The findings of the change of ownership survey, conducted 10/03/22 through 10/05/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for 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

The findings of the revisit to the re-licensure survey of 12/04//22, conducted 03/15/23 through 03/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 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 ensure the kitchen followed food handling practices and was clean and in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

a. Observations of cottage kitchens and meals throughout campus between 10/03/22 and 10/05/22 revealed the following:

* Drawers and cupboards had exposed wood, rendering the surfaces uncleanable;

* Baseboards were peeling away from walls and cabinets;

* Shelves of refrigerators were cracked and the bottom shelf on a refrigerator door was broken and loosely taped together;

* Dry storage shelves had dust, debris and white/gray accumulation;

* Debris and food splatters were noted inside and on the surfaces of refrigerators, freezers, microwaves, ovens, stoves, cabinets, and drawers;

* Oven vents were observed with dust and grease build-up and/or damaged filters;

* Undated and unlabeled opened foods and condiments in cabinets and refrigerators;

* Red/brown spills were noted on the top of a dishwasher door;

* Meat and eggs were noted on the top shelf of refrigerators;
* Meats being defrosted on a counter;
* Pasteurized eggs were unavailable for soft-cooked entrees;

* Staff members were not properly washing their hands between dirty/clean tasks;

* Staff members were unable to identify proper cooling methods, proper cooking times and temperatures, and potentially hazardous foods;
* Staff members were unable to answer questions related to forborne illness, including cross contamination, how to prevent foodborne illness, and signs/symptoms of foodborne illness;
* Staff were not consistently cleaning thermometers with an alcohol wipe between use;

* Gloves and masks were not being properly used by staff members;
* The freezer in the courtyard of Cottage D had a build-up of ice on the shelves and the coils; and

* Fish stored in the freezer showed signs of freezer burn.
 

b. Observations of the "Lower Shop Main Kitchen Supply" revealed the following:

* Floors throughout had an extensive build-up of black matter;

* Freezers and refrigerators had food debris on the floor and shelving; and

* Undated and unlabeled food items were noted in the walk in cooler.

c. During a tour of the kitchen in the Mt. Vernon cottage on 10/04/22 at 3:00 PM, the following were identified:

The thermometer in the door of the refrigerator registered 44 degrees Fahrenheit, which was above the minimum temperature required to ensure food safety. There was no change to the temperature when kitchen findings were reviewed with Staff 2 (Assistant Administrator) at 4:30 PM that day. It was recommended the facility check the temperature of the refrigerator with a different thermometer. Staff 2 re-checked the temperature of the refrigerator and noted it was 44 degrees Fahrenheit.  Survey directed the facility to dispose of the potentially contaminated food since the temperature of the refrigerator was above 41 degrees Fahrenheit, as it was unclear how long the temperature was above the minimum required.

On 10/05/20 at 8:20 AM, Staff 2 reported the temperature of refrigerator continued to be above the minimum required, and the facility was utilizing coolers to maintain perishable items at the proper temperature while the maintenance department attempted to fix the problem. She indicated food in the refrigerator would be disposed of.

Upon recheck at 1:00 PM on 10/05/22, a thermometer in the door of the refrigerator registered 38 degrees Fahrenheit.

d. During a tour of the kitchen in the Willow cottage on 10/03/22 and 10/04/22 the following was noted:

On 10/05/22, the refrigerator thermometer was observed to be 50 degrees Fahrenheit. Facility staff reported the temperature of the milk was 44.6 degrees Fahrenheit. Survey directed the facility to dispose of the potentially contaminated food if the temperature of the refrigerator was above 41 degrees, as it was unclear how long the temperature was above the minimum required. The facility provided a plan to keep refrigerated food for Willow in the "lower shop" walk in refrigerator until the Willow refrigerator could be repaired. The plan was approved by the survey team.
 

On 10/05/22, the need to ensure kitchens followed safe food handling practices and kitchens were clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). She acknowledged the findings.

Plan of Correction:

1- On 10/18/22, a walkthrough of each of the 9 homes was completed by the Administrator, Assistant Administrator and Maintenance Coordinator. The following has been addressed or is in process of being addressed:

a- All baseboards thoughout the homes that were not completely attached to the walls have been reattached and secured by the Maintenance Department until the contractor we are currently working with comes out to replace all basetrim throughout each of the homes.

b- Any shelving or surface in the refridgerators that was cracked or scratched has been replaced or repaired by the Maintenance Department.

c- all pantry's (dry storage shelves) are in process of beind deep cleaned by the housekeeper and the supervisor for each home.

