The findings of the re-licensure survey, conducted 04/03/23 through 04/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 first revisit to the re-licensure survey of 04/06/23, conducted 09/11/23 through 09/12/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services which were rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 04/03/23 through 04/06/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

1. Licensee employed during the survey separated from employment and removed as the licensee of the facility.

2. Experienced Executive Director hired as new licensee of the facility.

3. Executive Director will implement state regulations and company policy through Quality Management and Performance Improvement (QMPI) program. This QMPI Program will guide the facility's performance improvement efforts into all care and service areas. It will address clinical care issues by following trends and data collected through the Resident Care Report and Quality Indicator Benchmarks. Resident quality of life will be addressed through customer satisfaction scores, comment cards as well as resident interviews. QMPI will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents. It will utilize the best available evidence through data collection to define and measure goals. Using teams and individuals at each level to analyze data, find root causes and provide systemic change to eliminate issues and source of concern. The QMPI system will help develop a monitoring system to sustain the facility's continuous performance improvement and customer and associate satisfaction.

4. The Executive Director will be required to upload the monthly QMPI reports and meeting minutes into a shared drive that is monitored for compliance by the Regional Director of Operations and company Management Team.

Based on observation and interview, it was determined the facility failed to ensure all required postings were displayed in a routinely accessible and conspicuous location to residents and visitors, and available for inspection. Findings include, but are not limited to:

A tour of the facility conducted on 04/03/23 identified the facility lacked the following required postings:

* The name of administrator or designee in charge, posted by shift; and

* The facility staffing plan.

The need to ensure required postings were in an accessible and conspicuous location was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1. The name of the Executive Director or designee in charge will be posted by shift along with the facility staffing plans.

2. The facility license will be posted where residents and visitors can see it at all times. The name of the Executive Director or designee in chart will be posted by shift or when ever the administrator is out of the facility. The staffing plan will be posted. The most recent survey will be placed in a binder and available. The Ombudsman Notification poster will be posted along with other notices relevant to the residents or visitors required by the state and federal law. The facility Executive Director will verify this is done.

3. This will be evaluated on a weekly basis for 3 months to ensure compliance.

4. The Executive Director will review for compliance.

Based on observation, interview, and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During interviews with sampled and un-sampled residents on 04/03/23 through 04/06/23, residents reported the following concerns had not been resolved:

* Meal service:

- "Food is too salty;"

- "Some days dessert is not provided;"

- "Hard to get refills on drinks;" and

- "Fresh fruit bowl is on the independent living side of the building and too far for many residents to get to."

* Resident Council Minutes included the following complaints:

- Lost laundry;

- Shower and laundry schedules were posted in resident rooms, but staff were not following them;

- Food was not served in a timely manner;

- Food didn't taste good;

- Food ran out for residents that came to the dining room after 05:30 pm and there was no salad by 12:30 pm;

- More diabetic choices needed;

- Poor selection of desserts and no fresh fruit; and

- Servers weren't visible and did not provide drink refills or return to take dessert orders.

The Resident Council Minutes did not address progress/solution related to the complaints from previous months.

* Observations in the dining room on 04/03/23 and 04/05/23 during the lunch meal revealed the following:

- One resident at a table of four did not receive lunch until the others were almost done eating. The surveyor inquired and was told the meal ticket had been lost;

- No offering of coffee or juice refills after meal served on 04/03/23;

- Residents at the table observed to need to ask for dessert to be served on 04/05/23; and

- Residents observed waiting for 30-45 minutes for meal service on both dates.

* Residents interviewed reported the process for reporting complaints was to talk to Staff 2 (Resident Care Director), who would report the concerns to Staff 1 (Executive Director). Residents reported they would wait and hope the concern was addressed, often times not hearing anything more about their concern from staff.

During an interview on 04/04/23, Staff 1 stated the facility had a processes for resident grievances, but did not have documentation of recent grievances reported by residents.

The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 and Staff 2 on 04/06/23. They acknowledged the findings.

