The findings of the Change of Owner re-licensure survey conducted 03/08/22 through 03/10/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 03/10/22, conducted 05/09/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on 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 (#2) whose records were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 02/2022.

Resident 2's move-in evaluation failed to address the following:

* Visits to health practitioners, ER, hospital or nursing facility in the past year;

* Mental health issues including behavior or mood problems, history of treatment and effective non-drug interventions;

* Cognition, including memory, confusion, and decision making;

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

* Ability to use the call system;

* Pain: pharmaceutical and non-pharmaceutical interventions including how a person expresses pain or discomfort;

* Nutrition habits, fluid preferences and weight if indicated;

* Emergency evacuation ability;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors that impact the residents behavior.

The need to ensure the facility completed all required elements on Resident 2's new move-in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. They acknowledged the findings.

Resident evaluation tool has been update to reflect all required elements.

Nursing team has been in-serviced on updated tool and is in the process of updating all resident evaluation to ensure that evaluations are up to date.

Resident preferences form have also been updated and in-service has taken place (3/14/22) with admissions coordinator and nursing team that is is completed prior t o resident moving into the community.

Administrator and Vice President of Operations will be responsible for maing sure the corrections are completed.

Vice President of Operations will audit community annually for compliance.

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

Resident 1 was admitted to the facility in 05/2020 with a history of multiple back surgeries and  chronic pain.

The current service plan dated 01/04/22 noted the resident required one person assist with toileting, was "bed bound", and would become restless related to pain and anxiety.  The service plan directed staff to offer non-drug interventions before as needed medication for pain.

During interviews on 03/10/22 with Staff 4 (MT), Staff 5 (MT/CG) and Staff 10 (CG) they stated the following:

*Resident 1 required 2-3 people to provide incontinent care;

*S/he experienced increased pain and anxiety in the evening hours;

*The resident would use the call light more frequently when anxious or in pain;

*When his/her beard was trimmed s/he "feels better about himself"; and

*S/he preferred one to one companionship when restless.

Resident 1's service plan was not reflective related to number of staff needed to provide incontinent care, there was no description of how the resident demonstrated pain or restlessness, and there were no non-drug interventions identified to help with pain and anxiety.

Resident 1's service plan was reviewed with Staff 1 (Administrator) on 03/10/22 at 1:00 pm.  Staff 1 acknowledged the finding.

Service Plan tool has been updated to better capture and assist nursing team with needs and preferences of each individual resident.

Nursing team will audit service plan with care team members prior to quarterly service plan updates to ensure prefences and needs are being captured accurately in the service plan.

In-service and documents have been provided to assist nursing team and verbiage for ocmpletion in service planning.

Director of Nursing and Administrator will be responsible for monitoring and making sure corrections are completed.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 2 of 2 sampled residents (#s 2 and 4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 03/08/22, Resident's 2 and 4 were identified to be administered insulin injections by non-licensed staff.

1. Resident 2's MARs, reviewed from 02/11/22 through 03/08/22, revealed weekly insulin had been administered by Staff 3, 11 and 17 (MTs).

Initial delegations for Staff 3 (MT) completed 02/21/22 and Staff 17 (MT) completed 02/14/22, lacked documentation in the following areas:

* A rationale that the task could be safely delegated;

* Frequency the resident should be reassessed, including rationale;

* Frequency the MT should be supervised and reevaluated, including rationale; and

* Staff 11 (MT) was not delegated and had administered insulin on 03/07/22.

2.  Resident 4's MARs, reviewed from 02/01/22 through 03/08/22, revealed insulin had been administered by Staff 4, 5 and 11 (MTs).

Initial delegations for Staff 4 (MT) completed 02/07/22, Staff 5 (MT) completed 02/07/22 and Staff 11 completed on 02/18/22, lacked documentation in the following areas:

* A rationale that the task could be safely delegated;

* Frequency the resident should be reassessed, including rationale; and

* Frequency the MT should be supervised and reevaluated, including rationale.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator), Staff 2 (VP of Operations) and Staff 16 (RN) on 03/09/22. They acknowledged the findings.

