The findings of the re-licensure survey conducted 8/9/21 through 8/11/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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

A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first revisit, to the re-licensure survey of 08/11/21, conducted 11/29/21 through 12/01/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 re-visit to the re-licensure survey of 08/11/21, conducted 02/28/22 through 03/01/22, 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 57 for Memory Care Communities.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:  activities of daily living

bid: twice a day

CBG: capillary blood glucose or blood sugar

CG: caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH: Home Health

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR: Medication Administration Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:Resident Care Coordinator

RN:Registered Nurse

TAR:Treatment Administration Record

tid:three times a day

The findings of the third re-visit to the re-licensure survey of 12/01/21, conducted 07/15/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

During the relicensure survey, conducted 8/9/21 through 8/11/21, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

1. A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following areas:

OAR 411-054-0045 RN Delegation and Training

The facility put an immediate plan of correction in place during the survey and the situation was abated.   

2. Refer to deficiencies in the report.

1.Deficiencies in report have been reviewed and plan of correction will be put in place

2.POC will be reviewed and areas will be over seen to completion.

3.Will be monitor as stated in POC for each deficiencies

4.ED, RCC, and RN to monitor.

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

During the first revisit, to the relicensure survey of 08/11/21, conducted 11/29/21 through 12/01/21, administrative 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 the report.

Refer to C231, C252, C260,

C270, C282, C305, C310, CZ164

Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule-out abuse, failed to document all required areas of an investigation and report to the local SPD office if abuse or neglect could not be ruled out for 2 of 2 sampled residents (#s 2 and 3) with injuries of unknown cause and a fall. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 1/2021 with diagnoses including Alzheimer's. The resident's progress notes, Skin Monitoring: Comprehensive Certified Nursing Assistant Shower Review documentation and facility incident reports were reviewed. The following was identified:   

* On 3/9/21 staff documented adding the resident to alert charting for "having a cut on [his/her] finger."

* On 4/17/21 staff documented, "Res is on alert for a skin tear on [his/her] right hand on 4/16/21."

* On 6/3/21 staff documented bruising observed while giving Resident 3 a shower and circled the left torso area going from the front to the back of the resident's body.

* On 7/28/21 staff documented, "Res has bruises and marks appearing on [his/her] hands and arms. Res complains of pain."

There was no documented evidence the four occurrences had been investigated or reported to the local SPD or AAA office if abuse and/or neglect could not be ruled out.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out and if not, the injuries were reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

The surveyor requested Staff 1 to report the four occurrences to the local SPD office and obtained verification of the reports on 8/11/21.  

2. Resident 2 was admitted to the facility in 10/2019 with diagnoses including dementia and anxiety disorder.

A review of the resident's progress notes, dated 5/1/21 through 8/6/21, revealed the following:

* On 6/19/21 the resident was found on the floor in his/her room;

* On 6/26/21 Resident 2 had redness around his/her belly button;

* On 7/21/21  the resident's right foot was swollen and bruised; and

* On 7/24/21 Resident 2 had a small cut on his/her left pointer finger.

There was no documented evidence these incidents had been investigated or reported to the local SPD or AAA office if abuse and/or neglect could not be ruled out.

The need to investigate all incidents within 24 hours, including falls and injuries of unknown cause, and to report incidents if abuse and/or neglect could not reasonably be ruled out was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

The surveyor requested Staff 1 immediately report these incidents to the local SPD office during survey. Confirmation was received from Staff 1 prior to survey exit.

1. Falls and injury of unknown injury sent to APS as requested.

2. Abuse Reporting and Investigation Training for all employees to be completed by a trainer or "Elder abuse Prevention, Investigation and Reporting" provided by Oregon Care Partners on their website oregoncarepartners.com. The licensee shall ensure all employees, including but not limited to, direct care staff, med techs, Administrator, housekeeping, kitchen staff, maintenance, etc., to be trained on requirements of reporting abuse or suspected abuse to APS.

3.This will be monitored upon new hire and past staff to redo Abuse Reporting and Investigation Training

4. ED, RCC, and/or RN to complete

Based on interview and record review, it was determined the facility failed to ensure all incidents and injuries of unknown cause were investigated promptly and reported to the local SPD office if abuse was not ruled out for 1 of 2 sampled resident (# 2) who experienced injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2019 with diagnoses including dementia.

Review of the resident's 10/10/21 through 11/29/21 clinical record revealed there was no documented evidence the following injuries of unknown cause were investigated to rule out abuse or reported to the local SPD or AAA office as injuries of unknown cause when abuse was unable to be reasonably ruled out:

*10/21/21: "Skin tear on L (left) arm"; and

*11/07/21: "Bruise on L (left) arm".

The need to investigate all incidents and injuries of unknown cause within 24 hours and to report to the local SPD or AAA if abuse was not reasonably ruled out was discussed with Staff 1 (ED) and Staff 22 (RN) on 12/01/21. They acknowledged the findings.

The surveyor requested Staff 1 immediately report these incidents to the local SPD office during survey. Confirmation was received from Staff 1 prior to survey exit.

1.)Resident #2 investigation complete; SPD office was notified during survey.

2.) Educate DNS and RCM on importance of completing investigations within 24 hours of incident to rule out abuse/neglect.

   Educate staff on correctly completing incident reports and when to contact Admin/DNS

   Audit incident reports qam (M-F) in clinical meeting for injuries of unknown cause and follow up accordingly.

3.) Audits will be conducted M-F x 6weeks then reevaluated.

4.) Audits will be conducted by Administrator/DNS.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 8/9/21 at 2:00 pm, the facility's kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following:

* The perimeter of the floors and baseboards in the kitchen and dry food storage area;

* Underneath and behind the ice machine and dry storage shelves;

* Pipes and floor underneath the stove;

* Wall and pipes behind the three compartment-sink and dish machine; and

* Ceiling vents and the ventilation hood above the dish machine.

b. The following areas needed repair:

* Caulking in dish-machine area and around the three-compartment sink;

* Caulking around the back splash in food prep area;

* Broken plastic corner guard along wall of the kitchen office; and

* Chipped paint and wood on the kitchen doors and frames.

The areas that required cleaning and repair were observed and discussed with Staff 1 (ED), Staff 16 (Dietary Manager) and Staff 6 (Maintenance Director) on 8/10/21. They acknowledged the findings.

