The findings of the re-licensure survey, conducted 02/14/22 through 02/15/22, 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 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
MCCMemory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the first re-visit to the re-licensure survey of 02/15/22, conducted 05/26/22 through 05/27/22, 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 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
MCCMemory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the second revisit to the re-licensure survey of 02/15/22, conducted 07/20/22 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.
Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:
During the re-visit survey, conducted 05/26/22 through 05/27/22, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID 19 and made available to all facilities, were not being followed by the facility.
On multiple occasions throughout the survey, staff were observed in common areas without protective facemask's properly worn, as current regulations require. The infractions included failure to cover the wearer's mouth and nose.
On 05/26 and 05/27/22 the need for proper wearing of required protective facemask's by all staff was discussed with Staff 1 (Executive Director). She acknowledged the findings.
5/26 - 5/27/22 - Staff immediately re-educated and counseled on the importance of ongoing infection control and the proper usage of PPE.
6/10/22 In-service will be conducted with all staff to re-educate on proper use of PPE, and sanitizing, and to verify understanding.
RN will complete a competency check of all staff by 6/17/2022.
Executive Director, Assistant Executive Director, Health Services Director, Resident Care Coordinator, Environmental Services Director, Dining Services Director, and Manager on Duty will conduct daily walk throughs to ensure staff are complying with the proper usage of PPE and infection control for one month, and ongoing based on findings.
Executive Director will ensure compliance.
Prior education
Inservice was conducted with all staff on 5/25/22- Ongoing infection control and PPE usage.
Inservice was conducted with all staff on 4/25/22 - PPE, proper handwashing, and sanitizing.
Inservice was conducted with all staff on 3/10/22 - Ongoing infection control.
Inservice was conducted with all staff on 2/25/22 - PPE use, locations, COVID protocols, PPE required during outbreak N95 and Face shields. Hand washing and sanitizer. Encourage use of masks with all residents.
Inservice was conducted with all staff on 1/10/22 - Infection control, sanitizing, handwashing.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear instructions regarding the delivery of services and were updated quarterly for 3 of 6 sampled residents (#s 1, 3, and 4). Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 05/2013 with diagnoses including prostatic hypertrophy.
Observations and interviews with staff and the resident were conducted during survey. The current service plan dated 10/21/21, updated on 01/13/22, and temporary service plans from 11/14/21 through 02/14/22 were reviewed.
Resident 1 was observed to have a Foley catheter. The service plan did not provide instructions for staff on care and management of the Foley catheter and equipment.
The need to ensure service plans provided clear instruction was discussed with Staff 1 (Executive Director) on 02/15/22. She acknowledged the findings.
2. Resident 4 was admitted to the facility in 04/2021 with diagnoses including congestive heart failure.
Observations and interviews with staff and the resident were conducted during survey. The current service plan dated 10/24/21, updated on 01/18/22, and temporary service plans from 11/14/21 through 02/14/22 were reviewed.
The service plan was not reflective and did not provide clear instructions in the following areas:
* Edema;
* Oxygen administration; and
* Bi-pap machine.
The need to ensure service plans were reflective of the resident's current status and provided clear instructions was discussed with Staff 1 (Executive Director) on 02/15/22. She acknowledged the findings.
3. Resident 3 was admitted to the facility in 02/2019 with diagnoses including swelling of extremities.
The resident's most recent service plan, dated 09/26/21; quarterly evaluation, dated 12/22/21; change of condition evaluation, dated 01/10/22; and progress notes, dated 11/16/21 through 02/13/22, were reviewed. Staff and the resident were interviewed.
The resident's service plan was not reflective of his/her current status and care needs in the following areas:
* Chronic skin issues;
* Current wound;
* Edema;
* Intimate relationship;
* Compression socks; and
* Behavioral plan.
In addition, the facility failed to update the resident's service plan quarterly.
The need for service plans to be reflective and provide clear direction to staff, and to ensure service plans were updated quarterly, was discussed with Staff 1 (Executive Director) on 02/15/22. She acknowledged the findings.
Resident # 1, 3, 4: Service Plans were reviewed by 2/28/22 interim service plans placed per resident specific needs including but not limited to; management of Foley catheter and equipment, clear instructions on Oxygen administration and Bi-pap machines, Edema, current wounds, intimate relationship, compression socks and behavioral plan.
The facility will update all residents service plans quarterly and as needed to be reflective of resident's specific needs to provide clear direction to staff.
In-service was conducted on 2/25/2022 with health services and education was provided on the importance of updating service plans to be reflective of all residents' specific needs. Policy and procedure reviewed on updating service plans.
All remaining residents service plans will be reviewed by April 15, 2022, to assure they accurately reflect residents' specific needs.