1. All staff will complete the infection control training. RCC has been appointed and completed the Infection Control specialist training. Employees will follow the Infection control policy.

2. Employees will complete the infection control training during orientation to ensure complaince.  This will ensure timely completion of trainng and a safe, sanitary and comfortable environment.

3. Training documentation will be reviewed in the monthly QMPI meeting to ensure compliance.

4. The Executive Director will be responsible for ongoing compliance.  

Based on interview and record review, it was determined the facility failed to ensure resident evaluations, to include smoking evaluations when applicable, were performed at least quarterly, to correspond with quarterly service plan updates for 2 of 2 sampled residents (#s 1 and 5) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes and chronic obstructive pulmonary disease.

During the acuity interview it was reported that Resident 1 smoked independently on occasion.

Review of Resident 1's clinical records revealed a smoking evaluation was completed on 11/08/22. There was no documented evidence the quarterly smoking evaluation, due 01/08/23, was completed.

The need to ensure quarterly smoking evaluations were completed as required was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 09/2017 with diagnoses including macular degeneration and glaucoma.

The resident's most recent evaluation was dated 11/02/22.  There was no documented evidence the evaluation was completed quarterly.

The need to complete quarterly evaluations in a timely manner was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1. Pre-move in screening before move in. A move in evaluation will be completed within 72 hours of admission.  Each resident record will include the required Oregon demographic information. Resident 1-Quarterly Smoking evaluation has been completed. Resident 5- The quarterly evaluation has been done.

A)The resident evaluation will identify the residents preferences, strenghts and relationships as well as activities that are meaningful to the resident. Going forward the residents eval will include a 30 day review, the RN was educated on this practice. The facility administrator will assure only trained and experierienced staff perform resident evaluations.

2. We will have a delegated trained associate perform the evals as specified in the requirements listed. The resident evaluation will include all of the elements listed. Quarterly evaluations will be kept up to date and followed up on. We will ensure the significant change evals are completed in a timely manner and communication is done.  The qualified staff were eduated on the significant change critiera.  We are a non smoking facility and will not admit smokers going forward. There will be a quarterly smoking evaluation done on resident 1.

3. The evalautions and 30 day review will be montored in the QMPI process for 3 months.

4. The Executive Director will be responsible for ongoing compliance.  

3. Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes and chronic obstructive pulmonary disease.

Observations of Resident 1 during the survey, interviews with staff, and review of the clinical record, including the service plan dated 06/29/22, revealed the service plan was not reflective of the resident's needs and lacked clear instruction regarding the delivery of services in the following areas:

* Bed cane use;

* Transfer assistance;

* Use of wheelchair for mobility;

* Toileting assist;

* Instructions for cleaning and assistance for use of the Pur-Wik device at night;

* Pressure wounds to the right ankle and left heel;

* Pain; and

* Evacuation assist needed.

There was no documented evidence the resident's service plan had been updated quarterly.

The need to ensure service plans were reflective, provided clear instruction to staff, and were updated quarterly was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings, and no further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated quarterly, were reflective of residents' status, and provided clear direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2, and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2015 with diagnoses including Alzheimer's disease.

The resident's most recent service plan, dated 09/06/22, and quarterly evaluation, dated 02/09/23, were reviewed, and staff were interviewed. The service plan was not reflective in the following areas:

* Bathing;

* Escorts needed;

* Behaviors;

* Activities;

* History of urinary tract infections;

* Meal set-up assistance needed; and

* A recent fall.

There was no documented evidence the resident's service plan had been updated quarterly.

The need for service plans to be updated quarterly and be reflective of the resident's current status and care needs was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the resident's service plan had not been updated quarterly.

2. Resident 5 was admitted to the facility in 09/2017 with diagnoses including macular degeneration and glaucoma.

During an interview 04/04/23, Resident 5 reported s/he was "considered blind" and was unable to see to read or watch TV anymore. During the interview his/her lunch was delivered to the apartment. Staff set the meal on a table in front of the resident and left the room. After staff left, the resident took the cover off the meal, stated s/he couldn't see what it was, and asked the surveyor what had been served. When asked if staff usually oriented the resident to what was on their plate, s/he indicated "occasionally" they did, but "not usually."