1.Deep Clean provided by Healthcare Services Group or designee will conduct a deep clean of Kitchen in following areas: The perimeter of the floors and baseboards in the kitchen and dry food storage area; Underneath and behind the ice machine and dry storage shelves; Pipes and floor underneath the stove; Wall and pipes behind the three compartment-sink and dish machine; and Ceiling vents and the ventilation hood above the dish machine. Areas needing repair will be done by Maintenance as follows Caulking in dish-machine area and around the three-compartment sink; Caulking around the back splash in the food prep area; Broken plastic corner guard along wall of the kitchen office; and Chipped paint and wood on the kitchen doors and frames. 2. HealthCare Services Group Lead Educated on proper kitchen sanitation. 3. Once completed ED and Maintenance will do monthly walk thorough of the Kitchen to look for cleanliness and repairs needed. any area will be completed as needed 4. Maintenance will oversee all is completed and report back to ED.

2. Resident 1 was admitted to the unit on 4/2020 with diagnoses including vascular dementia. An evaluation dated 8/5/21 was reviewed and was not reflective of the resident's current status in the following areas:

* Narcotic use;

* Food allergies;

* Refusals to accept care; and

* Escorts to activities and meals.

In the section pertaining to weight loss and gain, Resident 1 was identified as a "new move-in" and that the staff were "unable to determine specific parameters at this time."   Resident 1 was not a recent move in.  

The need to ensure evaluations were reflective of the resident's current status and used to develop the resident's service plan was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and quarterly evaluations were accurate and reflective of current care needs for 2 of 2 sampled residents (#s 1 and 4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 7/2021.

Resident 4's move-in evaluation was reviewed and the following required elements were not addressed:

* Interests, hobbies, social and leisure activities;

* Spiritual and cultural preferences and traditions;

* History of mental health treatment;

* Effective non-drug interventions for mental health issues;

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

* List of treatments, including type, frequency and level of assistance needed;

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors impacting the resident's behavior, including noise, lighting and room temperature.

The need to address all elements identified in the rule was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Resident 4's evaluation has been reviewed and updated as necessary Action taken to correct violation is to add missing elements to the move-in evaluation to include Interests, hobbies, social, leisure activities. Spiritual, cultural preferences & traditions. History of treatment; and Effective non-drug interventions. Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; Personality: including how the person copes with change or challenging situations fluid preferences List of treatments: type, frequency and level of assistance needed. Review of risk indicators including: Complex medication regimen; Recent losses; Unsuccessful prior placements; Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.

2.The system will be corrected by having the evaluation rewritten to add elements above that were missing and update current residents on upcoming quarterly assessment.

3. Area will be reevaluated with each move-in and with upcoming quarterly evaluation

4. ED and/or RN is responsible to make sure correction are completed and monitored.

2. Resident 2 was admitted to the facility in 10/2019 with diagnoses including dementia.

During an interview with Staff 3 (Resident Care Coordinator) on 11/30/21, she reported that a quarterly evaluation had not been completed for Resident 2 to correspond with the 09/20/21 service plan.

The need to ensure evaluations were completed quarterly to correspond with service plan updates was discussed with Staff 1 (ED) and Staff 3 on 12/01/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#6) and failed to ensure quarterly evaluations were completed for 1 of 1 sampled resident (#2). This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 10/2021 with diagnoses including dementia.

The move-in evaluation failed to address the following elements:

* Spiritual and cultural preferences;

* List of current diagnoses;

* List of medications and PRN use;

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

* Environmental factors that impact the resident's behavior including but not limited to noise, lighting, room temperature.

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (ED) and Staff  22 (RN) on 12/01/21. They acknowledged the findings.

1.) Resident #6 move in evaluation complete; Resident #2 quarterly evaluation completed.

2.) Audit will be conducted of  records to ensure that quarterly evaluations and move in evaluations are current.

    Create schedule of upcoming evaluations due to correlate with care conference schedule.

     Audit move in evals and scheduled quarterly evals

weekly x6 weeks then reevaluate process

3.) Audit will be conducted weekly x 6 weeks then reevaluate.

4.) Audits to be conducted by DNS/designee.

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

1. Resident 1 was admitted to the facility in 4/2020 with diagnoses including vascular dementia. The resident's current service plan and temporary service plans were reviewed and the following components were not followed or did not provide clear caregiving instruction:

* Inconsistent information relating to ability to use the call light;

* The resident preferred the door to his/her unit to be locked, it was observed as unlocked on several occasions;

* Behavior interventions were not consistently followed; and

* Direction for staff to "engage the resident in life skills based on his/her interests and abilities," did not identify interests or abilities for Resident 1.   

2. Resident 3 was admitted to the facility on 1/2021 with diagnoses including dementia with behavioral disturbances. The resident's current service plan and temporary service plans were reviewed and the following areas did not provide clear caregiving instruction:

* Interests, hobbies, social, leisure activities;

* History of treatment for behaviors;

* Effective non-drug interventions for behaviors;

* Pain;

* Skin conditions;

* Nutrition habits, fluid preferences and weight; and

* Fall interventions.

The need for service plans to be followed and provide clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC). They acknowledged the findings.

3. Resident 2 was admitted to the facility in 10/2019, with diagnoses including dementia with behavioral disturbance and anxiety disorder.

A review of the resident's current service plan identified he/she had a dementia blanket which could be clipped to his/her wheelchair. The service plan instructed staff to "make sure [Resident 2's] blanket stays with [him/her] at all times."

Per observations during the survey, the resident did not have the dementia blanket with them at any time. Interviews with staff on 8/10/21 and 8/11/21 revealed not all staff were aware Resident 2 had a dementia blanket.

The need for staff to follow service plans was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Residenet 1, 2, and 3 service plan were reviewed and updated as needed.

2.RCC and RN have been educated on person centered service plans via Relias. Service plans will be updated to give clear instructions to staff to care for residents that is person centered. This includes but not limited to change in condition short term, significant, and needs. this also to include but not limit smoking, monthly weights, catheter cleaning, home health/outside providers, leg pain, ER visits, and Behaviors.

3. Facility will perform weekly service plan audits time 5 weeks then as needed to oversee and ensure elements are being captured and added to service plan

4. ED and RCC responsible

2. Resident 2 was admitted to the facility in 10/2019 with a diagnosis of dementia.

Review of  Resident 2's 09/20/21 service plan, interviews with staff and an observation of the resident revealed the service plan was not reflective in the following areas:

* Lesions/scabs on skin;

* Placement of sticky tape on the floor;

* Confusion with utensils, including putting them in his/her brief;

* Need for assistance with eating; and

* Constipation.

Resident 2's 9/20/2021 service plan failed to identify the resident required assistance with meals. During an interview with Staff 7 (CG) on 11/30/21, she reported the resident does "better with finger foods", sometimes "plays with utensils and will put them in (his/her) brief".

Resident 2 was observed eating mashed potatoes with his/her hands on 11/30/21 during the lunch meal.  