Delegation paperwork has been updated to asssit licensed nurse with completion of documentation in areas that were lacking.

Education has taken place with Medication Techs regarding delegation and requirements for sign-off.

Delegation of residents on insulin is being updated and reviewed and all paperwork is being updated to reflect new paperwork.

Director of Nursing will audit and review the delegation notebook monthly to ensure compliance.

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

1 a.  Resident 1's 02/01/22 through 02/28/22 MAR was reviewed and noted the following medications were documented as administered:

* Duloxetine (for depression);

* Melatonin (for sleep);

* Omeprazole (for reflux);

* Oxycodone (for pain);

* Polyethylene (for bowel care);

* Potassium (Supplement);

* Pregabalin (for pain)

* Metamucil (for bowel care);

* Simvastatin (for cholesterol); and

* Torsemide (diuretic).

There was no documented evidence written signed physician orders for the medications were in the resident's record.  The facility faxed the physician and received signed orders on 3/10/22 at the time of the survey.

b.  Resident 1 had orders for warfarin (to prevent blood clots) 2.5 mg to be administered on 2/15/22 and no warfarin was to be administered 02/16 through 02/20/22.  

The MAR dated 02/16 through 02/20/22 noted the medication was not held as ordered.

Following medication and treatment orders as prescribed was reviewed with Staff 1 (Administrator) on 03/10/22 at 1:00 pm.  At the time of the survey, Resident 1's physician's orders related to warfarin were being followed.

2. Resident 2 was admitted to the facility in 02/2022 with diagnoses including celiac disease.

Resident 2's 03/01/22 through 03/08/22 MAR was reviewed and noted the following:

* From 03/04/22- 03/08/22 CertaVite Senior (supplement) was not available and was not administered as prescribed.

During an interview with Staff 16 (RN) on 03/09/22, she reported the medication was still not available. Staff 16 reported she would need to follow up with MT who should have faxed the pharmacy.

The need to ensure medication orders were followed as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. The acknowledged the findings.

Licensed nurses will review the EMAR report daily of medications not given and follow company policy regarding missing medications. In-service has been completed (3/14/2022)

Community has added into quarterly service plan section to request/receive update signed physician orders for resident chart and EMAR.

Director of Nursing will be responsible for monitoring these corrections.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, provided clear instruction and parameters for administration of scheduled and PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1.  Resident 1's MAR dated 02/01/22 through 02/28/22 noted the following:

* Reguloid Orange Powder (Metamucil) one to three times daily for constipation.  There were no instructions to staff regarding when or how much to administer; and

* Diazepam as needed for spasm/anxiety without clear instruction about when and for what to administer the medication.

Resident 1's MARs were reviewed with Staff 1 (Administrator) on 03/10/22 at 1:00 pm.  Staff acknowledged the findings.

2.  Resident 2's MAR dated 03/01/22 through 03/08/22 noted the following:

* PRN Milk of Magnesia and PRN Docusate Sodium lacked parameters for the sequence of administration; and

* CBG checks prior to insulin administration lacked clear parameters for when to hold the insulin.

The need to ensure MAR's had clear instructions and parameters for unlicensed staff was reviewed with Staff 1 (Administrator), Staff 2 (VP of Operations) and Staff 16 (RN) on 03/09/22. They acknowledged the findings.

MARs are being reviewed as are all current Medication orders for clear parameters and updated by the licensed nurse.

Licensed nurses will review all new order and follow protocol of either faxing physician for clarified parameters for orders or in the case of PRN medications RN will clarify and write parameters in the MAR.

CBG checks have been added in the MAR for all residents on Insulin and parameters are now in place for when to hold insulin.

Medication staff have been in-serviced on these new protocols.

Director of Nursing is responsible for ensuring the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use, documented evidence the resident was informed of the risks and benefits associated with the device, documentation of less restrictive alternatives prior to use, and documented instructions to caregivers on the correct use and precautions of the device for 2 of 2 sampled residents (#s 1 and 2) who had half-length side rails on their bed. Findings include, but are not limited to:

1.  Resident 1 was admitted to the facility in 05/2020 with diagnoses including a history of back surgeries and chronic pain.  