A review of the resident's most recent service plan, dated 06/23/22, identified it had not been updated quarterly, and there was no information about the severity of the resident's vision loss or instructions to staff to orient the resident to what was on the plate at each meal.

The need to ensure the service plan was reflective of the resident's current status and care needs, provided clear direction to staff regarding the delivery of services, and was updated at least quarterly was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the service plan was not reflective of the resident's needs and had not been updated quarterly.

1. We have trained and delegated staff to complete the Person centered Service plan. The Service plan will reflect the residents needs. Resident 2- Service plan has been updated to reflect accurate information. Resident 5- Staff has been trained and understand  their role to assist with meal set up and orienation of her food. Information on residents vision has been added to her service plan. Quarterly evaluation will be done on time. Resident 1- Service plan has been updated to reflect residents needs.

2. Service plan completion will be reviewed for completion weekly during the care services meeting.

3. The service plan updates will be monitored monthly in the QMPI meeting.

4. The Executive Director will be responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1 and 2's most recent service plans lacked documentation 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 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1. The service plan meetings will be scheduled 30 days after admission and quarterly. They will include all parties involved in the residents care. The service plan for Resident # 2 was checked for correct needs and a care plan scheduled with the family to review.  

2. Care plans will be scheduled at 30 days, quarterly and significant change.  All parties involved will be invited to attend. The resident will be actively involved in the development of the service plan. There will be documentation if the resident chooses to not be involved.

3. This area will be evaluated every time an evaluation or significant change is completed to ensure that the service plan is developed by the service planning team and the resident.

4. The Executive Director will be responsible for ongoing compliance.

2. Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes and chronic obstructive pulmonary disease.

a. The resident's 06/29/22 service plan, temporary service plans, 01/24/23 through 04/03/23 progress notes, incident reports and physician communications were reviewed. The resident experienced multiple changes of condition without determination of what action or interventions were needed for the resident, resident-specific directions provided to staff, or progress documented at least weekly until resolution in the following areas:

* Fall with right humerus (arm) fracture;

* Orders and change of dosage orders for narcotic pain medication;

* Orders for bowel care medication for constipation;

* Wounds to the right ankle and left heel;

* Antibiotic for right ankle infection; and

* Change of antibiotic for right ankle infection (cellulitis).

b. The 03/28/23 progress notes indicated a left heel wound was identified while at a physician appointment and was determined to be an unstageable pressure ulcer. Staff 3 (RN) stated on 04/04/23 she had not been informed of the pressure ulcer.

The need to ensure changes of condition had documentation of what action or interventions were determined, that resident-specific directions were provided to staff, that there was documentation of progress at least weekly until resolution, and that significant changes of condition were referred to the facility RN was discussed with Staff 1 (Executive Director), Staff 2 (Resident Care Director), and Staff 3 on 04/04/23 and 04/06/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, that significant changes were referred to the facility RN, that interventions were determined, documented and communicated to staff on all shifts, and that changes were monitored, with progress documented at least weekly until resolution for 2 of 2 sampled residents (#s 1 and 2) who experienced changes in condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2015 with diagnoses including Alzheimer's disease.

The resident's clinical record was reviewed and the following changes of condition were identified:

* A fall on 02/08/23;

* Behaviors on 03/07/23 which resulted in a bruise on the resident's toe;

* An increase in quetiapine (an anti-psychotic medication); and

* A lump on the resident's right breast.

There was no documented evidence these changes of condition had been monitored through resolution.

The need for short-term changes of condition to be monitored through resolution, with progress documented at least weekly, was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the lack of monitoring to resolution.

1. Change of condition evaluations will be completed by a trained associate on time by the RN

Resident #1 and #2- change of condition evaluation ahs been completed. RN has been documenting weekly on both residents.