The need to ensure service plans were reflective of the resident's care needs and followed was discussed with Staff 1 (ED) and Staff  22 (RN) on 12/01/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 2 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 10/2021.

Observations made during the survey, interviews with care staff and review of the resident's clinical record revealed s/he had recently returned from the emergency department after experiencing a fall with an injury to his/her left wrist. The resident required increased assistance with ADL's.

Resident 6's service plan, dated 11/10/21, was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Bathing, including schedule and the need for staff assistance due to immobilized left arm; and

* Meals, including the need for staff assistance with cutting up food.

The need to ensure service plans were reflective of resident's care needs and provided clear direction to staff was discussed with Staff 1(ED) and Staff 22 (RN) on 12/1/21. They acknowledged the findings.

1.) Resident #6 service plan was updated to reflect wrist injury, bathing schedule and need for assistance, and cutting up of meals while wrist injured.

    Resident #2 service plan was updated to reflect lesions/scabs; confusion with utensils, assistance with dining and constipation.

2.) Audit service plans to ensure accuracy; update as needed.

    Educate RCC on correct service plan maintenance to ensure service plan matches resident needs.

    Audit service plans to ensure accuracy and completeness.

3.) Audits will be conducted weekly X 6 weeks then process reevaluated for need of continued monitoring.

4.) Audits will be conducted by DNS or designee.

Based on interview and record review, it was determined the facility failed to ensure a service planning team consisting 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 who was going to provide services to the resident, was involved in creating service plans for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

During the survey, service plans for Residents 1, 2 and 3 were reviewed. There was no documented evidence of the involvement of a service planning team.

The need to include the resident or their representative, and anyone else they request, in the service planning process was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Residents 1, 2, and 3 where reviewed and service plan updated to reflect.

2.Correction of system is to have documented evidence of service planning team to include Service Planning Team that consists 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 is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service planning meeting.

3.Area will be monitored weekly for 5 weeks then monthly

4.RCC, RN, and/or ED be responsible     

2. Resident 1 was admitted to the facility 4/2020 with diagnoses including vascular dementia and diabetes. There was documented evidence of the following short term changes of condition that required monitoring:  

a. Progress notes, incident reports and the service plan were reviewed. Resident 1 had documentation of resident to resident altercations on 4/13/21, 5/24/21, 6/12/21, 6/22/21 and 7/14/21. Previous interventions were to keep the residents involved in the altercations away from each other. There was no documentation of new interventions tried or monitored for effectiveness. There was no documented evidence Resident 1 was monitored through resolution for the resident to resident altercations.

b. On 6/27/21 staff documented Resident 1 was having trouble urinating. On 6/29/21 staff documented, "resident UA (urine analysis) was positive (for a urinary tract infection)." On 7/1/21, staff noted they were waiting on antibiotics to treat the infection and on 7/3/21 staff verified the antibiotic was started. There was no documented evidence the infection had resolved.  

c. Resident 1's July 1 through August 9, 2021 MARs were reviewed and revealed the resident did not receive Metformin (for diabetes) on 7/30/21 and 8/6/21. The documentation reviewed also reflected Resident 1 did not get an insulin injection as ordered on 8/6/21. There was no documented evidence the facility monitored Resident 1 for side effects due to not receiving his/her diabetic medications.

3. Resident 3 was admitted to the facility on 1/2021 with diagnosis including Alzheimer's and dementia with behavioral disturbances. There was documented evidence of the following short term changes of condition that required monitoring:  

a. During the acuity interview on 8/9/21 at 12:47 pm, Staff 3 reported the resident had a rash at times. Progress notes, Skin Monitoring: Comprehensive CNA Shower Review documentation, July 1 through August 9, 2021 MARs and the service plan were reviewed and revealed four separate skin issues. There was no documented evidence the skin issues had been resolved.

b. Resident 3 had documentation of nine falls from 1/19/21 through 7/8/21, two of which the resident was sent to the ER for hitting his/her head. There was no documented evidence new fall interventions were implemented and monitored for effectiveness. There was no documentation of the resident being monitored through resolution after the falls or for the emergency room visits.

c. Staff documented on 3/5/21 and 6/18/21 that Resident 3 had vomited. There was no documented evidence of monitoring through resolution relating to those two events.

d. Progress notes dated 1/11/21 through 8/7/21 reflected documented evidence of 17 behavioral episodes that either involved other residents at the facility or staff. There was no documented evidence the facility implemented interventions for the resident's behaviors, monitored those interventions for effectiveness or monitored the resident through resolution relating to the behaviors.

The need to ensure short term changes of conditions were monitored through resolution, and if applicable, new interventions be implemented and monitored for effectiveness was discussed with Staff 1, Staff 2 (RN) and Staff 3. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement interventions, monitor interventions for effectiveness and monitor through resolution for short-term changes of condition for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2019 with diagnoses including dementia with behavioral disturbance and anxiety disorder.

A review of the resident's progress notes, dated 5/1/21 through 8/6/21, revealed the resident experienced the following changes of condition:

* 5/1/21 - a resident-to-resident altercation;

* 5/15/21 - a second resident-to-resident altercation;

* 5/20/21 - a third resident-to-resident altercation;

* 5/24/21 - a fourth resident-to-resident altercation;

* 6/19/21 - found on the floor in his/her room;

* 6/24/21 - a cut on his/her right middle toe;

* 6/26/21 - redness around the resident's belly button;

* 7/21/21 - right foot was swollen and bruised; and

* 7/24/21 - a small cut on his/her left pointer finger.

There was no documented evidence these changes were monitored through resolution.

The need to monitor changes of condition through resolution was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1. Resident 1, 2, and 3 service plan updated to reflect current condition include but not limited to falls, Res to Res, ER visits, skin issues, insulin refusal and urinating problems.

2. RN and RCC will be educated on proper monitoring of changes of condition, including interventions and monitoring through resolution. After the fact, RN and RCC will implement the monitoring information into the development of service plans. Education provided by Divisional Director of Clinical Operations.  

3. Service plans will be updated and communicated with staff to reflect change of condition this will updated 30 days, quarterly, as needed and after the condition is resolved for the changes.

4. RCC, RN, and service plan team to monitor.       

Based on interview and record review, it was determined the facility failed to ensure actions and interventions were developed for residents who experienced short-term changes of condition, interventions were monitored for effectiveness and changes were monitored through resolution for 2 of 2 sampled residents (#s 2 and 6) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2019 with diagnoses including dementia.

Review of Resident 2's 10/10/21 through 11/29/21 clinical record revealed the resident experienced short-term changes of condition related to skin, falls and behaviors.

