The findings of the re-licensure survey, conducted 10/02/23 through 10/04/23, 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

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

During the survey, conducted 10/02/23 through 10/04/23, administrative oversight to ensure adequate resident care and quality of services rendered in the facility were found to be ineffective based on the number of citations.

Refer to deficiencies in report.

1. Facility administrator to complete retraining of Administrator duties, oversight, and responsibilities with company Operations Specialist or other designated representative.

2. Ongoing oversight and review from company operations specialist or other designated representative.

3. Weekly meetings to be held with the Administrator and operations team to review for compliance and understanding.

4. Facility Administrator and designated company operational support.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, for 1 of 1 sampled resident (#1) whose evaluation was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2023.
 

The initial evaluation failed to address the following required elements with sufficient information to develop an initial service plan:

* Personality: including how the person copes with change or challenging situations;

* Pain;

* Treatments;

* Fall risk or history;

* Emergency evacuation ability;

* Recent losses; and

* Elopement risk or history.

On 10/04/23, the need to ensure the initial evaluation addressed all required elements prior to the resident's admission was reviewed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

1. Resident #1's personality including how they cope with change, pain, treatments, fall risk/history, emergency evacuation ability, recent losses and elopement risk or history will be updated.

2. All components of move-in evaluations will be completed accurately and will reflect resident prior to moving in. Move-in evaluations to be completed by RN, ED, and/or RCC. RN, ED, and RCC to review move-in evaluation together to ensure all components of move-in evaluations are completed. Team to decide together whether resident is appropriate for community's setting based on move-in evaluation. Move in checklist will be completed with each evaluation to ensure completion.

3. Evaluations will be kept up to date quarterly and as needed. RN, ED, and RCC will be responsible to ensure that all components of move-in evaluations are completed efficiently and accurately.

4. ED will be responsible for ensuring this is complete.

Based on observation and interview, it was determined the facility failed to have a system which made service plans readily available to floor staff, to provide direction regarding provision of care, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose records were reviewed. Findings include, but are not limited to:

During interviews with staff, it was determined the current service plans for Residents 3, 4, 5 and 6 were kept in a locked medication room, which was not readily accessible to floor staff.

On 10/04/23, the need for a system which made current service plans readily available to floor staff was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.

1. Residents # 3, 4, 5, and 6 service plans were immediately made available to staff by moving them from the locked medication room to the break room, which is accessible by all staff.

2. After completing resident service plans RCC will place a printed copy in the service plan binder in the breakroom that is accessible to staff at all times for staff to review and awknowledge.

3. The ED and HSD will review the service plan binder monthly to ensure all service plans are present and current.

4. RCC and ED will be responsible for ensuring that all care plans are up to date and reflective of all needs. ED and RCC will be responsible for checking SPA dashboard daily and making changes to care plans as needed.

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 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 4 of 4 sampled residents (#s 3, 4, 5 and 6).  Findings include, but are not limited to:

Resident 3, 4, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 10/04/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.

1. Resident #3's current service plan will be reviewed by a service planning team and updated as needed.

Resident #4's current service plan will be reviewed by a service planning team and updated as needed.

Resident #5's current service plan will be reviewed by a service planning team and updated as needed.

Resident #6's current service olan will be reviewed by a service planning team and updated as needed.

2. The ED, RCC, HSD, and LSD will be trained on requirement of a team to participate in Service Planning. Training will be logged. A Servcie Planning Team will be assembled applicable to resident need and choice, and may include the ED or designee, the resident, the resident's legal representative, the RCC, at least 1 care staff, and anyone the resident requests to actively participate in the process. The PCP, Case Manager(s), and family/friends of the resident's choosing will be invited in advance. The HSD will participate if the resident is receiving nursing services or has a current COC. The Service Planning Team will review evals/re-evals and plan for care that addresses all the resident's needs, conditions, and preferences with clear instructions including who, what, where, when, why, how, and how often a service is to be proviced. All Service Planning Team members will sign the Service Plan and a copy will be placed in the Service Plan Binder where is is accessable to all care staff.