d- All refrigerators (inside and outside), freezers, microwaves (inside and outside), stoves (inside and outside), cabinets, drawers, dishwashers (inside and outside) and oven vents are in process of being deep cleaned by the supervisors and staff in each home.

e- Each damaged oven filter has been replaced or repaired by the Maintenance Coordinator.

f- All food has been properly labeled, sealed and dated by the supervisor and staff in the homes.

e- Eggs were inspected by food/supply department, all eggs are pasturized and from now on and will be left in their original container which shows they are pasturized. In the event eggs are not in the home and needed for a meal, the staff will call the lower shop and the food/supply workers will bring the eggs to the home. All staff have been trained on this process.

f- Kitchen drawers and cupboards have been sealed in the areas that were identified as uncleanable. We are currently working with an outside contractor to have all doors/cabinet doors replaced in every home.

g- All outside freezers are now defrosted by the Maintenance Department.

h- All food stored in the freezers has been inspected by the food/supply department to make sure all food which appeared to be freezer burned was removed. All frozen food will now be double bagged by the food/supply department to prevent freezer burn.

i- all eggs and raw meats have been moved to the bottom of the refridgerators, each supervisor for the home was trained on proper thawing and egg storage in the coordinator meeting on 10/20/22, each supervisor is in process of re-trainining each of their staff until the in-service for all staff on 11/15/22.

Lower Shop/Main Kitchen Supply Area:

a- all floors have been deep cleaned by the food/supply department and black matter is no longer present.

b- all freezers and refridgerators were deep cleaned by the food/supply department, no food debris is present.

c- all food that wasn't dated or labeled has been removed by the food/supply department.

2-  On 10/5/22, the refridgerators in the Willow and Mt. Vernon home were repaired by the Maintenance Coordinator. The temperature reading is now consistently between 38-40 degrees Fahrenheit.

3- A temperature log form was created by the Administrator and posted in each kitchen on 10/20/2022. The form requires staff to check the refridgerators internal temperature once per shift, note the temperature on the log with the time the temperature was checked and will require the staff noting the temperature to report any temperature over 40 degrees Fahrenheit to their supervisor immediately. The Food/supply department will check these logs at least twice a week to ensure they are being consistently filled in and that the temperatures are consitently at 40 degrees Fahrenheit or lower.

4- On 10/20/22, the Administrator met with each department supervisor to review and re-educate on the following (including but not limited to):

a-  our policies around kitchen cleaning, chore lists, holding employees accountable and checking their work after chores are completed.

b- the process for properly sealing, dating and labeling all food and fluids in the pantry, freezer, refridgerator and in dry storage.

c- the proper storage of eggs and keeping them in their original containers to show they are pasturized.

d- the proper process for thawing meat and where to store raw meat in the refridgerators.

e- proper hand hygeine including the situations where hands need to be washed and "double washed".

f- proper cooling methods, cooking times/temperatures, and hazardous foods.

g- Foodborne illness education including; signs and symptoms of food borne illness, what cross contamination is and how to prevent food borne illness.

h- Proper use of food thermometers, the need to use alcohol swabs to clean the thermometers (swabs physically handed to each person in this meeting).

i- The proper use of gloves and masks.

j- A competency test and copies of the Food Safety training manual was administered to all attendees by the Administrator to ensure understanding.

k- A plan was identified for each of the supervisors to work with each of the employees they supervise to re-train them on the subjects covered in this meeting until the mandatory in-service this November 15th.

5- An annual in-service training has been created and added to the training calendar. This in-service will be mandatory for all staff to attend and all will need to pass a competency exam following the training. The in-service will be taught by the Administrator and will include the subjects listed below (including but not limited to):

a- food safety including proper temperatures, cooking times, proper cool-down methods, hand hygeine, foodborne illness, proper cleaning methods, proper use of gloves and masks, how to use and clean thermometers.

b- temperature logs for each refridgerator, how to use, who fills in and when.

6- Laminated signs outlining proper use of a thermometer and proper food temperatures will be posted in each of the homes kitchens by the Administrator.

7- A Quality Assurance Auditing form has been created for the Lower Shop/main food receiving area. This audit will be conducted at least quarterly by the Administrator. This audit will require the auditor to make sure there is no food debris in or outside of any food storage area, nothing is unsealed and unlabeled, and flooring is clean and in good repair.

8- The Administrator and Assistant Administrator shall oversee and ensure these changes are implemented and monitored.   

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and were followed by staff for 1 of 8 sampled residents (# 1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in June 2019 with diagnoses including Alzheimer's disease.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 07/21/22, and progress notes dated 06/25/22 to 10/03/22 were completed. Staff indicated the resident was very stiff and frequently arched his/her body and stiffened, which had previously caused slides out of the wheelchair. The resident's service plan was not reflective and was not followed by staff in the following areas:

* Foot pedals only when being moved in the wheelchair;

* Seat alarm;

* Ability to communicate needs; and

* Use of non-skid product under the resident's cushion and bottom.