* Review of Resident 2's 9/21/21 service plan and subsequent temporary service plans revealed an extensive behavior plan. During the time frame reviewed, the resident was involved in 14 resident-to-resident altercations. There was no documented evidence the facility consistently monitored the effectiveness of the existing behavioral interventions.

* Resident 2 experienced multiple short-term changes of condition related to skin and falls. There was no documented evidence the facility monitored the changes in the resident's condition at least weekly through resolution.

The need to ensure short-term changes of condition were monitored at least weekly through resolution and that interventions were monitored for effectiveness was discussed with Staff 1 (ED) and Staff 22 (RN) on 12/01/21. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 10/2021. The resident's clinical record and 11/29/21 service plan were reviewed and revealed the following:.

The resident experienced the following short-term changes in condition without documented monitoring of each condition at least weekly through resolution:

* 10/15/21-Small wound to the outside of right foot;

* 10/15/21-Small wound on the right small toe;

* 10/20/21-Rash of the perineal area; and

* 11/16/21-Skin tear on left hand.

In a 12/01/21 interview with Staff 22 (RN), he confirmed the facility lacked an effective system for monitoring skin issues and stated they were working on a new system.

The need to ensure short-term changes in condition were monitored weekly through resolution, interventions determined, documented and communicated to staff on each shift was discussed with Staff 1 (ED) and Staff 22 on 12/01/21. They acknowledged the findings.

1.) Resident #2 & # 6  skin audit was performed, documentation completed and is being reeavaluated weekly by RN.

    Resident #2 & #6 service plan interventions are being monitored for effectiveness and updated as appropriate.

2.) Audit skin  for intactness and add treatments and interventions as needed

Nurse to follow up weekly on skin conditions until resolved.

   Staff to be educated bu DNS to complete skin sheets when noticing any new or changed skin conditions ,how to identify change of condion, changes in behavior or falls and who to notify.

   Audit for short term changes of condition using clinical meeting tool, dashboard, 24 hour report, new orders and alerts and update service plan as needed.

3.) Skin audits will be conducted weekly by chart review and wound rounds ongoing

     Audit of short term changes to be conducted M-F in clinical meeting for 6 weeks the re-evaluate

4,) The DNS or designee will be responsible for these audits

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (#1) who received insulin injections by unlicensed facility staff. Resident 1 was at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to:

During the acuity interview on 8/9/21, Staff 3 (RCC) identified Resident 1 received routine insulin daily by non-licensed staff.

Review of Resident 1's record revealed no documented evidence of an RN assessment to address how the resident's condition remained stable and predictable or determination of frequency resident should be reassessed, including rationale.

During an interview and observation of Staff 2's (RN) delegation binder on 8/11/21 at 11:40 am, there was no documented evidence any of the non-licensed staff had been delegated by an RN, including:

* Rationale why the task could be safely delegated;

* Skills, abilities and willingness of non-licensed staff to complete the task;

* Task was taught to the non-licensed staff and they were competent to safely perform task;

* Written instructions available including risks, side effects, response, and risk factors:

* Non-licensed staff were taught the task was client specific and not transferable;

* Determination of frequency the non-licensed staff should be supervised and reevaluated, including rationale; and

* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance.

Staff 1 (ED) and Staff 2 noted there were three residents residing in the ALF and two residents residing in the MCC that required insulin administration. In addition, 12 staff had the potential to administer insulin and would require delegation.  

On 8/11/21, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1, Staff 2 and Staff 3. They acknowledged the above findings. The surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.

On 8/11/21 at 3:00 pm, a plan to address the delegation issue which included licensed staff administering insulin until delegation was completed was accepted and the situation was abated.

We have Identified the need for redelegation/retraining on the following residents that have insulin needing delegation from RN.

Using CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation to redelegate/retrain to each resident identified above until each med-tech has been redelgated/retrained the shift they are and will work. Starting afternoon 8/11/2021 until completed Sandra RN will be conducting redelgated/Retraining. Licensed nurse will do insulin for residents until delegation is completed.

New staff member that are hired will also use CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation CBC Delegation Review to do initial and continuing RN delegation

New Residents will use CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation or internal form to document and determine if delegation for staff is needed.

*If an internal form is created for RN delegation is will cover all components presented in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation.

3. Delegation will be audited monthly for 3 months and every 60 days for 120 day residents will be reviewed and reevaluated and document on with information needed that is provided in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation at this time RN will determine if resident is still stable and safe to continue to have a delegated task to a non-licensed staff. Then every 60 days but no more than every 180 days residents will be reevaluated and document on with information needed that is provided in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation or with internal form with all componates laid out in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation    at this time RN will determine if resident is still stable and safe to continue to have a delegated task to a non-licensed staff.

4. RN and Divisional Director of Clinal Operations and ED  

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:

A facility acuity interview conducted during the survey revealed Resident 5 was administered insulin injections by non-licensed staff.

1. Delegation records and  11/1/21 through 11/28/21 MAR for Resident 5 were reviewed on 12/1/21 and revealed the following:

a. Staff 10 documented on the MAR she administered Resident 5's insulin injection on 11/05/21, 11/06/21, 11/07/21, 11/08/21, 11/11/21, 11/12/21, 11/14/21, 11/17/21, 11/18/21, 11/19/21, 11/20/21, 11/23/21, 11/24/21, 11/25/21 and 11/26/21.

The evaluation for Staff 10's skills and ability and initial delegation was completed on 8/25/21 and was due to be re-evaluated within 60 days.

b. Staff 18 documented on the MAR she administered Resident 5's insulin injection on 11/09/21.

The evaluation for Staff 18's skills and ability and initial delegation was completed on 9/14/21 and was due to be re-evaluated within 60 days.

c. Staff 19 documented on the MAR she administered Resident 5's insulin injection on 11/01/21 and 11/02/21.

The evaluation for Staff 19's skills and ability and initial delegation was completed on 8/30/21 and was due to be re-evaluated within 60 days.

The facility lacked documented evidence Staff 10,18 and 19's skills and abilities were re-evaluated and the tasks re-delegated within 60 days of the initial delegation in accordance with (OSBN) Division 47 Rules.

2. Staff 10 and 19's transfer of delegations were completed on 11/4/21.  After there required re-evaluation dates had past. The current facility RN accepted the outgoing RN's plan for supervision of Staff 10 and 19.

The facility lacked documented evidence, any parts of delegation needing to be changed as a result of a transfer of delegation were completed during the transfer of delegation process for Staff 10 and 19 in accordance with (OSBN) Division 47 Rules.

The need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 22 (RN). No further documentation was provided.