3. The ED and HSD will review the service plan binder monthly to ensure all service plans are present and current.

4. RCC and ED will be responsible for ensuring that all care plans are up to date and reflective of all needs. ED and RCC will be responsible for checking SPA dashboard daily and making changes to care plans as needed.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident, failed to evaluate significant changes of condition and communicate interventions to staff on each shift for 1 of 4 sampled residents (#6) who experienced changes of condition. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes.

Observations of the resident, interviews with staff, and review of the resident's most recent service plan, dated 07/20/23, weight records from 04/01/23 through 10/01/23, interim service plans (ISPs), incident investigations, physician communications and progress notes from 07/01/23 through 10/02/23 were completed.

a. The resident experienced the following short-term changes of condition:

* 09/27/23: unwitnessed fall and inability to bear weight;

* 09/27/23: increased weakness with resident found "hanging half off his bed" with "trouble sitting up on his own";

* 09/30/23: unwitnessed fall with injury to right elbow and bruising on right cheek;

* 09/30/23: unwitnessed fall; and

* 10/01/23: unwitnessed fall.

The facility failed to evaluate, determine interventions or actions needed and communicate to staff regarding Resident 6's changes of condition.

In a discussion with Staff 3 (Health Services Director) on 10/02/03, she stated that interventions and instructions to staff would be placed via an interim service plan to address the falls.

On 10/02/23, the need to evaluate falls, determine interventions and communicate those to staff was addressed with Staff 3. She acknowledged the findings.

b. Review of weight records revealed the following:

* 08/06/23 - 160.0 pounds;

* 09/10/23 - 151.0 pounds; and

* 10/03/23 - 151.0 pounds (weight obtained during the survey).

The resident lost 9 pounds, or 5.6% of his/her total body weight, in 30 days, which constituted a significant weight loss and significant change of condition. There was no documentation the facility evaluated the significant change of condition, documented the change, or updated the service plan.

The need for the facility to ensure residents who had a significant change of condition were evaluated and resident-specific instructions or interventions were developed and reviewed for effectiveness was discussed with Staff 2 (Regional Director of Operations), Staff 3 and Staff 5 (RCC) on 10/04/23. They acknowledged the findings, and no further information was provided.

1. Root Cause Analysis for Resident #6 completed for all falls, resident specific interventions added to care plan along with ISP's. A significant change of condition will be completed by HSD for Resident #6 for weight loss, falls, ER visits, increased confusion, weakness, increased ADL assistance, and admission to hospice. Resident #6 has is also placed on weekly High Risk Monitoring, resident will be closely monitored & care plan updated to be reflective of significant change.

2. ED, RCC, and HSD will participate in High Risk Meetings and review all residents to ensure that any residents with changes have a significant change of condition on file. HSD is taking the Role of the RN in Community Based Care Oregin Healthcare Association class 10/17/23-10/19/23. Resident Assistants and Med Techs will be trained to identify, document and notify HSD/RCC/ED of resident status changes. A short Term and Significant COC Checklist will be developed to facilitate all steps in the COC process. HSD to take monitoring COC course provided by Oregon Care Partners.  

3. HSD will be responsible for completing a significant change of condition assessment.

4. ED will be responsible for making sure that HSD is completing significant changes of conditions in a timely manner.

Based on interview and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition and documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (#6) who experienced significant changes. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes.

A review of the Resident's clinical record, including the current service plan, dated 07/20/23, progress notes 07/01/23 through 10/01/23, and weight records from 04/01/23 through 10/01/23 was completed, and staff were interviewed. The following was identified:

a. Review of weight records revealed the following:

* 08/06/23 - 160.0 pounds; and

* 09/10/23 - 151.0 pounds.

The resident lost 9 pounds, or 5.6% of his/her total body weight, in 30 days, which constituted a significant weight loss and required an RN assessment. At time of survey, 10/03/23, resident weighed 151.0 pounds.

There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN.

b. Progress notes from 09/23/23 through 09/27/23 indicated that the resident had multiple trips to the ER, increased confusion, increased weakness, increased need for ADL assistance, and falls.