The need to ensure resident service plans were reflective of current care needs and were consistently followed was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. They acknowledged the findings.

Plan of Correction:

1- On 10/26/22 the nurse overseeing service plans for the residents in the Cascade home reviewed resident 1's service plan that was surveyed and found deficient. These service plans were clarified, corrected and now reflect the residents care level and needs. All staff in the home were re-trained on the Service plan and the updates made to the service plan. The nursing team is currently auditing each residents service plans to make sure they are reflective of each residents current care needs. Updates to service plans will be made by nursing as needed.

2- An interview of the staff members interviewed and observed by state auditors was conducted by the Administrator. After these interviews, it was determined that the staff were not following the proper shift report protocol which requires all staff to read each residents service plan, quiz their fellow employees to help learn the service plan and to report any inconsistencies, incorrect information or any item within the service plan that doesn't reflect the residents current needs to nursing which would trigger an evaluation and possible assessment if determined necessary.

3- On 10/10/22, each staff in the Cascade home as well as all other homes were retrained on the protocol for shift report and the importance of knowing/following care plans and reporting changes or inaccuracies to nursing.

4- A new laminated "quick refrence" sheet has been created for each resident and posted in their bedroom above their bed. This will help both new staff and senior staff have a quicker way to read, know and follow important highlights from each residents care plan. The laminated signs will be updated with each change or update to the service plan, by the supervisor for each home.This is not a substitute for the service plans. This laminated "quick refrence" guide will include the following:

a- types of alarms and when they should be set

b- transfer instructions including equipment use

c- ambulation instructions including any adaptive equipment

d- any miscelanous equipment or instructions for dressing or undressing

e- any safety instructions

f- a picture of how the bedroom should be set up will be posted

5- A new section will be added to our New Hire class to discuss the importance of knowing/following service plans, will review our shift report protocol including reporting inconsistencies, errors or changes to nursing and how to use the "quick refrence" laminated signs. Each new hire will be required to attend this class and pass the competency exam within 30 days of hire.

6- An additional section has been added to our annual training plan, taught by the Administrator, which will review the importance of knowing/following service plans, will review our shift report protocol including reporting inconsistencies, errors or changes to nursing and how to use the "quick reference" laminated signs. Each employee will be required to attend the class and pass the competency quiz annually.

7- As part of the quarterly updates to the Acuity Based Staffing Tool, the Administrator will compare each residents service plan with observed care completion for each resident to make sure the care provided and observed match what is listed in each of the residents service plan.

8- A new section to the Quality Assurance Auditing Tool has been added which will require the auditor to observe shift report in each home. This audit will ensure shift report protocol is followed, known and that each service plan is reviewed and known by the staff in the home. These audits will occur at least quarterly by the Administrator, Assistant Administrator, and staffing Coordinator.

9-An auditing schedule has been created for the Administrator, Assistant Administrator and Staffing Coordinator to ensure audits for each home are done routinely at least quarterly.

10- The Administrator and Assistant Administrator shall oversee and ensure these changes are implemented and monitored.   

2. Resident 1 was admitted to the facility in June 2019 with diagnoses including Alzheimer's.

Observations of the resident, interviews with staff, review of the service plan dated 07/21/22, and progress notes dated 06/25/22 through 10/04/22 were reviewed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Rash on the chest;

* Weight changes;

* Skin breakdown on the genitals; and

* Antibiotic use after skin cancer removal.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. They acknowledged the findings.

3. Resident 6 was admitted to the facility in August 2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan dated 07/21/22, and progress notes dated 06/27/22 through 10/04/22 were reviewed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Head injury;

* Blisters to the foot;

* Loose stools;

* Behaviors including resident altercations; and

* Falls.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. They acknowledged the findings.

5. Resident 3 was admitted to the facility in November 2019 with diagnoses including Alzheimer's and diabetes.

Observations of the resident, interviews with staff and review of the current service plan, short-term service plans, incident report investigations, and progress notes dated 06/25/22 through 10/03/22 were completed.

The resident experienced multiple short-term changes without documented monitoring of progress and/or effectiveness of interventions at least weekly until resolution in the following areas:

* 07/01/22-Non-injury fall;

* 07/17/22-Blister on right foot; and

* 09/12/22-Fall with skin tear to the right elbow.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 9 (Health Services Coordinator/LPN) on 10/05/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when significant, interventions were determined, documented, communicated to staff, monitored for effectiveness, and the changes monitored at least weekly through resolution for 5 of 8 sampled residents (#s 1, 3, 5, 6 and 7). Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in February 2021 with diagnoses including Alzheimer's Disease.