1.) Staff 10 and 18 were re-evaluated and redelegated by RN. Staff 19's delegation rescinded by RN due to prn status; does not perform task frequently enough to maintain skill.

2.) All delegations are on tracking calendar and will be re-evaluated and delegated prior to expiration of delegation or with change of condition of resident or change in status of med tech.

   Delegations will be audited to be sure schedule is maintained.

3.) RN will create and maintain delegation calendar annually and as needed to reflect changes.

   Delegations will be audited monthly to ensure schedule is being followed.

4.) Administrator will be resposible to ensure that schedule is being followed.

Based on interview and record review, the facility failed to ensure medication administration was documented by the same person who administered the medication for 1 of 3 sampled resident (#5) whose medication administration record was reviewed. Findings include, but are not limited to

Resident 5 was admitted to the facility 08/2021.

Review of Resident 5's 8/11/21 physician orders and 11/01/21 through 11/29/21 MAR revealed the facility had an order to administer daily scheduled lantus injections (insulin) to the resident.

On 11/30/21, Staff 22 reported that the medication was administered by delegated medication technicians from the assisted living facility, but initialed by the memory care medication technician on the following occasions:

11/3/21, 11/4/21, 11/10/21, 11/13/21, 11/15/21, 11/16/21, 11/21/21, 11/22/21, 11/27/21 and 11/28/21.

The need to ensure medication administration was documented by the same person that administered the medication was discussed with Staff 1 (ED) and Staff 22 on 11/30/21. They acknowledged the findings.

1.) Resident #5  record was noted to reflect insulin given by delegated staff.

2.) Staff educated  on proper documentation to ensure the record reflects who actually provided medication. Staff must log out and allow apprpriate person to log on to complete documentation.

     Staff educated to notify RN and MD of any documentation errors so they can be amended.

     Audit will conducted comparing MAR documentation to staff assignment to ensure that documentation and assigned staff match.

3.) Education provided by RN 12/10; Audits to be performed M-F x 6 weeks then re-evaluated.

4.) Audits will be conducted by RN od designee.

Based on interview and record review, it was determined the facility failed to ensure orders were administered as prescribed and signed physician's orders were in place for all medications administered to the residents for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 4/2020 with diagnoses including vascular dementia and diabetes. Review of the resident's July 1 through August 9, 2021 MARs and physician orders revealed the following medications and treatments were not administered as prescribed:

* Ciprofloxacin (to treat infections) was to be administered twice a day for seven days but was documented as given from 7/3/21 through 7/8/21, which was six days;

* 7/16/21 - Atorvastatin (to lower cholesterol) and Trazadone (for depression) was not given due to "on order from pharmacy";

* Metformin (for diabetes) was not administered due to "nauseated/vomiting" on 7/30/21 and 8/6/21;

* Blood pressures were not documented as being taken prior to administering Metoprolol (for hypertension) on 7/31/21, 8/7/21 and 8/8/21;

* Basaglar insulin injection was not administered on 8/6/21 due to staff not being able to locate the needle that fit the pen; and

* Blood sugars were not taken as ordered on 7/11/21, 7/21/21, 7/31/21, 8/1/21 and 8/2/21 due to the resident "sleeping" and not taken on 8/6/21 due to the resident being "nauseated/vomiting."

2. Resident 3 was admitted to the facility in 1/2021 with diagnoses including Alzheimer's. July 1 through August 10, 2021 MARs and physician's orders were reviewed.  

a. The following medications had no documented evidence of a physician's order in the resident's medical chart:

* Diclofenac gel (for low back pain);

* Hydrochlorothiazide (for swollen legs);

* Hydrocodone (for low back pain);

* Quetiapine (for dementia with behavioral disturbance);

* Clonazepam (for aggression); and

* Fleet enema (for constipation).

The following PRN constipation medications lacked specific physician ordered parameters:

* Milk of Magnesia;

* Bisacodyl tablets; and

* Bisacodyl suppository.  

The need to ensure orders were administered as prescribed and signed physician's orders were in place for all medications administered was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

3. Resident 2's July 1 through August 9, 2021 MARs were reviewed and revealed there were no physician orders for the following medications:

* Lorazepam (for anxiety); and

* PRN Tramadol (for pain).

The need to have signed physician orders in the resident's chart was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

4. Resident 4's July 27 through August 9, 2021 MARs were reviewed and it was revealed there was no physician's order for Refresh liquid gel eyedrops (for dry eyes).

The need to have signed physician orders in the resident's chart was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Resident 1, 2, 3, and 4 reviewed and orders signed and placed in EHR system

2.All physicians faxed with current orders and received added to EHR system. New orders will be scanned into EHR system

3.Orders will be reviewed during daily clinical and uploaded as needed.

4.RN and RCC to monitor.   

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to orders for 3 of 3 sampled residents (#s 1, 2 and 3) who had documented medication refusals. Findings include, but are not limited to:

July 1 through August 10, 2021 MARs, physician/prescriber orders and progress notes dated 5/9/21 through 8/9/21 were reviewed for Residents 1, 2 and 3. There was documented evidence that each resident had medication refusals.

Documentation of the refusals for the residents was requested during the survey. On 8/11/21 at 11:30 am, Staff 1 (ED) confirmed there was no documented evidence the residents' physician/practitioner was notified each time the residents refused to consent to orders or monthly as ordered.  

The need to ensure documentation of the residents' refusals to consent to the physician's/practitioner's orders was discussed with Staff 1, Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Residents 1, 2, and 3 refusals where reviewed and Dr. faxed.

2.Med-Tech staff instructed and trained when a refusal happens to fax DR of the refusal and use a medication refusal fax for DR via medication refusal form.

3.This will be evaluated weekly.

4.RN to monitor and complete.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when 1 of 1 sampled resident (#2) refused to consent to an order. This is a repeat citation. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2019 with diagnoses including dementia.

Review of the resident's 11/01/21 through 11/29/21 MAR revealed the resident refused the following scheduled medications:

* On 11/03/21, 11/04/21, 11/10/21 and 11/15/21: docusate sodium (bowel care);

* On 11/15/21: hydroxyzine (antihistamine), Buproprion (depression), melatonin (supplement), Milk of Magnesia (bowel care), multivitamin (supplement), verapamil (HTN), senna (bowel care), quetiapine (behavior) and Tylenol (pain).

There was no documented evidence the refusals were reported to the physician.

The need to ensure the physician or other practitioner was notified when a resident refused to consent to an order was discussed with Staff 1 (ED) and Staff 22 (RN) on 12/01/21. No further documentation was provided.

1.) Resident #2 physician was notified of previously refused medications.

2.) Refusals will be submitted to physician daily via fax.