Progress notes from 09/28/23 indicated the resident had been admitted to hospice.

Based on the resident's 7/20/23 service plan and interviews with staff, prior to the dates listed above the resident did not have confusion, was independent with all ADLs, did not have a history of falls, and ambulated independently.

The changes above constituted a significant change of condition and required an RN assessment.

During an interview on 10/04/23, Staff 3 (Health Services Director) stated the RN assessment had not yet been completed.

The need to ensure an RN assessed all significant changes of condition including findings, resident status, and interventions made as a result of the assessment within 48 hours was discussed with Staff 2 (Regional Director of Operations), Staff 3 and Staff 5 (RCC) on 10/04/23. They acknowledged the findings, and no additional documentation was provided.

1. A significant change of condition will be completed by HSD for Resident #6 for weight loss, falls, ER visits, increased confusion, weakness, increased ADL assistance, and admission to hospice. Resident #6 has is also placed on weekly High Risk Monitoring, resident will be closely monitored & care plan updated to be reflective of significant change.

2. HSD will be re-trained on significant changes of condition, including the responsibility for completing a significant change of condition assessment within 48 hours of the change. HSD will receive training from Nurse Consultants as well as taking Role of RN in Community Based Care Course 10/17/23-10/19/23. HSD also to take monitoring change of condition course provided by Oregon Care Partners.

3  HSD will be responsible for evaluating that all changes of condition were accurately identified and completed on a weekly basis during high risk meeting.

4. ED will be responsible for making sure that HSD is completing significant changes of conditions in a timely manner.

2. Observations made during the survey, 10/02/23 through 10/03/23, determined the facility failed to establish and maintain infection prevention and control protocols including protocols to prevent the development and transmission of communicable diseases:

* On 10/02/23, a caregiver was observed entering an unsampled resident's room, who was positive for Covid-19, without first donning full PPE including a disposable gown; and

* On 10/03/23, two caregivers were observed entering an unsampled resident's room, who was positive for Covid-19, without first donning full PPE including a disposable gown.

Upon interviews with staff, it was noted that the facility had run out of disposable gowns and caregivers had been told they should utilize trash bags to cover their clothing.

The need to establish and maintain infection prevention and control protocols, including protocols to prevent the development and transmission of communicable diseases, was discussed with Staff 2 (Regional Director of Operations), Staff 3 (Health Services Director) and Staff 5 (RCC) on 10/04/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols and have a designated "Infection Control Specialist." Findings include, but are not limited to:

1. In an interview on 10/02/23, Staff 1 (Executive Director) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols, qualified by education, training and experience or certification, and who had completed specialized training in infection prevention and control protocols.

On 10/04/23, the need to ensure the facility had a qualified "Infection Control Specialist" was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

1. HSD is the designated infection control specialist for community. HSD completed the required specialized training infection control specialist training for community based care on October 11, 2023. Adequate supply of PPE has been aquired. RCC will ensure all staff have completed and the pre-service infection prevention and control for community based care. HSD will provide education about handwashing and properly donning and doffing PPE in staff meeting and document this training.  

2. HSD/ED will aquire and maintain an adequate supply of PPE including disposable gowns utilitizing the OHA COVID-19 outbreak PPE calculator. Pre-service infection prevention training will be required before providing care.

3. HSD/ED will assess PPE supply monthly and daily during an outbreak and order any additional needed supplies to maintain and adequate supply. Community will also audit new employee training records monthly to ensure compliance.

4. HSD & ED will be responsible for ensuring adequate PPE supplies. ED, RCC & HSD are responsible for ensuring staff training is completed.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written and signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 3, 5 and 6) whose MARs and orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2020 with diagnoses including diabetes.

Resident 3's MARs, dated 09/01/23 through 09/30/23 and physician orders were reviewed and revealed the following:

Resident 3 had physician orders for staff to check the resident's blood sugars four times a day, and an order instructing staff to administer five units of Humalog insulin for blood glucose levels over 390. This was in addition to the scheduled insulin ordered.