2. Trained staff will identify changes in residents physical, emotional and mental functioning. They will document and report the resident changes. RN will determine if further action is required. RN will document any changes that need made along with interventions. Short term changes of conditions will be monitored, documented and communicated with the staff. Progress will be documented weekly.

3. Weekly review will be done to ensure significant changes are completed and accurate in a timely manner during the Care Services meeting.  

4. The Executive Director will be responsible for ongoing compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced significant changes of condition were assessed by the RN and/or the assessments were completed in a timely manner and included findings, resident status, and interventions made as a result of the assessment, for 1 of 1 sampled resident (#1) who experienced significant changes in condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes and chronic obstructive pulmonary disease.

During the acuity interview on 04/03/23, Staff 6 (MT) reported that Resident 1 had  fallen in January 2023 and sustained a fractured arm. Staff 6 stated the resident also had an open sore on the right ankle.

Review of the 01/15/23 through 04/03/23 progress notes, service plan, temporary service plans, and incident reports revealed the following significant changes of condition:

a. On 1/31/23 Resident 1 had a fall and sustained a fracture to the right proximal humerus (upper arm), which resulted in decreased mobility, pain, and a need for increased assistance in transfers, dressing, grooming, hygiene, toileting, and wheelchair mobility.

During interviews on on 04/04/23 and 04/05/23 with Staff 6 and Staff 7 (CG) it was reported that prior to the resident's fall, s/he was independent with bed mobility, transfers, mobility using the wheelchair, toileting, dressing, grooming, and hygiene.  They stated that after the fall Resident 1 needed one person assist with ADLs and mobility.

There was no documented evidence an RN assessment had been completed after the significant change of condition or the service plan updated to reflect the increased level of assistance needed after the fall with injury.

Observations of Resident 1 during survey revealed s/he had since regained full range of motion in the right arm, no longer had right arm pain, and was more independent with ADLs, although continued to require assistance with transfers, toileting, and escort to and from the dining room.

b. On 03/23/23 the progress notes identified an open area to the resident's right lateral ankle, the size of a pea, which was observed to be red, warm to touch, and painful.

On 03/28/23 a progress note written after Resident 1 returned from a physician appointment indicated the wound to the right ankle was determined to be a stage two pressure ulcer and there was an unstageable pressure ulcer to the left heel.

Staff 3 (RN) stated on 04/04/23 she had not been informed of the pressure ulcers, therefore the RN assessment did not occur until 04/04/23, which did not include information on the resident's status.

On 04/06/23, the need to ensure an RN assessment was completed in a timely manner, and included documentation of findings made, resident status, and interventions when residents experienced significant changes in condition was discussed with Staff 1 (Executive Director), Staff 2 (Resident Care Director) and Staff 3 (RN). They acknowledged the findings.

1. Facility RN will be regularly scheduled on site and available for phone consultation. Resident 1- significant change evaluation has been completed by RN. Progress notes have been made, temporary service plan being followed, communication with staff. RN following at least weekly.

2. Facility RN will be available and regularly scheduled on site. RN will be available for phone consultation. Facility RN will complete signifiant change evaluations on time. Facility RN will participate in service planning team and review the service plan with in 48 hours.

3. RN Oversight schedule will be monitored weekly by the Executive Director.

4.The Executive Director will be responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (# 1), who had a Freestyle Libre 14 day sensor for continuous blood glucose monitoring. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes and was independent with insulin administration. Facility staff were changing Resident 1's Freestyle Libre 14 day sensor every 14 days. The device was affixed to the back of the resident's upper arm and provided continuous blood sugar monitoring.

Review of the current delegation records for Resident 1 on 04/04/23 revealed no documented evidence of delegation completed for facility staff responsible for removal and replacement of the Freestyle Libre sensor.

On 04/04/23, Staff 3 (RN) stated she was unaware the task required delegation and would complete the delegation process on the date of the next scheduled change of the Freestyle Libre device.

On 04/06/23, the need to ensure all staff who removed and administered any continuous blood sugar monitoring devices were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Executive Director).  She acknowledged the findings.