    Audit will be completed comparing refusals in MAR to fax receipts and corrected accordingly.

3.) Audit will be completed Monday through Friday for 6 weeks then re-evaluated.

4.) Audits to be completed by RN/designee.

3. Resident 1's July 1 through August 9, 2021 MARs were reviewed. There were multiple PRN medications prescribed for the same diagnosis that gave no instruction to unlicensed staff as to which order the medications were to be administered.

The following medications had no documented instruction:

* PRN acetaminophen and hydrocodone (for pain);

* Albuteral and Symbicort (for shortness of breath or wheezing);

* Metoclopramide and ondansetron (for nausea); and

* Milk of Magnesia, bisacodyl tablets and bisacodyl suppository (for constipation).

4. Resident 3's July 1 through August 10, 2021 MARs and physician orders were reviewed and there were duplicate orders for acetaminophen, bisacodyl suppository and Milk of Magnesia.

The need to ensure MARs had resident specific parameters for PRN medications used for the same diagnosis and were accurate was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR and TAR was kept for all medications and treatments ordered by a legal prescriber and administered by the facility and included medication-specific instructions and resident-specific parameters for PRN medications for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to:

1. Resident 2's July 1 through August 9, 2021 MARs and TARs were reviewed and revealed multiple blanks in the documentation for the following treatments:

* Respiratory screening; and

* Optifoam dressing change.

The need for accurate MARs and TARs was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

2. Resident 4's July 1 through August 9, 2021 MARs and TARs were reviewed and revealed multiple PRN bowel care medications lacked resident-specific parameters,  PRN Carb/Levo (for Parkinson's disease) lacked resident-specific indicators for use and there were duplicate orders for acetaminophen/Tylenol, bisacodyl suppository and Milk of Magnesia.

The need to ensure there were clear parameters, instructions and indicators for use for all PRN medications was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Resident # 1, 2, 3, and 4 reviewed and PRN medication updated.

2.PRN medication sent to PCP to request resident specified parameters for Bowel medication and if a PRN medication for same class of medication which should be used first.

3.Evaluation will weekly and upon move-in

4. RN to monitor and complete

Based on interview and record review, the facility failed to ensure MARs were accurate and included resident-specific instructions and parameters for the administration of PRN medications for 2 of 2 sampled residents (#s 2 and 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2019 with a diagnosis of dementia.

Review of the 11/1/21 through 11/29/21 MAR and 08/11/21 physician order summary revealed the following:

*PRN Tramadol (pain) lacked information regarding how the resident expressed pain;

*PRN Hydroxyzine (antihistamine) lacked parameters when to administer the medication; and

*PRN Milk of Magnesia (bowel care) lacked parameters.

The need to ensure the MAR included clear instruction to staff and parameters for the administration of PRN medications was discussed with Staff 1 (ED) and Staff 22 (RN) on 12/01/21. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 10/2021 with diagnoses including dementia.

A review of the resident's 11/01/21 through 11/21/21 MAR revealed the following:

PRN bowel care medications (bisacodyl 5 mg tab, fleet enema, and milk of magnesia) lacked clear parameters for when to use one versus the others.

The need to ensure MAR's were accurate for all medications ordered by a legally recognized prescriber and are administered by the facility was discussed with Staff 1 (ED) and Staff 22 (RN) on 12/02/21.  They acknowledged the findings.

1.) Resident #2 MAR was updated to include parameters for prn medications, including pain, bowel protocol and antihistamine. #6 MARs updated to included perameiters on PRN Bowel care medications

2.) All residents prn medication to be reviewed and parameters updated as needed.

3.) Audit weekly to ensure all new prn orders have appropriate parameters x 6 weeks then re-evaluate.

4.) Audits to be completed by RN or designee.

Based on interview and record review, it was determined the facility failed to ensure documentation of non-pharmacological interventions had been attempted prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (# 3) who was prescribed PRN medications to treat behaviors. Findings include, but are not limited to:

Resident 3's July 1 through August 10, 2021 MARs were reviewed and indicated a PRN dose of clonazepam (for aggression) was administered on 7/14/21. There was no documented evidence the facility tried non-drug interventions and were ineffective prior to administering the medication.

The need to ensure staff documented non-pharmacological interventions were attempted and ineffective prior to the administration of a PRN psychotropic medication was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. No additional information was provided.

1.Resident 3's medications reviewed and order updated to reflect non-pharmaceutical intervention prior to giving a PRN Psychotropic medication.

2.Medications where reviewed and updated to have non-pharmaceutical interventions in place to prior to giving medication

3.Monitored Via clinical meeting and updated as needed.

4.RN and/or RCC to monitor.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 9 and 15) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 8/11/21 and revealed Staff 9 (MT) and Staff 15 (CG), hired on 7/7/21 and 6/22/21 respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC) and Staff 5 (Business Office) on 8/11/21. They acknowledged the findings.

1. Staff #9 and 15 have been reviewed and 30 day compentices have been completed for those missing and by Day 30 of any new hire will be completed:  Competency demonstrated within 30 days of hire: Role of service plans in providing individualized care, providing assistance with ADLs, Changes associated with normal aging, Identification, documentation and reporting of changes of condition, Conditions that require assessment, treatment, observation and reporting, General food safety, serving and sanitation Other duties as applicable (Med pass, treatments), First Aid/Abdominal Thrust

2. Have a written instruction to complete 30 day compancies and a check/sign-off sheet in this order.

3. Every new hire by 30 days

4. ED, RN and/or RCC to complete and monitor.   

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

Fire and life safety records for February 2021 through July 2021 were reviewed on 8/9/21 and the following were identified:

1. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.

2. The facility's fire drill documentation did not include the following elements:

* Escape route used;

* Resident evacuation problems encountered; and

* Number of occupants evacuated.

The need to ensure the facility instructed staff in fire and life safety every other month and conducted fire drills on alternating months to include documentation of all required components was discussed with Staff 6 (Maintenance Director) on 8/10/21 and Staff 1 (ED) on 8/11/21. They acknowledged the findings.

1.Actions taken to correct situation is to update fire dill form to included Escape routes used, residents who resisted or failed to participate in drill., Number of occupants evacuated, evidence of alternate routes used during fire drill. This also includes fire safety training in required areas and residents in attendance annually.  

2. Maintenance will conduct fire drills every other month and training of other Fire and life safety instruction to staff on alternate month   

3. Correction will be monitored monthly

4. Maintenances team to complete.  

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Review of fire and life safety records for February 2021 through July 2021 revealed the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills;

* Fire and life safety training was provided to residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and

* A written record of fire safety training, including content of the training sessions and the residents attending.