There were five occasions between 09/14/23 and 09/30/23 when Resident 3's blood glucose levels were greater than 390 with no documented evidence that the additional five units of insulin was administered.

Staff 3 (Health Services Director) on 10/03/23 acknowledged the additional insulin was not documented as administered for the blood glucose levels greater than 390.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Regional Director of Operations) on 10/04/23 and Staff 3 and Staff 4 (RN Consultant) on 10/03/23. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 11/2018, with diagnoses including diabetes, hypertension, and congestive heart failure.

Review of Resident 5's MARs, dated 09/01/23 through 09/30/23, and signed physician orders dated 09/22/23, indicated the following:

Resident 5 had a physician's order for weekly weights. The MARs revealed the weight was not taken on 09/19/23, as ordered.

On 10/04/23, the need to ensure all treatment orders were carried out as prescribed was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.

2. Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes.  

The resident's physician orders and 09/01/23 through 10/01/23 MARs were reviewed.

a. There were no signed physician orders in Resident 6's chart for the following medications:

* Ondansetron 4 mg (for nausea);

* Nitroglycerin 0.4 mg (for chest pain);

* Loperamide 2 mg (for loose stools);

* Epinephrine 0.3 mg/0.3 ml (for anaphylaxis);

* Docusate sodium 100 mg (for constipation); and

* Tamsulosin 0.4 mg (for urinary retention).  

In an interview with Staff 3 (Health Services Director) on 10/04/23, she verified there were no signed orders in the resident's chart for the above medications.

b. On 09/30/23, hospice faxed signed orders to the facility with instructions for wound care for the resident's right arm, including "Change Telfa [sic] dressing and roll gauze 2 times weekly and PRN."

During an interview on 10/04/23, Staff 18 (MT) stated the treatment order was not transcribed to the MAR/TAR, and there was no documentation the facility was providing wound care as ordered.

The need to have signed physician orders in the resident's record and ensure all treatment orders were carried out as prescribed was discussed with Staff 2 (Regional Director of Operations), Staff 3 and Staff 5 (RCC) on 10/04/23. They acknowledged the findings.

1. Resident #3 HSD will address insulin order with provider and have order changed so additional prn insulin isn't accidentally omitted. Resident #5's weekly weights are unable to be obtained as resident went to ER October 6, 2023 and is now at a skilled nursing facility. Weekly weights will be implemented upon resident's return. Resident #6 updated physician orders including the medications listed were requested, signed and returned by provider. Resident #6's right arm skin tear is healed and therefore doesn't require any further treatment order transcription/wound care.

2. RCC/HSD will print, review and request physician orders every 90 days. System implemented for RCC to complete second order review and HSD to complete third review of any provider orders including treatment orders, ensuring that they are transcribed correctly in MAR and completed.  

3. RCC, and HSD will be responsible for ensuring that the quarterly physician orders process is being followed every 90 days. RCC and HSD will audit the return of the orders and follow up with providers as needed until all orders are returned signed by provider. RCC and HSD to complete second and third order checks daily.

4. HSD to monitor and ensure this process is completed.

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 2 of 3 sampled residents (#s 3 and 6) who had medication refusals. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2020 with diagnoses including diabetes and insomnia.

Resident 3's 07/04/23 through 10/02/23 progress notes, physician communications, and 09/01/23 through 09/30/23 MAR/TAR were reviewed.

The resident had an order for Trazodone 50 mg, one tablet every night for insomnia.  There were 13 occasions between 09/01/23 and 09/30/23 when the resident refused the medication. There was no documented evidence the facility notified the physician/practitioner of the medication refusals.

On 10/03/23 Staff 3 (Health Services Director) reported there was no documentation the facility staff notified the physician each time the resident refused the medication. There was no evidence the facility had a system for notifying prescribers when a resident refused to consent to orders.

The need to ensure the facility notified the physician/practitioner of medication refusals as ordered was discussed with Staff 2 (Regional Director of Operations) and Staff 3 on 10/03/23 and 10/04/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes.

