocol within 24 hrs to LN. LN to be available via phone. Reviewed requirement with RN. Staff notified to call ED if they cannot reach the RN.

2c)Implementation of Clinical Meeting with ED, LN and RCC after stand up daily to help identify any changes of condition for RN assessment.

3) Review of above systems every two weeks for 60 days, then quarterly and PRN.

4)Executive Director and/or Regional Nurse

Based on interview and record review, it was determined the facility failed to ensure the RN completed a timely assessment when 1 of 2 sampled residents (#3) experienced significant changes of condition. Resident 3 experienced falls with a laceration to forehead, a brain bleed and right radial nerve palsy. Findings include, but are not limited to:

Resident 3 was admitted to the facility with vascular dementia and monoplegia of the left arm (paralysis).

Review of  Resident 3's facility record revealed the following:

1. On 8/9/21, Resident 3 was found on the floor and reported s/he hit his/her head. The resident was transported to the hospital and returned that day with a diagnoses of right radial nerve palsy, a nerve injury that impacted the resident's strength and functional use of his/her right arm. During interviews with Staff 4 (RCC) and Staff 6 (CG) they reported that, prior to the fall, the resident was able to feed themselves, change the television channel with the remote control, manage clothing and toilet hygiene unassisted and manipulate grooming tools when desired. After the fall, they reported the resident required assistance with all of the above-mentioned tasks. This constituted a significant change of condition for which there was no documented evidence an RN assessment had been completed.

2. On 8/17/24, Resident 3 fell off the toilet and sustained a laceration to his/her forehead. S/he was transported the the emergency department by ambulance and returned the same day with sutures to the forehead laceration and a diagnosis of a small brain bleed. Staff 4 reported in an interview that Resident 3 walked with a walker with supervision prior to the injury, but had not walked since. This constituted a significant change for which there was no documented evidence an RN assessment had been completed.

On 8/24/21, the resident was observed to be transported in a wheelchair by facility staff.

3. Review of Resident 3's facility record revealed the following medication changes:

* 6/22/21 Resident 3 had an increase to her dosage of Prozac:

* 6/30/21 Resident 3's Buprenorphine HCL - Naloxone HCL for pain was changed to administration via patches on her skin vs orally.

* 7/8/21 Resident's Buprenorphine HCL - Naloxone HCL was increased from one to two patches.

* 7/22/21 Resident's Buprenorphine HCL - Naloxone HCL was decreased from two to one patch.

Resident 3 experienced an unwitnessed non-injury fall on 7/9/21. The medication technician who completed the form checked a box which indicated medication changes may have been a predisposing factor.

Resident 3 experienced an unwitnessed non-injury fall on 7/24/21.

In a progress note written 8/4/21, Staff 2 (RN) indicated Resident 3 had changes to the above medications with a subsequent increase in agitation and falls. The 8/24/21 RN progress note was written 26 days and 11 days respectively after the 7/9/21 and 7/24/21 falls. The RN indicated in the 8/4/21 note that she had contacted the doctor and the resident would be seen the following day for an evaluation.

Resident 3 experienced significant changes of condition without documented evidence an RN assessment was completed to include findings, resident status, and interventions made as a result.  Resident 3 experienced changes to medication which potentially contributed to increased falls without a timely RN assessment to document on the resident condition.  Resident 3's changes of condition were discussed with Staff 1 (ED) and Staff 2 on 8/25/21. They acknowledged the findings.

1) Resident 1, 2 & 3 assesment and SP updated by RN to reflect current needs and status including fall interventions. Counseling with RN by Regional Nurse on importance of resident change in condition, timeliness and lack of follow through.

2a) Daily Clinical Meeting on the agenda: Falls with or without injury, residents sent out to hospital, med changes and monitoring, behavorial changes.

2b) TSP in PCC for acute changes. Med Tech and caregiver training to identify acute changes with resident and reporting to LN.

2c)RN assessments to be done 24 hours after fall or other incident unless emergent. Document in PCC and place on alert.

2d) Implementation of Fall Intervention Team to review any falls, high risk and review of interventions.

3) Falls, change of conditions will be reviewed in Clincal meeting daily. Falll Intervention Team to meet at least monthly & PRN.  