Review of the resident's current service plan and temporary service plans, 06/28/22 through 10/03/22 progress notes, vitals records, and weight records revealed the following:

a. Progress notes on 08/20/22 and 08/25/22 stated the resident experienced falls from bed on those dates. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident following the falls.

b. Review of Resident 2's weights recorded in multiple documents revealed a discrepancy in the weights entered.  There was no documented evidence the facility monitored the weights and addressed the discrepancies to determine if the resident had experienced a change of condition.

The need to ensure the facility addressed the needs of the resident following the falls and the weight fluctuations was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. They acknowledged the findings.

4. Resident 7 was admitted to the facility in September 2022 with diagnoses including Alzheimer's. Resident 7's record was reviewed for changes of condition and revealed the following:

a. Resident 7 experienced 15 falls between 09/01/22 and 10/03/22. Incident reports, progress notes, and temporary service plans identified interventions to mitigate falls; however, the records lacked evidence that interventions were being monitored for effectiveness after each subsequent fall.

In an interview on 10/04/22, Staff 1 (Administrator) and Staff 9 (Health Services Coordinator/LPN) indicated Resident 7 frequently left the campus with friends and family where s/he consumed marijuana. An intervention was put into place to include having friends and family notify the facility if the Resident consumed marijuana to ensure increased monitoring and supervision to minimize further occurrences of falls.
 

On 10/05/22, the need to ensure interventions were monitored for effectiveness was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.

b. Resident 7's record indicated s/he experienced a 13 pound weight loss from 09/01/2022 to 09/15/22 which constituted a 6.3% loss in two weeks.

There was no documented evidence of ongoing monitoring of the resident's weight, no documentation the weight loss was reported to the RN and there were no interventions implemented to minimize further weight loss.

Resident 7 was observed independently eating lunch on 10/04/22 and breakfast on 10/05/22. The resident ate 100% of the meals provided.

On 10/05/22, the surveyor requested a current weight for Resident 7. The weight was noted as 191 pounds, a 1 pound weight loss since 09/15/22.

On 10/05/2022, the need to ensure residents who experienced significant weight loss were referred to the RN, resident-specific interventions were developed and communicated to staff and were monitored until resolution was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.

Plan of Correction:

1- On 10/17/22, the nurse managing fall tracking for resident 5 reviewed all fall trends and new interventions/actions have been implememted. The supervisor and staff for that home have been trained on the new actions/interventions by the nurse.

2- On 10/11/22, the nurse managing 2's care reviewed all current and past weight trends. An RN assessment has since been completed for weight loss. Going forward, the RN will do weekly rounds for all residents to review weight trends for the week to make sure deviations are being reported in a timely and accurate manner.

3- The nurse has audited and reviewed all of resident 1's sevice plans, past acute issues, weight trends and completed an evaluation of residents skin condition. Resident 1's service plan has been updated with instructions to the staff on what to monitor for and when to report changes in these issues.

4- The Nurse who manages resident 6's plan of care has completed an audit and review of skin condition, past and present acute service plans/issues, fall trends and interventions put into place following each acute issue including blisters to the foot, loose stools, behaviors including altercations and falls with head injury. Several updates including resident specific instructions to the staff and new interventions have been added to resident 6's service plan. The supervisor and employees in the home were trained by the nurse for each new addition or change in the plan of care.

5-  The nurse managing fall tracking for resident 7 is currently reviewing each intervention put into place for multiple falls to determine if the intervention has been effective or if a change in the plan needs to be made. The nurse will update the fall tracking form as well as resident 7's service plan. The supervisor and employees for that home will be retrained by the nurse for each new addition or change made to the service plan.

6- On 10/7/22, the nurse managing resident 7's plan of care reviewed the interventions and service plan around the potential of marijuana use related to a pattern of falls. The service plan has been clarified and this intervention has now been reviewed by the nurse for effectiveness. APS was contacted by the Administrator on 10/5/22 to seek guidance regarding this situation.

7- On 10/5/22, An RN assessment was completed for weight loss and interventions have been ordered and are now implemented to help prevent further weight loss. On 10/5/22 the RN reviewed all current and past weight trends to make sure no further weight deviations had not been reported for assessment. Going forward, the RN will do weekly rounds for all residents and will review weights to make sure deviations are reported in a timely and accurate manner.

8- On 10/11/22, the nurse managing resident 3's plan of care, completed an audit of fall trends, and skin issues both resolved and active. All interventions put into place were reviewed for effectiveness and the service plan was updated and clarified. The supervisor and staff have been trained by the nurse, on the additions and clarifications to the service plan. Skin check completed by nursing for documentation.