On 10/01/23, the resident refused five medications including:

* Glipizide ER 10 mg (for diabetes);

* Docusate sodium 100 mg (for constipation);                                

* Jardiance 25 mg (for diabetes);

* Isosorbide mono ER 30 mg (for heart disease); and

* Preservision (for supplement).

During an interview on 10/03/21, Staff 14 (MT) stated when a resident refused medication, the facility contacted the physician or hospice. This could happen via phone call, fax, or in-person communication. They were unable to provide documentation that confirmed the physician or hospice was notified of the above refusals.

The need to notify the physician/practitioner when a resident refused to consent to orders was discussed with Staff 2 (Regional Director of Operations), Staff 3 (Health Services Director) and Staff 5 (RCC) on 10/04/23. They acknowledged the findings.

1. Resident #3's provider was notified of Trazodone refusal, order was discontinued by provider.  Resident #6 medications have been discontinued by provider.

2. Med Tech will notify prescriber each time when a resident refuses to consent to an order(s) via fax to provider. Med Tech training will be held and training will be documented.

3. HSD/RCC will audit the MAR exceptions report weekly for refusals and if provider was notified via fax.

4. ED and RCC will ensure this is completed.

2. Resident 5 was admitted to the facility in 11/2018, with diagnoses including diabetes, hypertension, and congestive heart failure.

Review of the resident's MAR, dated 09/01/23 through 09/30/23, identified the following:

The MAR lacked reasons for use for the following medications:

* Ferrous Sulfate 325 mg;

* Folic Acid 1mg; and

* Gabapentin 100 mg.

On 10/04/23, the need to ensure MARs were accurate and included reasons for use for all medications was discussed with Staff 2 (Regional Director of Operations) and Staff 5 (RCC). They acknowledged the findings.

3. Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia and Type 2 diabetes.

Resident 6's 09/01/23 through 10/01/23 MAR was reviewed and the following PRN medications lacked resident-specific parameters for administration:

* Acetaminophen 325 mg tablet, acetaminophen 650 mg suppository, hydromorphone 10 mg/ml liquid, and hydromorphone 2 mg tablet were prescribed to treat pain;

* Acetaminophen 325 mg tablet and acetaminophen 650 mg suppository were both prescribed to treat fever;

* Haloperidol 2 mg/ml and ondansetron 4 mg were both prescribed to treat nausea; and

* Hydromorphone 10 mg/ml liquid, hydromorphone 2 mg tablet, and lorazepam 0.5 mg were prescribed to treat dyspnea (difficulty breathing).

The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 2 (Regional Director of Operations), Staff 3 (Health Services Director) and Staff 5 (RCC) on 10/04/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications and treatments ordered by a legal prescriber and administered by the facility, and included reason for use, medication-specific instructions, and resident-specific parameters for PRN medications for 3 of 4 sampled residents (#s 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 05/2021 with diagnoses including chronic ischemic heart disease and diabetes.

Review of the resident's 09/01/23 through 09/30/23 MAR, 07/05/23 through 10/01/23 outside provider notes, and signed physician orders revealed the following:

* The resident had a physician order for Lidocaine 4% cream "for catheter related pain".  A hospice RN removed the resident's catheter on 07/02/23 and s/he refused to let the nurse put it back in; and

* The 09/01/23 through 09/30/23 MAR indicated the resident refused the Lidocaine on 25 occasions and staff administered the cream on five occasions.

In an interview on 10/04/23, Staff 14 (MT) stated she didn't think the Lidocaine had been administered at all in 09/2023 and thought the pain medication should have been discontinued when the resident's catheter was removed.

The need to ensure MARs were accurate was discussed with Staff 3 (Health Services Director) on 10/03/23 and with Staff 2 (Regional Director of Operations) on 10/04/23. No additional documentation was provided.

1. Resident #4's MAR has been reviewed by HSD for accuracy, PRN Lidocaine for catheter related pain was discontinued by provider on 10/7/23 as it was no longer indicated. Resident #5's reasons for use for medications listed have been added to MAR. Resident #6's PRN medications have been updated by HSD to include resident specific parameters and instructions.