4) Executive Director

2. Resident 1 was admitted to the facility in August 2018 with diagnoses including dementia.

Current physician orders and Resident 1's August 1-23, 2021 MAR were reviewed. There was no documented evidence physician orders were carried out as prescribed for the following:

* COVID-19 monitoring daily lacked documentation on seven occasions; and

* Levothyroxine ordered daily for hypothyroidism was not documented as administered as ordered on 8/11/21.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/24/21. They acknowledged the findings.

3. Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia.

Physician orders dated 8/9/21 and Resident 3's August 1-23, 2021 MAR were reviewed. There was no documented evidence physician orders were carried out as prescribed for the following:

* COVID-19 monitoring daily lacked documentation on five occasions;

* Temazepam ordered daily at 9:00 pm for insomnia was not documented as administered as ordered on 8/2/2.

* Hand therapy "carrot" for contractures in left hand was not documented as applied six times;

* Compression stockings for edema ordered to be donned in the AM and removed in the PM were not documented as applied six times; and

* Diclofenac Sodium for pain was not documented as administered on 8/2/21.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as written for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in April 2021 with diagnoses including chronic heart failure, chronic respiratory failure and morbid obesity.

Current physician orders and Resident 2's August 1-23, 2021 MAR were reviewed. There was no documented evidence physician orders were carried out as prescribed on 18 occasions for the following treatments:

* COVID-19 monitoring:

* Bi-PAP;

* Oxygen; and

* Nebulizer.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.

1) Staff training and counseling on documentation of medications, treatments, VS and COVID monitoring. MAR/TAR audits daily X 30 days, then weekly.

2) Daily MAR/TAR audits by RCC monitored by RN. RCC to print daily audit and bring to daily clinical meeting.

3) Daily X 30 days then weekly at minimum.

4) Executive Director

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 09/2021 with diagnoses including major depression.

Resident 9 had an ordered, dated 10/12/21 to receive fluoxetine (for depression) daily.

Review of the Resident's 11/15/21 through 11/30/21 MAR revealed the medication had not been administered as ordered.

During an interview on 12/14/21, Staff 12 (RN Consultant) stated, there was no documented evidence of a physician's order to hold the medication. She indicated the previous RN may have placed the order on hold when the facility was out of the medication.

On 12/7/21, a signed physician summary instructed the facility to hold fluoxetine.

Review of  Resident 9's 12/01/21 through 12/12/21 MAR revealed the medication had been administered daily, not held as ordered.

The need to ensure written, signed physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 12 (RN Consultant) and Staff 13 (RN). They acknowledged the findings.  

1) Monday through Friday Clinical Meetings: Daily review of 24 hour report and review of new and exsisting Physician orders.

Resident 9 received doctor order for medication. MAR audit of this resident to ensure Physician orders are being followed.

Daily MAR/TAR audits. Review admission MAR and return from hospital orders to ensure Physician orders are being followed.

Ongoing education with Med Tech's.

2) Daily Clinical Meetings with ED, RN and RCC and utilization of white board and green book.

3) Daily

4) ED, RN, RCC

Based on interview and record review, it was determined the facility failed to ensure physician's orders were followed for 1 of 2 sampled residents (#12) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the facility in 2019 with diagnoses including diabetes.

a. Resident 12 had physician orders, dated 12/30/21, to administer Polytrim drops (an eye drop to treat bacterial infection of the eye) every four hours while awake for seven days.

Resident 12's 01/01/22 through 01/25/22 MAR revealed the eye drops were not administered until 01/12/22.

b. Resident 12 had physician orders, dated 01/10/22, to administer Polytrim drops (an eye drop to treat bacterial infection of the eye) four times a day for seven days.

Resident 12's 01/01/22 through 01/25/22 MAR revealed the eye drops were administered for nine days (received five extra doses) without clear documentation of why.

On 01/25/22, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 13 (RN/Health Services Director). They acknowledged the findings.

1)Daily Clinical meeting with review of whiteboard and green book: Including review of MAR/TAR audit, 24 hour report and communication, TSP's.  Physician orders and faxes upon admission, return from Physician appointments and hospital discharge orders using the Triple check system.

Twice a month Med Tech meetings with documented training.  

2)Through Daily Clinical meetings with review of above systems.

3)Daily through triple check system and daily audits.