The need to ensure alternate exit routes were used during fire drills, fire and life safety instruction was provided to residents upon admission and at least annually and there was a written record of fire safety training was discussed Staff 6 (Maintenance Director) on 8/10/21 and Staff 1 (ED) on 8/11/21. They acknowledged the findings.

1. Action taken to correct is have residents be instructed of fire and life safety within 24 hours and then annual.

2.Maintiance team to instruct resident upon move in with documentation evidence.

3.Monthly and with new move-in

4.Maintiance team to monitor.

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

Refer to C150, C231, C252, C260, C270, C282, C305, C310, CZ164.

Refer to C150, C231, C252, C260,

C270, C282, C305, C310, CZ164.

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

Refer to Z164.

Refer to Z164 tag

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were maintained in good repair and were free of litter and refuse. Findings include, but are not limited to:

The courtyard of the MCC was observed during survey.

The pathways within the interior courtyard had multiple drop-offs ranging from 1-3 inches from the sidewalk to the planting bed. The drop-offs created a potential fall hazard for residents who used the courtyard.

There was litter and refuse observed outside the exit door from the common area where residents were observed watching movies.  

The drop-offs, litter and refuse was shown to and discussed with Staff 1 (ED) on 8/10/21. He acknowledged the findings.

1.Action taken to correct rule violation is to fill areas of drop offs that potently cause a safety hazard with material to eliminate drop offs.

2. Drop offs will be filled in as needed.

3 Drop offs will be check monthly by rounds with Maintenance team and fill as needed.

4. Maintenance will be in charge of filling areas and ED/Maintenance for monitoring.     

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Please refer to C 150, C 231, C 240, C 372, C 420, C 422 and C 510.

1.Deficiencies in report have been reviewed and plan of correction will be put in place to include but not limited to C150, C231, C240, C372, C420, C422, and C510

2.POC will be reviewed and areas will be over seen to completion.

3.Will be monitor as stated in POC for each deficiencie

4.ED, RCC, and RN to monitor.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Please refer to C 150 and C 231.

Please refer to C150 and C231.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 9 and 15) completed all required pre-service orientation and 30-day competency demonstration and 1 of 2 long term staff (#12) completed 16 hours of annual training. Findings include, but are not limited to:

A review of staff training records revealed the following:

1. Staff 9 (MT) and Staff 15 (CG) were hired 7/7/21 and 6/22/21, respectively. There was no documented evidence they had completed one or more elements of the required pre-service orientation prior to performing any job duties:

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

2. There was no documented evidence that Staff 9 and Staff 15 demonstrated competency in their job duties within 30 days of hire in one or more of the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* Other duties as applicable (e.g. medication pass, treatments).

3. There was no documented evidence Staff 12 (CG), hired 11/15/19, completed the required 10 hours of annual training related to provision of care in community-based care or the required 6 hours related to dementia care.

The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC) and Staff 5 (Business Office) on 8/11/21. They acknowledged the findings.

1.Staff #9 and 15 was reviewed and training conducted where needed. 2. System in place orientation will be completed in this order Day Zero (Before New hire papers)- Pre-Service Training via Oregon Care Partners Day Zero (new hire papers)- Resident Rights, Abuse, Pride (Abuse), gait belt, Fire safety walk-through, Emergency prepares, Incident reporting, HIPAA, wandering, Job description, and background check. Day one & two(on computer off floor) - Alternatives to Restraints in Elder Care, Alzheimer's Disease and Related Disorders: Activities of Daily Living, Alzheimer's Disease and Related Disorders: The Physical Environment, Assisting Residents with Activities of Daily Living, Assisting with Medication Administration, Body Systems and the Aging Process, Care of Residents With Dementia In A, Challenging Behaviors in Dementia Care, Communication and People with Dementia, Dementia Care: Caregiver Self-Care, Dementia Care: Normal Aging vs. Dementia/Alzheimers, Dementia Care: Performing ADLs, Dementia Care: Understanding Alzheimer's Disease ,eCOURSE: Point of Care (POC) for Senior Living, Empowering Residents through ADLs, Essentials of Resident Rights, Ethics and the Care of Persons Living with Dementia, First Aid, Food Safety Fundamentals, Principles of Infection Control, PRN Medication Management, Record and Report Condition Changes, Service Plans for ALF, Understanding Dementia. Day three and four: skills check list on the job in MC Day five and six: skills check list on the job in MC or ALF. Competency demonstrated within 30 days of hire: Role of service plans in providing individualized care, providing assistance with ADLs, Changes associated with normal aging, Identification, documentation and reporting of changes of condition, Conditions that require assessment, treatment, observation and reporting, General food safety, serving and sanitation Other duties as applicable (Med pass, treatments), First Aid/Abdominal Thrust Annual training will be conducted via Staff meetings and Online computer training. To include a minimum of 16 hours of in-service training annual by hire date and 6 of which will be dementia in topic.  3. Every new hire and quarterly. 4. ED, RN and/or RCC.  

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Please refer to: C 252, C 260, C 262, C270, C 282, C 303, C 305, C 310, C 330 and C 340.

1.Deficiencies in report have been reviewed and plan of correction will be put in place to include but not limited to C150, C231, C240, C372, C420, C422, and C510

2.POC will be reviewed and areas will be over seen to completion.

3.Will be monitor as stated in POC for each deficiencie

4.ED, RCC, and RN to monitor.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Please refer to: C 252, C 260, C270, C 282, C290, C301, C 305 and C 310.

Please refer to: C 252, C 260, C270, C

282, C290, C301, C 305 and C 310.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and included in residents' service plans for 3 of 4 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Residents 2, 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status, needs and preferences.

The need to develop individualized service plans addressing residents' nutrition and hydration preferences and needs and document them in the service plan was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Resident 2,3, and 4 service plan have been reviewed and updated for nutrition and hydration.

2.Service plans will be updated to reflect individualized nutrition and hydration status, needs and preferences via interviewing resident and/or family if resident unable to be interviewed.

3.Will update at care conference, New move-in, and as needed.

4.RCC to monitor and complete

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for residents that promoted or helped sustain the physical and emotional well-being of the residents and failed to ensure individualized activity plans were developed for each resident, based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3 and 4's service plans, assessments and evaluations were reviewed. There was no documented evidence the facility had evaluated the residents in the following required components:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

There was no documented evidence of specific activity plans which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

2. Per observation on the unit, no scheduled group or individualized activities were observed during the course of the survey.

The unit was observed throughout the survey process from 8/9/21 through 8/11/21. Per the August 2021 Activity Calendar, on 8/9/21 there were no scheduled activities listed as the day was blocked out stating, "National Book Lovers Day!" There were no reading activities observed on that day from 12:15 pm through 5:00 pm.