2. HSD will be retrained re the need for clear order parameters and order instructions for Med Techs. HSD and RCC will be trained re use of reports in QMar to verify all PRNs have instructions. A training log will be used. The LN doing 3rd checks will be responsible for adding / ensuring resident specific instructions are present for all PRNs in QMar.

3. LN will monitor compliance in QMar daily x5, weekly x4, and monthly there after.

4. The HSD and ED are responsible for compliance.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications at least quarterly and obtain a physician or other legally recognized practitioner's written order of approval for self-administration of medications for 1 of 1 sampled resident (#2) who administered their own medication. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2021. Resident 2 was identified as administering his/her own medications during the acuity interview on 10/02/23. Review of Resident 2's record identified the following:

* An evaluation to determine Resident 2's ability to safely self-administer medications was completed on 08/16/21. There was not an updated evaluation for the resident to safely self-administer their medications.

* There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer their medications.

On 10/04/23, the need to ensure the facility obtained a physician order for residents who chose to self-administer their own medications and residents were evaluated at least quarterly for their ability to safely self-administer medications was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

1. Resident #2 will have a self medication evaluation completed by October 23, 2023.

2. HSD AND RCC will be retrained re the regulatory stipulations of Self Medication. A training log will be used. Residents who wish to administer their own medication(s) will be evaluated at a minimum of at move in and quarterly thereafter using a standard Frontier Self Medication Evaluation tool. HSD will direct the evaluation of each resident currently self administering medication using the tool. A PCP order will be obtained identifying which/all medications the resident is approved to self administer.The signed, dated self med evaluation will be attached to the resident's file and the PCP order for self medication will be added to the MAR so it is renewed every 90 days. If the resident is deemed not safe to self administer some/all of their medication, the resident, family, and PCP will be advised of the findings and the resident's medication will be provided by the community.

3. The ability to self administer medication will be reevaluated quarterly for residents who wish to do so, or as their condition changes in an effort to facilitate their independence and safe medication administration.

4. HSD and ED are responsible for compliance.  

Based on observation, interview, and record review, it was determined the facility failed to ensure the use of a supportive device with restraining qualities was thoroughly assessed by an RN, PT, or OT prior to use, instruct caregivers on the correct use of and precautions related to the supportive device, document use of the device in the resident's service plan, and/or evaluate the device on a quarterly basis for 1 of 1 sampled resident (# 5) who used a supportive device. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 05/2021 with diagnoses including chronic ischemic heart disease and diabetes.

During an interview with the resident on 10/03/23, the surveyor observed half side rails in the up position on both sides of the resident's bed. The rails were securely attached.

A review of the resident's current service plan, dated 07/10/23, indicated the resident had a "right-sided bed cane." The service plan did not have instructions to caregivers on the correct use of  the side rail and precautions related to the supportive device.

There was no documented evidence an assessment of the side rails was completed by an RN, PT, or OT.

The lack of an assessment of the resident's side rails was discussed with Staff 3 (Health Services Director) on 10/03/23 and with Staff 2 (Regional Director of Operations) on 10/04/23. No additional information was provided.

1. Resident #5's HSD completed assessment of supportive device (right sided bed cane) with restraining qualities. Service plan including correct use  and precautions related to supportive device will be updated in service plan and evaluated quarterly. Resident #4 HSD completed assessment of supportive device (half bed rails) with restraining qualities. Service plan including correct use of precautions related to supportive device including correct use will be updated in service plan and evaluated quarterly.

2. HSD, RCC & ED will be retrained re the regulatory stipulations for a resident to have a supportive device, including RN assessment tool and physician order. Supportive Devices currently in place will be identified through a room by room check and safe use of the device will be assessed via the Postural Support Device with Restraining Qualities Assessment and re-assessed Quarterly there after. Approved devices will be added to the Service Plan including use instructions for staff and re-assessed no less than quarterly and with a change of condition. Devices found to be un-safe will be removed and the HSD will work with the resident, RP, and PCP to identfy a safe device that meets the resident needs. The PreMoveIn Eval will be used to identify supportive devices so they can be assessed at move in, added to Service Plan, and staff trained in their use.