4)ED/RN/RCC  

Based on interview and record review, it was determined the facility failed to notify the physician when 1 of 2 sampled residents (# 3) refused to consent to medication and treatment orders. Findings include, but are not limited to:

Resident 3's 8/1/21-8/23/21 MAR and 8/3/21 physician orders were reviewed. There was no documented evidence in the resident's facility record the physician was notified when Resident 3 refused to consent to the following medication and treatment orders:

* Darifenacin Hydrobromide ER (overactive bladder) on 8/1/21, 8/2/21, 8/3/21;

* Buprenorphine HCL-Naloxalone HCL (pain) on 8/19/21; and

* Hand therapy "carrot" (contractures left hand) on 8/5/21, 8/6/21, 8/8/21, 8/18/21, 8/22/21.

The need to notify the physician when residents refused to consent to medication and treatment orders was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

1) Education/counseling for staff who did not notify PCP per policy for resident sample.

2) Complete training on Resident Right to Refuse Policies and  with MTs. Review any refusal of meds with the regular MAR/TAR audit reviewed at daily clinical meeting.

3) MAR/TAR audits daily X 30 days then weekly

4. Executive Director

2. Resident 1 was admitted to the facility in August 2018 with a diagnosis of dementia.

Resident 1's August 1 through August 23, 2021 MAR was reviewed and identified the following PRN pain medications ordered:

* Acetaminophen oral PRN every six hours for mild to moderate pain "level 1-4 out of 10"; and

* Morphine Sulfate oral every two hours as needed for pain or shortness of breath.

Staff 4 (RCC) reported on 8/25/21 that Resident 1 was unable to verbalize  pain using the pain scale, but the resident would show facial grimacing and/or say "ouch" when in pain.

There were no clear instructions for which medication should be used first or in what order the remaining medications should be utilized for the resident's pain.

The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included parameters for the administration of PRN medications and had clear instructions to staff for the administration of all medications and treatments the facility was responsible to administer. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in July 2020 with diagnoses including vascular dementia.

Review of Resident 3's current physician orders and 8/1/21- 8/23/21 MARs revealed the following:

* PRN Trazadone 1 - 2 tablets for sleep lacked clear instructions regarding when the resident should be given one versus two tablets.

* Scheduled buprenophrine - naloxolone for pain indicated the facility was to "start with 1/2 tab three times a day, then go to one tablet three times a day if needed." There were no clear instructions on when the resident should be given half tab versus a full tab.

* Diclofenac sodium gel for pain lacked instructions where staff should apply the gel.

* Milk of Magnesia, glycerin suppository and enema prescribed for constipation, lacked parameters and clear instruction regarding when to administer the medication and in what sequence.

*Inaccurate documentation on the MAR of staff who administered diclofenac gel and triamcinalone cream.

The need to ensure MARs were accurate, included parameters and clear instructions for the administration of all medications and treatments the facility was responsible to administer and  the individual administering the medication initialed the MAR was discussed with  Staff 1 (ED) and Staff 2 (RN) on 8/25/21. They acknowledged the findings.

1) Residents 1, 2 & 3 medication parameter and instructions issues identified to be reviewed and fixed in the MAR in accordance with the C310 rule

2)Training with staff to get clarification orders by physician. Med Tech training on parameters and directions of specific resident orders.

Audit all MAR's identify orders and parameters with specific instructions.Triple check process implementation for new admit orders and all new physician orders. Implementation of non verbal pain scale tool for staff. LN will identify the need and document in PCC.

Pharmacy to complete cart audit, and continue quarterly pharmacy/medication review.

3) Will evaluate with each admission and quarterly for each resident.

4) RN or ED

Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed, included a thorough review by an RN, PT or OT prior to use, documented less restrictive alternatives prior to use, and provided instruction to caregivers on the correct use of and precautions for the device for 1 of 2 sampled residents (#1) who had side rails on their bed. Findings include, but are not limited to:

Resident 1 was admitted to the facility August 2018.

On 8/23/21 the resident's bed was observed to have two quarter length side rails in the up position.

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, nor was there evidence the service plan had identified the use of and precautions related to the device.

The lack of assessment and instructions provided for use of supportive devices with potentially restraining qualities was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/24/21. They acknowledged the findings.