9- In order to assure all staff know and follow the protocol of reporting each change in condition to nursing/supervisor, a laminated packet has been created by our nursing team and has been posted in each home as a quick refrence guide. This packet clearly lists the different types of changes in condition, signs and symptoms of each, how the staff should respond/who to call and phone numbers are listed at the top of the packet for easy access for all staff.

10- An additional section has been added to the annual training plan, taught by nursing or Nurse Practitioner, which will review the laminated change in condition packet, will re-train all staff on what changes in condition are (including significant) and who to report these changes to per shift. Each staff will be required to attend this class as part of their annual training plan.

11- On 10/20/2022, each supervisor for each home was re-trained by the Administrator on change in condition and as a group we reviewed the laminated change in condition packet.

12- An audit was completed by 10/14/22, for each resident, by our nursing staff, to make sure there were no additional falls, severe weight deviations or any other change in condition that had not been reported to nursing for an evaluation or assessment.  

13- The fall tracking tool that our medical team uses to document falls, track trends and list interventions was updated by nursing on 10/17/22. A new section was added to the tool which will require nursing to continueously evaluate each fall, review past and current interventions to see if they remain useful or appropriate and to track fall trends in a clearer way. This fall tracking tool will be reviewed by the Nurse Practitioner and Administrator in each quarterly review for each resident to ensure the fall tracking tool is being used appropriately and accurately by nursing.

14- The Administrator will now compile a list of each incident for each resident in a report format and bring it to each quarterly review for the medical team to review. This will help identify trends for incidents in a clearer way.

15- During survey it was identified that weights were being entered in many different places which was causing confusion in addition to discrepancies in the weights entered. To prevent reocurrance and to make sure weight deviations are accurately reported for evaluation or assessment, we will now only enter vitals and weights in one place. Instead of using the electronic recording system, we will now use the paper form (orange vitals signs sheet) which will be located in each home in a binder specifically for vitals signs recording. This form has been updated with clear instructions to the staff checking and recording vitals on what and when to report deviations in any vitals sign.

16- The paper vitals signs sheet will be checked by each supervisor for each home at least weekly to make sure issues are being reported in an accurate and timely manner. On 10/20/22 each supervisor for each home was trained by the Administrator on the new vitals signs reporting and recording process. At this meeting a plan was outlined for each supervisor to train their staff in each home on the new process for recording and reporting vital sign deviations.

17- The RN will now do rounds to each home weekly to review each acute service plan as part of our weekly monitoring for acute issues and will also review each orange paper vital signs sheet to make sure any issues are identified and addressed in a timely and accurate manner.

18- A rounding schedule has now been created by the RN to ensure each home will be visited at least weekly so all vitals and acute service plans are reviewed at least weekly.

19- On 10/20/2022, the medical team and Administrator reviewed the regulations and requirements for changes of condition, monitoring changes in condition and situations which require an RN assessment vs. an evaluation from the LPN.

20- Each of our Acute Service plan forms are currently being reviewed and revised by the nursing team. The revisions will have clearer and more descriptive instructions for monitoring and documentation for the staff to follow. Each Acute Service plan in place for an active issue, will be reviewed weekly by the RN.

21- A section taught by the Administrator, has been added to the New Hire Class and to the annual training plan. This section will review the list below (including but not limited to):

a- Proper documentation while monitoring an acute condition.

b- PIC responsibilities for reporting changes in condition to nursing.

c- shift report protocol including reading all care plans and acute care plans.

d- recording weight/vitals and when to report issues to nursing.

e- The importance of knowing and following service plans.

All new hires will be required to attend this New Hire class within 30 days of hire and all senior staff will be required to attend this class annually as part of the annual training requirement.

22- The Administrator, Assistant Administrator shall oversee and ensure these changes are implemented and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was performed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 1 of 6 sampled residents (#7) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 7 was admitted to the facility on 09/01/22 with diagnoses including Alzheimer's disease.

Review of the resident's weight records from 09/01/22 through 09/15/22 showed the following:

The resident experienced a 13-pound weight loss from 09/01/22 to 09/15/22, which constituted a 6.3% weight loss in two weeks. The resident weighed 205 pounds on 09/01/22 and 192 pounds on 09/15/22.

There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

Resident 7 was observed independently eating lunch on 10/04/22 and breakfast on 10/05/22. The resident ate 100% of the meals provided.

A current weight was requested by the surveyor on 10/05/22; the resident weighed 191 pounds.

On 10/05/22 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.