3. ED & HSD will designate a staff member to walk the community monthly looking for supportive devices to report to the HSD. Completion of this task will be documented in a log. The records of Resident(s) identified as having a Supportive Device will be reviewed by the HSD to ensure that a current Postural Support Device with Restraining Qualities Assessment is on file and the service plan includeds the device and instructions for use.

4. RCC, HSD, and ED are responsible for compliance.   

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 21 and 22) demonstrated competency of skills in all assigned job duties within 30 days of hire and 1 of 3 newly hired staff (# 22) was trained in first aid and abdominal thrust. Findings include, but are not limited to:

Training records were reviewed on 10/04/23 and revealed the following:

a. Staff 21 (CG), hired on 07/20/23, lacked documented evidence of competency within 30 days of hire in the following required topics:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation, and reporting changes of condition;

* Conditions that require assessment, treatment, observation, and reporting; and

* General food safety, serving, and sanitation.

b. Staff 22 (CG), hired 07/13/23, lacked documented evidence of competency within 30 days of hire in the following required topics:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting changes of condition;

* Conditions that require assessment, treatment, observation, and reporting; and

* General food safety, serving, and sanitation.

Additionally, there was no documented evidence Staff 22 had completed first aid and abdominal thrust training within 30 days of hire.

On 10/04/23, the need to ensure staff had documented evidence of competency demonstration within 30 days of hire and completion of first aid and abdominal thrust training, was discussed with Staff 2 (Regional Director of Operations), She acknowledged the findings.

1. Staff #21 required trainings will be completed. Staff #22 required trainings will be completed including first aid and abdominal thrust training.

2. All employee files were pulled for training records, this audit was conducted by Office Manager and ED.

A new hire checklist will be implemented that incudes preservice training and training that must be completed within the first 30 days of employment. A job specific competency checklist which identifies competencies that must be completed preservice and those that must be completed within 30 days will be maintained in the RCC office until completed. The job specific skills check list will include the dates of skills checked as competent, signed by the trainer and trainee. The Scheduling Coordinator/designee will not schedule the new employee until the pre-service skills checklist is completed. Scheduling Coordinator/designee will not schedule the new employee beyond day 30 unless the required items identified on the job specific skills checklist have been completed. When the pre-service items and the items required within 30 days have been completed, the checklist will be added to the employee file in the Business Office.

3-4.Training record audits will be conducted Quarterly by office manager. ED will be responsible for ensuring that this audit is conducted quarterly. Moving forward all new employees must complete all training requirements prior to starting person centered care. ED, Office Manager, and RCC will be responsible for ensuring all training requirements are completed prior to starting hands-on training.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 17, 18, and 20) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 10/04/23.

There was no documented evidence Staff 17 (MT), hired 08/17/22, Staff 18 (MT,) hired 09/14/22, and Staff 20 (CG/MT), hired 06/16/22, had completed a minimum of 12 hours of annual in-service training, basesd on hire dates,  related to the provision of care, at least six of which needed to relate to dementia care.

On 10/04/23, the need to ensure all required in-service training hours were completed annually was reviewed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

1. Staff #17, staff #18, and staff #20 will completed a minimum of 12 hours of annual in service training related to the provision of care with at least six relate to dementia care.

2. Office manager and ED will audited all employee files for required education. Identified needed training will be completed for staff identified and documented in their employee records.

3-4.Training record audits will be conducted quarterly by the Office Manager. ED will be responsible for ensuring that this audit is conducted quarterly.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills were being conducted every other month, all required components of fire drills were documented, and fire and life safety instruction was provided on alternate months to staff. Findings include, but are not limited to:

1. On 10/04/23, fire drill records were reviewed from April 2023 through October 2023 with Staff 2 (Regional Director of Operations). Fire drill records revealed the facility failed to conduct fire drills every other month and failed to document the following required components:

* Date and time of fire drill;

* Location of simulated fire origin;

* Escape route used;

* Problems encountered;

* Evacuation time-period needed;

* Staff members on duty and participating; and

* Number of occupants evacuated.