1) Resident assessed and side rails removed if appropriate, assessment in PCC. Ensure risk vs benefit flyer reviewed with POA/resident per the OAR. Audit if enablers to be completed

2)Review Restraint/Supportive Device Policy & Procedure with staff and Educate staff on how to identify enablers for reporting and identifying enablers in the facility.

3) Enabler training included in new hire orientation and annually.

4) Executive Director

Based on interview and record review, it was determined the facility failed to meet requirements for Fire and Life Safety drills and instruction, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 8/24/21 identified the following deficiencies:

* There was no documented evidence that Fire and Life Safety instruction was provided to staff on alternating months; and

* Fire drill records kept by the facility lacked the following components:

    - evacuation times;

    - number of residents evacuated; and

    - staff who participated.

On 8/25/21 the need to ensure all requirements were met for Fire and Life Safety drills and instruction according to the OFC was discussed with Staff 1 (ED). She acknowledged the findings. No further information was provided.

Action taken to correct violation.

1) Fire Drills will be conducted and documented every other month at different times of the day, evening and night shifts. Documentation of Staff on duty, date and time of day, location of simulated fire, escape route, and number of occupants evacuated. Also, problems with residents who resisted or failed to participate in drill.

New employees and residents will be educated on the fire and evacuation plans and documented upon hire and move in for resident.

2. All information uploaded into TELS for tracking.

3. TELS evaluated monthly.

4. Maintenance Director.

Based on interview and record review, it was determined the facility failed to meet requirements for Fire and Life Safety instruction and documentation, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 8/24/21 identified the following deficiencies:

* There was no documented evidence that residents were instructed on fire safety procedures within 24 hours of admission; and

* Records showed no documented evidence that annual training on fire safety was provided to residents.

On 8/24/21 the need to meet requirements for Fire and Life Safety instruction and documentation, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings. No further information was provided.

Action taken to correct violation.

1) List of all current residents and their ability to evacuate listed in the fire book. Residents will be provided information on evacuation and fire plan within 24 hrs of admission. Staff will provide fire evacuation assistance to residents from building to point of safety.

Fire alarm system will be activated during every drill and documented.

2) Fire and Evacuation drills will be uploaded into the TELS system.

3) Monitored monthly.

4) Monitored by Maintenance Director and Executive Director.

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 Division. Findings include, but are not limited to:

Refer to C 303.

1) Daily review of white board and green book: including Review of 24 hour report, MAR/TAR audit, TSP's, Physician orders and faxes, Triple check system for faxes, Progress notes, incident reports and review of outside providers notes.

2) Utilization of white board and green book.

3) Daily, Monday through Friday

4)ED, RN, RCC

Based on interview and record review, it was determined the facility failed to ensure their survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:

Refer to C 303.

1) Be in compliance with POC using the systems implemented.

2)Training and daily audits to stay in compliance.

3) Daily in Clinical Meeting and med audits.

4)ED/RN/RCC

Based on interview and record review, it was determined the facility failed to maintain a safe outdoor area for resident use.  Findings include, but are not limited to:

On 8/23/21 at 1:10 pm, the exterior pathways surrounding the building were observed. Along extensive sections of the concrete walkways there were multiple areas with drop-offs approximately one to four inches high, from the concrete surfaces to the bark dust beds. This created a potential tripping hazard for residents using assistive devices.

On 8/23/21 the need to maintain a safe outdoor area for resident use was discussed with Staff 1 (ED).  She acknowledged the outdoor drop-offs presented a safety hazard for residents.  

Action taken to correct violation.

1) Concrete areas to be smoothed and accessible for residents safety. Sidewalk drop off areas filled in with rock or bark.

2) Monthly environmental inspections.

3)Monthly environment inspections.

4) Maintenance Director.

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

During a walk-through of the facility on 8/25/21 at 1:45 pm, multiple exit doors were found to have no alarm or system in place to alert staff when a resident exited the building.

On 8/25/21 the need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited was discussed with Staff 1 (ED). She acknowledged the findings.

Action taken to correct violation.

1) Exit alarms placed on doors for resident safety.

1a) Facility cell phone available for resident use 24 hrs daily.

2) Monthly battery checks for door alarms.

2a) Phone usage sign for residents in main hallway.

3) Monthly

3a) Daily

4) Maintenance Director

4a) Executive Director