1. The RN has delegated resident #1's freestyle Libre and is currently working to delegate all med techs to use this device.

2. The delegation Binder is in place and training and education has been provided to all staff for all delegation needs. The Registered Nurse will assess the residents situation to determine whether or not delegation of a task of nursing care could be safely done. The RN will report unsafe practices to the Executive Director and/or the appropriate state agency(ies).

3. This will be monitored on a weekly basis during the Care Services Meeting to ensure accuracy and timely delegation is being done with staff.

4. The Executive Director will be responsible for continued compliance.  

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 1) who had medication refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes.

Resident 1's 01/24/23 through 04/03/23 progress notes, physician communications, and 03/01/23 through 04/03/23 MAR/TAR were reviewed. The resident's record showed multiple refusals of the following topical medications:

* Mupirocin External Ointment was to be applied to a sore on the resident's right foot three times a day. The MAR indicated the resident refused application of the ointment on 55 occasions between 03/01/23 and 03/31/23.

* Voltaren External Gel was to be applied to the resident's painful joints four times a day. The MAR indicated the resident refused application of the gel on 38 occasions between 03/01/23 through 03/31/23.

On 04/05/23 Staff 2 (Resident Care Director) reported there was no documented evidence the facility staff notified the physician each time the resident refused the topical medications. There was no evidence the facility had a system for notifying prescribers when a resident refused to consent to orders.

Both medications were ordered to be changed from scheduled to PRN on 03/31/23.

The need to ensure the facility notified the physician/practitioner of medication refusals as ordered was discussed with Staff 1 (Executive Director) and Staff 2 on 04/06/23. They acknowledged the findings.

1. The following actions were taken to correct the violation. Resident #1s physician has been contacted. Documentation has been done.

2. The staff were  education on proper documentation and notification of refused medications. The physician or responsible party will be contacted with each missed dose and proper documentation will be made at that time. The facility will notficy the physician of medication refusals on a daily basis.

3. This will be monitored weekly during the Care Services meeting.

4. The Executive Director will be responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed upon move-in, and at least quarterly thereafter, to assure their ability to self-administer medications for 1 of 1 sampled resident (# 1), reviewed for self administration of insulin. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes.

During the acuity interview on 04/03/23, it was identified that Resident 1 self-administered his/her own insulin daily.

The resident's 01/24/23 through 04/03/23 progress notes, evaluations, physician orders, and the 03/01/23 through 04/03/23 MARs were reviewed.

There was no documented evidence a self-administration evaluation had been completed for Resident 1. Staff 2 (Resident Care Director) confirmed there was no evaluation of the resident's ability to self-administer his/her insulin on move-in or quarterly thereafter.

The need to ensure residents who self-administered their medications were evaluated upon move-in and at least quarterly thereafter was discussed with Staff 1 (Executive Director) and Staff 2 on 04/06/23. No additional documentation was provided.

1. The self administer evaluation has been completed on all residents doing their own medication. Orders have been received for all residents who are self administering.

2. The self medication administration evaluation will be completed quarterly on all residents who self administer medications. Orders will be obtained for all residents self-administering.

3. The self administration process will be reviewed in the monthly QMPI meeting for 3 months and then quarterly.

4. The Executive Director will be responsible for continued compliance.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters, there were non-pharmacological interventions in place, and staff attempted non-drug interventions and documented they were ineffective prior to administering the medication for 1 of 1 sampled resident (# 2) who was prescribed PRN psychotropics. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 11/2015 with diagnoses including Alzheimer's disease. The resident's 03/01/23 through 04/03/23 MARs and signed physician orders were reviewed.

The resident was prescribed two PRN psychotropic medications:

* Haloperidol 1 mg, 0.5 mg every two hours as needed for nausea, vomiting, delirium, or increased agitation; and

* Lorazepam 0.5 mg every two hours as needed for anxiety, restlessness, or dyspnea.

There were no parameters on the MAR for either medication to indicate symptoms for which these medications would be administered, which medication to administer first, or non-pharmacological interventions to attempt prior to administration of either medication.