2. The facility failed to provide documented evidence fire and life safety instruction was being provided to staff on alternating months from fire drills.

On 10/04/23, the need to ensure documentation that fire drills were being conducted every other month, all required components of fire drills were documented, and fire and life safety instruction was provided on alternate months to staff was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

1) Environmental Services Director will perform and document fire, life & safety training with staff on alternate months.

2) Improve fire drill and life safety training documentation. Environmental Services Director Provide written documentation regarding escape route, evacuation time, number of occupants and alternate escape routes used.

3) The fire drill and training completion will be reviewed on a monthly basis.

4)Executive Director and Environmental Services Director are responsible for making sure fire drills and training are complete.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures annually. Findings include, but are not limited to:

On 10/04/23, facility fire and life safety records were reviewed and lacked documented evidence the following required elements were completed:

* A written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

On 10/04/23, the need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

1) Residents will be re-instructed annually on fire and life safety procedures. Facility to hold an all-resident training for immediate compliance

2) Environmental Services Director will conduct and document annual review.

3) Environmental Services Director to meet with new admissions to instruct and educate on fire and life safety procedures within 24 hours of move-in.

4) The Executive Director will be responsible for ensuring annual re-training is completed by checking and reviewing documentation monthly.

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

The exterior of the facility was toured on 10/02/23 and 10/03/23. The following deficiencies were identified:

* Exterior pathways around the perimeter of the building contained drop-offs up to two inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents; and

* The exterior of the facility had an excess of cobwebs throughout.  

On 10/03/23, the building's exterior was toured with Staff 1 (ED). She acknowledged the findings.

1) Landscaping contractor to address facility pathway edges that have drops off of 2 inches or greater. Environmental Services Director to schedule a building washe to address excess of cobwebs/debris. Environmental Services Director and Executive Director will confirm that the contractor solutions are effective.

2) Environmental Services Director to complete weekly exterior audit of the community and to report any changes to Executive Director.

3) Environmental Services Director to evaluate and verify no signs of deterioration on pathway edges monthly.

4) Environmental Services Director and Executive Director to fulfill ongoing monitoring of pathway edges and cleanliness of exterior monthly.

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

Observations of the facility on 10/02/23 and 10/04/23 identified the following areas in need of cleaning and repair:

* Multiple areas of the carpet in the dining room and corridors throughout the facility had stains and black spots;

* Vinyl flooring in laundry rooms had cracks and/or tears;

* Multiple dining room chairs had stains;
* Multiple dining room tables had exposed wood; and
* Handrails near the front desk were worn, with exposed wood.

On 10/03/23, the areas in need of cleaning and repair were reviewed with Staff 1 (ED). She acknowledged the findings.

1) Community to finalize vendor quotes to address carpeting, cracked vinyl flooring, dining room tables and chairs, and replacement of worn handrails.

2) Weekly audits to be completed by environmental Services Director to ensure all areas of community are cleanable and in good repair. Weekly schedule developed with Environmental Services Director and Executive Director to address;

3) To be monitored weekly with review meeting between Environmental Services Director and Executive Director to track progress on repairs and also ensure preventative maintence is in place to maintain clean and good repair of the facility.

4) Responsible party is the Evironmental Services Director. Executive Director will meet weekly to review progress of ongoing maintenance program.

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

During the survey, the exit doors from the ALF to the exterior of the building failed to have a working alarm or other acceptable system to alert staff when residents left the building.

On 10/04/23, the lack of alarms on exit doors was discussed with Staff 2 (Regional Director of Operations). She acknowledged the findings.

1) Alarms to be affixed to exit doors to audibly notify of exit door being opened for immediate compliance.

2) Environmental Services Director to contact current call system provider to activate and/or seek services to place alarm sensors to doors that exit the dining room and main hallway exit doors.

3) Weekly checks to confirm alarm system is operative for exit doors to be completed by Environmental Services Director.

4)Environmental Services Director is responsible for monitoring the alert pager/call system and Executive Director to verify implementation is effective.