Plan of Correction:

1- In response to the findings from survey, the resident who expierenced significant weight loss has now had an RN assessment and the plan has been updated to help prevent further weight loss.

2- A complete audit was completed by the RN by 10/17/22 for every resident to review weight trends and address any further RN assessments that are needed.

3- The RN will now do weekly rounds for each resident, at each home, to review the weights and vital signs trends for the current week as a double check to make sure each weight or other vital signs fluxuation/abnormalities were reported to the medical team as required by our protocol.

4- In order to make sure vital signs including weights, are accurately recorded and reported, we have discontinued the use of Elder Mark, the electronic medical record system, for recording vitals including weights. We will now only use a paper sheet (orange sheet) to record weekly vitals signs checks. The form has  written perimeters and guidelines at the top of the form, for reporting weight loss, gains or any other abnormalities to nursing. The Coordinators for each home, will be responsible to review each residents vitals including weight weekly and report any abnormalities to nursing.

5- The medical order in Elder Mark that requires weekly vitals signs checks and reporting was updated to prompt the med passer to now record all weekly vitals on the orange sheet and to refer to instructions on the orange sheet for recording and reporting.

6- On 10/20/22 a team meeting which was attended by every supervisor including nursing, was conducted by the Administrator to review the rules and regulations around change in Condition reporting and monitoring including weight loss or gains withing the significant catagory.

7- Our quality assurance auditing form has been updated which will require the auditor to check each residents weight/vitals trends and will make sure it was reported and assessed by the RN as needed. This audit will be completed by the Administrator, Assistant Administrator and Staffing Coordinator at least quarterly.

8- An additional section to the annual training plan has been added. The Nurse Practitioner or RN will review rules, regulations, our policies and procedures around Change in Condition identification, reporting, required assessments and monitoring/documentation. Each employee will be required to attend this class and pass the competency exam annually.

9- The Administrator, Assistant Administrator and RN shall oversee and ensure these changes are implimented and monitored.   

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 10/03/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Resident 4's insulin administration record and MARs, reviewed from 09/01/22 through 10/03/22, revealed insulin had been given by Staff 15 (Cedar Resident Coordinator/MT), Staff 28 (Shift Supervisor/MT) and Staff 29 (Shift Supervisor/MT) on multiple occasions.

The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 15, completed 08/30/22, Staff 28, completed 06/22/22 and Staff 29, completed 08/25/22, lacked documentation in the following areas:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and

* Individual observation/return demonstration of competence, to include determination if the staff remained capable and willing to safely perform the task.

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 (Assistant Administrator) and Staff 8 (Health Services Director/RN) on 10/05/22. They acknowledged the findings. No further information was provided.

Plan of Correction:

1- An audit was conducted and completed by the RN on 10/6/22 to review each delegated task, each employee who is delegated and the documentation around delegations. Employees have been re-delegated using updated delegation form, RN assessmanets have been completed for every resident with a delegated task.

2- The RN and medical team have updated our RN delegation forms which now include sections for the following:

a- Nursing assessment and condition of the resident.

b- identify if the residents condition remains stable and predictable.

c- individual observation with return demonstration of competence which also includes a section of the determination if the staff remained capable and willing to safely preform the task.

d- date specific timelines for observation and return demonstrations/follow up for each delegated staff.

3- The RN will now attend each quarterly review for every resident that has delegated tasks to review all documentation around the delegated task and to determine if the residents condition continues to be stable and predictable. The RN's attendance will ensure that the communication between the prescribing NP for that resident will be clear and goals of care discussed to ensure that the current plan continues to be appropriate for each resident with delegated tasks.

4- During quarterly reviews, the Nurse Practitioner will review all delegation documentation to make sure rules and regulations are followed.

5- On December 6th, the RN will attend the OHCA educational series on the RN role in long-term care.

6- The Administrator, RN and Assistant Administrator shall oversee and ensure these changes are implemented 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 thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#6) who had a merry walker. Findings include, but are not limited to:

Resident 6 was admitted to the facility in August 2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 07/21/22 showed the resident had a merry walker s/he used when out of bed. The resident was able to stand and sit without staff assistance once assisted into the merry walker. The resident additionally ate all his/her meals while seated in the merry walker.

Review of the resident's record showed the last evaluation of the merry walker was completed in November 2021. The device was not evaluated at least quarterly to determine safety and appropriateness for the resident.

The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. The staff acknowledged the findings.

Plan of Correction:

1- An audit of all residents has been completed by the nursing team to identify every resident that has any device with restraining quality and to make sure each resident has current evaluations completed for devices with restraining qualities.

2- The quarterly pre-conference evaluation form filled out by nursing before each residents quarterly review, has been updated with a section identifying if each resident has a device with potentially restraining qualities and if so, will prompt the nurse to complete the quarterly evaluation.