In an interview on 04/06/23, Staff 6 (MT) reported she was not aware non-drug interventions had to be attempted without success prior to administering a PRN psychotropic. She confirmed there were no parameters on the electronic version of the MAR and reported there was no one auditing MARs for accuracy.

The need to have resident-specific parameters and to document non-pharmacological interventions attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/07/23. They acknowledged the lack of parameters for the medications.

1. All residents with psychotropic medications were identified and orders checked for parameters for when to administer.  Supplemental behavior documetation was added to the eMar and POC to ensure non-pharmacologicial interventions are attempted prior to medication administration.  All care staff were educated on the new supplemental documentation.

2. All new psychotropic orders will include the supplemental behavior documetation.  The RN will verify this after the order is entered.

3. The RN will review the orders weekly for 3 months to ensure the process is being followed.  The RN will report on the progress at the monthly QMPI meeting.

4. The RN and the Executive Director will ensure compliance through the QMPI quarterly audit.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device, and failed to include the use of the supportive device in the resident's service plan for 1 of 1 sampled resident (# 3) who used a supportive device with restraining qualities. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 07/2020 with diagnoses including dementia. During the acuity interview on 04/03/23, Resident 3 was identified as having side rails on his/her bed.

There was no documented evidence an RN, PT, or OT had completed a thorough assessment, less restrictive alternatives had been evaluated, or use of the device had been added to the resident's service plan.

In an interview on 04/06/23, Staff 7 (CG) stated she had not received any instruction about the correct use of and precautions related to the use of Resident 3's side rails.

On 04/06/23 side rails were observed in the up position on both sides of the resident's bed. Upon examination, it was determined both side rails were loose and there was a gap between the mattress and the right side rail.

The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT, less restrictive alternatives were evaluated, staff were instructed on the use of and precautions related to the devices, and use of supportive devices were included on residents' service plans was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1. All residents with supportive devices were identified and evaluated for need by a Registered Nurse using an Bed Rail assessment, a progress note was added to support the need.

2. All residents with supportive devices will be evaluated on admission and quarterly by a Registered Nurse to ensure safety and continued need.

3. An audit of all residents with supportive devices will be completed monthly for 3 months by the RN.

4. The results of the audit will be reviewed in the monthly QMPI meeting.   

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 2, 3, 8, and 9) completed all required elements of pre-service orientation before beginning their job responsibilities and training in all required dementia topics prior to providing care to residents. Findings include, but are not limited to:

Staff training records were reviewed on 04/05/23.

1. There was no documented evidence Staff 2 (Resident Care Director), Staff 3 (RN), Staff 8 (MT), or Staff 9 (CG), hired 12/01/22, 02/14/23, 01/23/23, and 01/31/23, respectively, completed one or more of the following pre-service orientation topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention; and

* Fire safety and emergency procedures.

The need to ensure all new employees complete pre-service orientation before beginning their job duties was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

2. There was no documented evidence Staff 2, Staff 8, or Staff 9 completed one or more of the following dementia training topics prior to providing care to residents:

* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to behaviors; reducing the use of antipsychotics;

* Strategies for addressing social needs and engaging them in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and use of the person-centered approach.

The need to ensure all new staff complete required dementia training prior to providing care to residents was discussed with Staff 2 (Executive Director) and Staff 3 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1.An audit was completed for all direct care staff to identify training needs. Care staff were advised in writing of the required trainings and deadline for completion.

2. All new care associates education will be reviewed for completion prior to starting floor orientation. For current care staff, a monthly audit will be completed for 3 months to ensure compliance with education requirements.

3.  Associate education records will be reviewed quarterly as part of the QMPI process.

4. The Executive Director will review compliance in the monthly QMPI meeting.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 2, 8, and 9) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 04/05/23.

There was no documented evidence Staff 2 (Resident Care Director), Staff 8 (MT), or Staff 9 (CG) demonstrated satisfactory in one of more of the following required areas:

* 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 which require assessment, treatment, observation, and reporting;

* General food safety, serving, and sanitation;

* Other duties as applicable (med pass, treatments); and

* First aid/abdominal thrust.