On 8/10/21 the calendar stated there would be a coffee hour at 6:30 am and "Tootsie Tuesday" at 10:00 am. Observations were made on the unit on 8/10/21 from 9:26 am through 3:30 pm. There were no pedicures observed during that time.

The scheduled activity for 8/11/21 reflected at 1:00 pm there would be "Music Appreciation." Music was on in the common dining room throughout the survey, but there was nothing different relating to music that was observed at 1:00 pm on 8/11/21.

The failure to ensure an evaluation of the residents' current abilities and interests in order to develop an individualized activity plan, failure to implement the plan and failure to provide meaningful unscheduled and scheduled activities was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Resident 1, 2, 3 and 4 was interviewed on what actvities they would like and service plan updated to reflect. Hire on an Activities/life enrichment coordinator to oversee a Resident Services: Activities program that has social and recreational activities that are based on individual and group interests. This Activities director/ Life enrichment coordinator will also take webinar via Oregon Care partners called Life Enrichment.

2.ED or designee will oversee activates are completed with monthly meetings on how and what is needed for Activates/Life enrichment Coordinator to complete their job.

3. Oversite from will be completed monthly with resident interviews via care conferences.

4.ED to oversee  

Based on interview and record review, it was determined the facility  failed to ensure individualized activity evaluations and plans were developed for 2 of 2 sampled residents (#s 2 and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 and 6's service plans, assessments and evaluations were reviewed. There was no documented evidence the facility had evaluated the residents in the following required components:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions.

There was no documented evidence of specific activity plans which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

The failure to ensure an individualize activity evaluation and plan was developed for each resident was discussed with Staff 1 (ED) and Staff 22 (RN) on 12/01/21. They acknowledged the findings.

1.) Residents  #2 and #6 activity assessments have been updated to include past and current interests, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptions necessary for the resident to participate and activities that could be used as behavioral interventions.

2.) Service plans to be updated to reflect activity preferences and schedule.

    Schedule activies evaluations to coordinate with care conferences and update service plan with any changes. Any new admissions activity evaluations will be done within 72 hours of admit.

    Audit activity assessments weekly for changes to plan, new admissions and quarterly updates.

3.) Audits will be conducted for 6 weeks then reevaluated.

4.) The administrator or designee.

Based on observation, interview and record review, it was determined the facility failed to evaluate each Memory Care Community resident for activities and develop an individualized activity plan based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 7 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

There were 22 residents who were diagnosed with dementia who resided in the MCC at the time of the survey. The residents' ability to participate in the activities that were offered on the unit during the survey varied. Some residents stayed in their rooms and did not participate in any scheduled activities while others joined group activities and needed some degree of assistance to understand and participate in the activities.

Observations on 02/28/22 from 2:15 pm through 4:10 pm revealed seven residents in the dining room with no activities being conducted. One resident asked a caregiver what they should be doing.

The activity information that was documented and included in Resident 1, 7 and 8's service plans consisted of a list of activities the residents currently enjoyed or enjoyed in the past. There was no documented evidence the following areas had been evaluated:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

The facility had not developed an individualized activity plan for Residents 1, 7 and 8 based on a comprehensive activity evaluation which detailed what, when, how and how often staff should offer and assist the residents with activities.

In an interview on 03/01/21, Staff 8 (Activities Director) reported she was new to the position, never received training, and had not reviewed the Oregon Administrative Rules regarding activity requirements in a Memory Care Community.

The need to conduct a comprehensive activity evaluation and develop an individualized activity plan was reviewed with Staff 1 (ED) and Staff 25 (Regional RN) on 03/01/22. They acknowledged the facility needed to conduct a more thorough evaluation and use the information to develop more individualized activity plans.

1.Activities care plan and evaluation updated for resident 1, 2, and 3 will be created to match OAR.

2.An activities care plan will be created for residents in the Memory care to include person centered based on resident preferences Daily routine activities, group activities, and spontaneous activities. Also, to include information from evaluation to create activity care plan.  Staff to be trained on how to do activities throughout the day to increase joy of the residents in the memory care unit. Activities care plans will be reviewed and updated at quarterly care conferences and with change of condition. Increased training for Activities director as well as evaluation updated to include Current abilities and skills; Emotional and social needs and patterns; Physical abilities and limitations; Adaptations necessary for the resident to participate; and Identification of activities for behavioral interventions.

3.weekly for 5 weeks.

4.Administrator and Activities director

Based on interview and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 1 of 4 sampled residents (# 3) and others in the community. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 1/2021 with diagnoses including Alzheimer's and dementia with behavioral disturbances.  

The resident's service plan did not address the resident's behaviors and effective resident specific interventions or approaches for staff to utilize for the behaviors.

Resident 3's progress notes dated from 1/11/21 through 8/7/21 indicated the resident had at least 17 documented incidents of behaviors and aggression directed towards other residents and staff.  There was no documented evidence the facility developed an individualized behavior plan to address behaviors.

Observations of the resident with Staff 7 (MT/CG) on 8/10/21 showed the resident not wanting the staff member walking too close beside him/her while being escorted to lunch. Staff 7 confirmed Resident 3 didn't always want assistance and would "try to hit us" when staff would attempt to explain why the assistance was needed. Staff 7 stated the intervention was to make sure the resident was safe and re-approach later. S/he was also observed on multiple occasions trying to go into other residents' rooms, both with and without staff beside him/her. Staff 7 reported they just to keep Resident 3 and the other resident "away from each other."

On 8/11/21, Staff 3 (RCC) confirmed she completed the service plans and acknowledged it could be adapted more around trying to prevent behaviors prior to occurring and give direction to staff about how to redirect the resident if behaviors were being exhibited.  

The need to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted the resident and others in the community was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 on 8/11/21. They acknowledged the findings.

1. Resident 3 reviewed and service plan update.

2. Residents will be reviewed and behavioral care plan created and up dated as needed with incidents to included individualized interventions to help assist the care for resident's behaviors.

3. Weekly, Care conference, and as needed

4. RCC and/or RN to monitor.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility's secured outdoor recreation area was toured on 8/10/21. There was a dining room chair and metal garbage can observed near one of the doors. Both items were easily movable and not of sufficient weight or design to prevent injury or not to aid in elopement.

During a walk-through of the facility on the same day, Staff 1 (ED) was shown the concerns and he acknowledged the findings.

1.Secure outdoor recreation area toured. Debris and moveable non weighted furniture removed.

2.Rounds will be done by maintenance team and debris and moveable non-weighted furniture removed as needed.

3.Rounds to be completed weekly

4. Maintenance team to monitor