3- The Administrator and/or Assistant Administrator will review the quarterly nursing evaluations in the actual quarterly review for each resident, to make sure the rules and regulations are met. This will be documented on the documentatoin of changes form fille out by the Administrator or Assistant Administrator in each quarterly resident review.

4- The Administrator and Assistant Administrator shall oversee and ensure these changes are implemented and monitored.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff completed first aid training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/04/22 and 10/05/22. The following was identified:

There was no documented evidence Staff 21 (CG/MT), Staff 31(CG), and Staff 32 (CG/MT), hired 07/05/22, 07/20/22, and 08/02/22, respectively, completed first aid training within 30 days of hire.

In an interview on 10/05/22, Staff 3 (HR Coordinator) reported these three staff were unable to attend a scheduled new hire orientation class and she neglected to provide the training when they were able to attend.

The need to ensure all new staff demonstrate competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. They acknowledged the findings.

Plan of Correction:

1- An audit of each employees training hours was completed by the HR Coordinator on 10/20/22 to identify any further employees who have not completed the required training within 30 days of hire. Each employee identified as deficient, has now completed the required training and is now back in compliance.

2- The HR Coordinator will now conduct  bi-montly audits for every new employee to make sure the rules and regulations are met for required training within 30 days of hire.

3- Our policy for newly hired employees has been updated. This update will remove new employees from the schedule if the employee is unable or misses the required training classes and will not allow the employee to work or be scheduled to work until the class is attended. Each supervisor was trained regarding this change on 10/24/22.

4- The Administrator, Assistant Administrator and HR Coordinator shall oversee and ensure these changes are implemented and monitored.

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

Tours of the facility's resident cottages and common areas, conducted 10/03/22 through 10/05/22, revealed the following:

Cascade:

* Baseboards in common areas and bathrooms had pulled away from the wall;

* Baseboards in bathrooms had an accumulation of dark matter around the top and bottom edges;

* A large piece of linoleum was missing from the bathroom floor in the front of the house;

* Multiple areas of the flooring had seams which had pulled apart and an accumulation of dark matter was noted at the edges;

* A light in the dining room was cracked with a large piece taped back in place;

* Multiple ceiling lights throughout the house had dead insects and debris inside the covers;

* Storage cupboard/drawers in the back of the dining room were gouged and scraped;

* Grab bars in the bathrooms had a brown/red discoloration at the edges and a white discoloration along the bar;

* Flooring in the living room was gouged and scraped near the transfer pole and large scratches were noted in the flooring of the other common areas;

* Multiple chair backs in the dining room had stains of varying colors, elevated table had scrapes and scratches up and down the legs and the feet of the table were seated in duct taped wrapped foam with exposed/frayed edges;

* Resident 6's merry walker had exposed foam padding and frayed/torn duct tape on the upper edges;

* An assist bar in the front of house bathroom was wrapped in foam and duct tape, the foam was exposed in multiple areas and the duct tape was torn and frayed;

* Large chips were noted to the floor of the shower with exposed under surface; and

* Baseboards throughout unit had large black streaks/scuffs.

Willow:

* A green couch in the living room had stains on the seating area;

* Multiple ceiling lights throughout the house had dead insects and debris inside the covers;

* There was a gap in the flooring where the shower stall and floor met; and

* There was black tape on the front deck flooring which was frayed and peeling off.

Mt. Vernon:

*The main entrance doormat was taped to the floor with yellow tape, which had frayed and had partially peeled away from the floor;

* The baseboard in the shower room had separated from the wall; there was a build up of brown matter in the corners of the shower stall; and the paint on the mount for the grab bar had peeled off;

* Floors throughout the house had gouges, scrapes, and black smudges/streaks; and

* Three green chairs and the love seat in the living room had areas on the seat cushions where the fabric had ripped.

Aspen:

*Chipped laminate flooring in the hallway outside Rooms 4 and 5 and in the dining room;

*The finish on the piano in the living room was wearing off in places and it had chips and gouges;

*There were scratches on the laminate flooring in the living room; and

*There was a build-up of black matter where the baseboard met the flooring in the bathroom by the dining room.

Birch:

*In the bathroom connected to the laundry room, the top of the garbage can was rusted;

*The fireplace cabinet under the TV in the living room was chipped along the bottom edge;

*The cabinet holding the fish tank in the living room had scrapes, splinters, and exposed bare wood; and

*The three-drawer cabinet in the dining room was chipped and the finish was wearing off around the handles and along the bottom edge.

The environment was toured with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) during survey. They acknowledged the findings.