The need for direct care staff to demonstrate satisfactory performance in assigned job duties within 30 days of hire was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1.All care associates will be given re-education using onboarding checklist.  

2. The RN or Executive Director will review the education documents of all new associates during the New Associate Care Plan review prior to the 30 day review.  

3. An audit of all new associate education documentation will be conducted in the first 30 days of the associates hire date to ensure compliance.

4. The Executive Director will review compliance in the monthly QMPI meeting.

Based on interview and record review, it was determined the facility failed to ensure long-term employees completed 12 hours of annual in-service training, including a minimum of six hours on dementia care, for 2 of 2 long-term staff (#s 6 and 7). Findings include, but are not limited to:

Staff training records were reviewed on 04/05/23.

There was no documented evidence Staff 6 (MT), hired 04/28/20, or Staff 7 (CG), hired 08/08/19, had completed a total of 12 hours of annual in-service training, which included a minimum of six hours related to dementia care.

The need to ensure long-term staff complete the required number of annual training hours, including dementia care, was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1.All care associates will be given re-education on the required annual trainings including the 6 hour dementia training requirement.

2. The ED or RCD or designee will review associates annual education documentation during the month of  their hire date to ensure compliance.   

3. The review of the associates annual education documetation will be an ongoing process with the associates annual evalaution, the ED will be responsible to ensure ongoing compliance.

4. The Executive Director will review education compliance in the monthly QMPI meeting.

Based on interview and record review, it was determined the facility failed to include all required elements on fire drill documentation, per the Oregon Fire Code (OFC), and failed to ensure all facility staff were trained and aware of the designated point of safety. Findings include, but are not limited to:

Fire and life safety records dated 10/21/22 through 03/30/23 were reviewed on 04/04/23. The following was identified:

Fire drill documentation did not include one or more of the following required elements:

* Location of simulated fire origin;

* Escape route used;

* Evacuation time period needed; and

* Evidence alternate routes were used during fire drills.

Multiple staff interviewed on 04/04/23 were unaware of the designated point of safety.

The need to follow all OFC requirements pertaining to fire drills and documentation was discussed with Staff 1 (Executive Director), Staff 2 (Resident Care Director), and Staff 4 (Maintenance Director) on 04/04/23 and 04/06/23. They acknowledged the findings. No additional information was provided.

1. Facility fire drill forms changed to incorporate OFC requirements.

2. Maintenance Director or designee will implement company established Safety Committee and QMPI programs.

3. Safety Committee meetings scheduled on a monthly basis. Compliance will be monitored through monthly QMPI program/meetings.

4. The Executive Director will be responsible for compliance.

Based on observation and interview, it was determined the facility failed to ensure outside surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the interior courtyard on 04/03/23 and the outside of the building on 04/05/23 revealed the following areas which could have presented tripping hazards:

* Multiple drop-offs along the pathways, from 1" to 8";

* Multiple areas of broken and/or uneven concrete; and

* Two door mats outside exit doors which did not lie flat on the ground.

The drop-offs areas, uneven concrete and door mats were shown to and discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 04/05/23. They acknowledged the need for smooth surfaces to prevent tripping hazards.

1. Maintenance Director obtained professional contractor to raise and level, or shave raised edges of concrete pathways of interior courtyard. Door mats outside the exit doors were repaired or replaced.

2. Maintenance Director or designee will monitor safety of facility grounds as part of the QMPI and Safety Committee program.