Executive Director, Health Services Director, and Resident Care Coordinator will conduct weekly review of all residents' service plans for one month, then resume quarterly and as needed to maintain ongoing compliance. Executive Director will ensure compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 3 of 3 sampled residents (#s 2, 4, and 5) reviewed for the delegation of insulin injections by unlicensed staff. Findings include, but are not limited to:
Residents 2, 4, and 5 were identified as having insulin-dependent diabetes and were administered insulin injections by non-licensed staff. Resident 4 was also receiving sliding scale insulin.
On 02/14/22, the facility's RN delegation records were reviewed and revealed the following:
* The previous facility delegating RN left the position on 01/18/22; and
* There was no transfer of delegation documentation completed.
In an interview with Staff 2 (Vice President of Operations), she stated there was no RN currently responsible for the delegation process for the facility.
Due to the facility not having a delegating RN, there were no MT staff with current delegations in place to administer insulin injections in the facility.
Staff 1 (Executive Director) provided an immediate plan for ensuring delegations were completed, and until completed licensed nurses would be administering all ordered insulin injections.
On 02/14/22, the need to ensure RN delegation was completed and maintained as required by rule was discussed with Staff 1. She confirmed the findings.
2/14/2022 - Effective immediately, all med techs were removed from administering insulin until the Health Service Director delegated each individual med tech.
Insulin was administered by a licensed nurse until new Health Services Director was able to delegate all med techs.
All med techs have been delegated to administer insulin per the POC date of 2/21/2022.
2/21/2022 - Health Services Director completed current nursing assessment of the individual residents, including rationale based on the competency and frequency the med tech should be supervised and re-evaluated. Health Service Director will continue to assess per resident needs and OSBN rules.
Executive Director will ensure compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility-administered medications and orders for 1 of 6 sampled residents (#5) whose medication records were reviewed. Findings include, but are not limited to:
Resident 5 was admitted to the facility in July 2020 with diagnoses including diabetes and edema.
Review of the resident's 11/19/21 through 02/11/22 progress notes, physician communications, interim service plans, home health nursing visit notes, the 01/01/22 through 02/14/22 MARs, and interviews with staff showed the following:
* The resident was noted to have severe edema/swelling to both legs. The resident had blisters to the legs and intermittent drainage noted.
* Home health notes indicated the resident had dressings in place to both legs. The dressings were changed with each home health visit. The severity of the edema and drainage varied with each visit.
* Observations of the resident on 02/15/22 showed ace wraps were in place on the resident's lower legs.
* The resident's MARs/TARs did not reflect the leg wounds or resident-specific instructions for staff regarding replacement of the dressings if they became soiled or dislodged.
The need to ensure MARs/TARs had complete documentation and direction for staff regarding dressings and skin issues was discussed with Staff 1 (Executive Director) on 02/15/22. She acknowledged the findings.
Resident #5 MAR was updated on 2/15/2022 to reflect specific/current leg wounds and resident specific instructions for staff regarding replacement of the dressing if they become soiled or dislodged. In-service was conducted on 2/25/2022 with health services and education was provided regarding the importance of entering in outside provider notes into the progress notes, MAR, TAR with resident specific instructions, in addition to updating the service plan regarding resident specific instructions for care staff on what to watch for and who to report to should the dressing become soiled or dislodged.
Health Services Director and Resident Care Coordinator will conduct daily (5 days a weekly) review order transcription to check for accuracy for two weeks and then continue per facility policy.
All remaining residents MAR/TAR will be reviewed by April 14, 2022, to assure they accurately reflect residents' specific needs.
Executive Director will ensure compliance.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:
Observations of the facility on 02/14/22 and 02/15/22 showed the following areas in need of cleaning or repair:
* Multiple doors had scrapes or large black streaks;
* Multiple benches in the hallways, on both floors, had dark spots/stains of various sizes;
* The arms of Resident 5's wheelchair had large tears with exposed foam;
* Rooms 101, 127, and 130 had multiple dark stains on the carpet, of varying sizes; and
* Rooms 101 and 130 had strong odors of urine and/or feces;
The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) on 02/15/22. She acknowledged the findings.
ESD repaired and painted on all the large scrapes and black streaks on 2/14/2022.
ESD cleaned furniture with stains on all four hallways 2/15/2022.
ESD will conduct weekly walk through for one month, then bi-weekly and as needed to ensure all repairs are made and furniture is clean and free from stains.
Resident #101 and #130 carpets cleaned/sanitized on 1/15/2022.
Resident # 127 carpet cleaned/sanitized on 3/2/2022.
Resident #130 arm rest replaced on 3/2/2022
ESD to provide weekly cleaning/sanitizing of Resident #101, 127, 130 apartments until new flooring is placed with a completion date of 3/30/2022.
At staff in-service conducted on 2/25/2022, reviewed the importance of and process for staff to complete work orders for repairs and the cleaning and sanitizing of carpets and furniture so that all necessary repairs and maintenance happen as needed.
In addition to the system above for as needed repairs and maintenance, ESD is utilizing scheduling system to ensure all carpets are maintained bi-annually and as needed. Executive Director will ensure compliance
There are no detail notes for this visit.