Observations during the survey on 03/10/22 revealed Resident 1 had a hospital bed. Bilateral side rails were observed on the bed in the down position.  Resident 1 was not in the bed during the observation.  

There was no documented evidence the following required elements were completed:

* Assessment by an RN, PT or OT;

* Documentation of less restrictive alternatives prior to use of the device;

* Documentation the resident was informed of risks and benefits associated with the device; and

* Instruction provided to staff on the correct use and precautions of use of the device.

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT and completion of all required elements was discussed with Staff 1 (Administrator) on 03/10/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2022 with diagnoses including Parkinson's disease.  

Observations during the survey on 03/09/22 revealed Resident 2 had a hospital bed with a quarter length side rail on one side of the bed. The side rail was in the up position. Resident 2 was seated in a recliner chair during the observation.  

There was no documented evidence the following required elements were completed:

* Assessment by facility RN, PT or OT;

* Documentation the resident requested or approved of the device;

* The facility had informed the individual of the risks and benefits associated with the device;

* Documented other less restrictive alternatives evaluated prior to the use of the device;

* Instructed caregivers on the correct use and precautions related to use of the device; and

* Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan.

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT and completion of all required elements was discussed with Staff 1 (Administrator), Staff 2 VP of Operations) and Staff 16 (RN) on 03/09/22. They acknowledged the findings.

RN will assess all residents who have side rails with commmunity ancillary side rail assessment.

Instructions to staff will be noted in the service plans of each resident with side rails on the correct use and precautions of the device(s).

In-Service to take place on safety and risks of side rails as well as proper maintenance.

Side Rails will be evaluted on a quarterly basis.

Director of Nursing, Maintenance Director and Administrator will be responsible for ensuring that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Review of fire drill and fire and life safety records for 07/2021 through 03/2022 identified the following deficiencies:

* Fire and life safety instruction for staff was not conducted and documented on alternate months of the fire drills; and

* There was no documentation of the following required components:

- Escape route used;

- Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and

- Number of occupants evacuated.

The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. They acknowledged the findings.

Fire drill documentation forms have been udpate to reflect information that was lacking in previous drills. In-service has been done with Maintenance Director regarding new from and requirements moving forward.

A safety program and training calendar has been created and will be followed and documentation will take place when training sessions occur.

Maintenance Director and Administrator will be responsible for monitoring and completing the corrections.

Vice President of Operations will audit every 6 months.

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

Fire and life safety records, reviewed between 07/2021 through 03/2022, revealed the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills;

* Fire and life safety training for residents 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;

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

* There was no documented evidence the facility identified residents who were unable or unwilling to participate in the fire drills therefore, there was no documented evidence immediate changes were made to ensure the evacuation standard was met.

The need to ensure alternate exit routes were used during fire drills, fire and life safety instruction was provided to residents at least annually, and documentation of residents who declined to participate in fire drills with the changes made to ensure the facility was able to maintain the evacuation standard was discussed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. They acknowledged the findings.

Fire drill documentation has been updated to reflect information to identify residents unwilling to participate in drills and changes to evacuation standards.

Service plans have been update to include a section that staff will review fire and life safety procedures annually with residents.

Director of Nursing, Maintenance Director and Administrator will be responsible for monitoring and completing the corrections.

Vice President of Operations will audit every 6 months.

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 03/08/22. Exterior pathways in the courtyard and around the perimeter of the building contained multiple drop offs up to four inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents.

On 03/08/22, the building's exterior was toured with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 15 (Maintenance Director). They acknowledged the findings.

Exterior pathways will be monitored for potential drop offs and fall hazards and will be managed as they are identified.

All identified hazards from tour on 3/8/2022 have been filled in and leveled.

Maintance Director will walk the building exterior routinely to monitor the pathways and grounds.

Maintenance Director and Administrator will be responsible to see that the corrections are completed and monitored.

Vice President of Operations will monitor on quarterly visits.