3. Facility safety will be reviewed and monitored on a quarterly basis as part of the QMPI program.

4. Executive Director will monitor safety inspections and ensure compliance on a quarterly basis.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were clean and in good repair. Findings include, but are not limited to:

The facility was toured on 04/03/23, 04/04/23, and 04/05/23, and the following was identified:

* Carpeting throughout the facility had stains, patched areas which were discolored, and areas which did not lay flat;

* Doors, door jambs, and wall corners throughout the facility were scratched, scraped, and/or gouged;

* The half-wall next to the scale was unstable and the top had exposed, splintered wood;

* Multiple ceiling tiles were stained and/or had holes;

* The front panel of the PTAC (heating and air conditioning) unit in the movie room was open and unable to stay closed;

* There was debris on the vinyl flooring in the movie room;

* A projection screen was leaned against the kitchenette counter in the movie room, which created an accident hazard;

* There was a hole in the wall near Room 114 which went clear through to the adjacent area;

* The wall next to the door jamb on the lower left corner of Room 114 was missing wallpaper and a white substance had been layered over the area; and

* A wall in the laundry room had an area covered with spackle, and two walls in the laundry area had places where something had been removed from the wall and the area had not been painted to match the rest of the wall.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 04/05/23 and discussed with Staff 1 and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings.

1. Maintenance Director or designee will have the hallway carpets professionally cleaned and will repair the carpet where needed. Scraped doors, door jams, wall corners will be repaired. The half-wall repaired and secured. Stained/damaged ceiling tiles will be replaced. The front panel of the PTAC unit in the movie room will be repaired or replaced if necessary.Debris from the movie room floor will be removed. The projection screen in the movie room will be stored in a way as to not cause a safety hazard. The hole in the wall adjacent to room 114 will be repaired. The wall missing wallpaper with a white substance near room 114 will be repaired. The walls in the laundry room will be repaired.

2. Maintenance Director or designee will monitor appearance of facility grounds as part of the QMPI and Safety Committee program.

3. Facility appearance will be reviewed and monitored on a quarterly basis as part of the QMPI program.

4. Executive Director will monitor safety inspections and ensure compliance on a quarterly basis.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit (F). Findings include, but are not limited to:

* On 04/04/23, the surveyor recorded water temperatures of 106.2 degrees F in the kitchen and 106.3 degrees F in the bathroom of Room 129.

* On 04/05/23, the surveyor and Staff 4 (Maintenance Director) observed the following water temperatures:

- Room 111:  Kitchen 116.1 degrees F; bathroom 116 degrees F;

- Room 118:  Kitchen 102.6 degrees F; bathroom 112.5 degrees F;

- Room 127:  Kitchen 123.3 degrees F; bathroom 124.3 degrees F; and

- Room 130:  Kitchen 117 degrees F; bathroom 111 degrees F.

During the temperature observations, Staff 4 reported he was aware of the water temperatures in Room 129 and had been working to regulate the temperatures for the past few days. Staff 4 indicated he was unaware of the fluctuations in temperatures in other rooms.

The need to keep water temperatures in the range of 110 degrees F to 120 degrees F was discussed with Staff 4 (Maintenance Director) on 04/05/23 and Staff 1 (Executive Director) and Staff 2 (Resident Care Director) on 04/06/23. They acknowledged the findings and the need to correct water temperatures outside of the required range as quickly as possible.

1. Maintenance Director will have the plumbing system affecting water temperature evaluated and repaired by a professional plumbing service.

2. Maintenance Director or designee will monitor water temperatures as part of the QMPI and Safety Committee program.

3. Facility safety will be reviewed and monitored on a quarterly basis as part of the QMPI program.

4. Executive Director will monitor safety inspections and ensure compliance on a quarterly basis.

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 04/03/23, it was identified that exit doors to the interior courtyard did not have alarms or other acceptable system which alerted staff when residents exited the building.

The need for exit doors to have a system in place to notify staff when residents exited the building into the interior courtyard was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 04/05/23, and Staff 1 and Staff 2 (Resident Care Director) on 04/06/23.

1. Maintenance Director or designee will install door sensors on the exit doors to the interior courtyard that will integrate with the existing call system.

2. Maintenance Director or designee will monitor safety of facility grounds as part of the QMPI and Safety Committee program.

3. Facility safety will be reviewed and monitored on a quarterly basis as part of the QMPI program.

4. Executive Director will monitor safety inspections and ensure compliance on a quarterly basis.