Plan of Correction:

1- On 10/18/22, a walkthrough of each of our 9 homes was completed by the Maintenance Coordinator, Administrator and Assistant Administrator. The following was identified and has been addressed or is in process of being addressed:

Cascade Home:

a- baseboards in both restrooms have been cleaned and black matter has been removed by the supervisor for the home.

b- the light cover in the dining room which was cracked and taped has been replaced by the Maintenance Department.

c- all ceiling lights have been cleaned by the Maintenance Department.

d- the storage drawers in the back of the dining room have been painted by the Maintenance Department.

e- grab bars in both restrooms have been replaced by the Maintenance Department.

f- each of the chairs in the dining room have been steam cleaned by the Maintenance Department and are now free of stains. The elevated dining room table legs have been repaired so no scratches are present. The foam and duct tape have been removed from the bottom of the dining room table legs by the Maintenance Department.

g- foam and duct tape has been removed from resident 6's merry walker by the supervisor for the home.

h- the foam and duct tape has been removed from the  assist bar in the front restoom by the supervisor for the home.

g- the chips in the floor of the shower surface have been sealed and repaired by the Maintenance Department.

h- Baseboards throughout the home have been cleaned to remove any dirt, build-up, black streaks by the supervisor for the home. Any baseboards that were pulling away from the walls have been resecured by the Maintenance Department until the scheduled replacement of all baseboards is completed by the outside contractor we are working with.

i- We are currently working with an outside contractor to have floors with missing linoleum, floors where seams have seperated or deep scratches rendering the floors uncleanable replaced.

Willow Home:

a- The green couch with noted stains has been steam cleaned by the Maintenance Department.

b- all ceiling lights have been cleaned by the Maintenance Department.

c- the gap in the floor where the shower stall and floor meet has been caulked by the Maintenance Department.

d- the black duct tape on the front walkway has been replaced by the Maintenance Department and is no longer frayed or damaged.

Mt. Vernon Home:

a- the duct tape has been removed from the main entrance mat by the Maintenance Departement.

b- the baseboard in the back restroom has been reattached and secured by the Maintenance Department until the hired contractor replaces all baseboards throughout the home. The shower stall has been deep cleaned by the supervisor for the home and the brown matter has been removed. The mount for the grab bar has been repainted by the Maintenance Department.

c- the three green chairs and loveseat in the livingroom that were worn or torn have been removed by the Maintenance Department and replaced with alternate furniture that is in good repair.

d-  We are currently working with an outside contractor to have all flooring that is currently damaged, chipped, scratched or has large gaps replaced.

e- The supervisor and staff for the Mt. Vernon home have deep cleaned the flooring to remove the black smudges and streaks.

The Aspen Home:

a- The piano was removed from the home by the Maintenance Department.

b- the black matter located where the baseboard met the flooring in the front restroom has been cleaned and removed by the supervisor for the home.

c- We are currently working with an outside contractor to have all flooring that is currently scratched, gouged, chipped replaced.

The Birch Home:

a- The garbage can in the back restroom has been replaced by the Maintenance Department.

b- the fireplace cabinet under the TV has been removed by the Maintenance Department.

c- The cabinet holding the fishtank will be replaced with a different material by the Maintenance Department.

d- The three-drawer cabinet in the dining room has been repainted by the Maintenance Department.

2- Updated chore lists which the Maintenance workers/food and supply workers will complete, have been created by the Administrator and Maintenance Coordinator to include the scheduled (at least quarterly) cleaning and inspection of the following for each home:

a- checking all lights thoughout the home to make sure they are clean and in good repair. If dirty, clean and if covers or light itself is damaged, repair.

b- check the paint and surfaces throughout the home to make sure walls, cupboards, the storage drawers, grab bar bases and other furniture is free from gouges, missing paint, scratches or any other issue that would make them uncleanable. If the above is noted, Maintenance Department will be notified for repair.

c- check baseboards throughout the home to make sure they are all in good repair, fully attached to the wall with no gaps. If any issue is identified, Maintenance Department will be notified for repair.

d- check all handrails for rust, scrapes, gouges or any other sign of disrepair. If noted, notify Maintenance Department for repair.

3- The Environmental Quality Auditing tool which will be completed for each home at least quarterly by the Administrator, Assistant Administrator and Staffing Coordinator has been updated to include the following:

a- checking all floors throughout each room in the homes for scratches, gouges, disrepair, buildup or any other issue that would render the surface uncleanable in any way. If this is identified, the Maintenance Department will be contacted by the auditor for repair.

b- visually inspecting all basetrim thoughout each room in each home to make sure they are clean, in good repair and fully attached to the wall. If the above is not met, the Maintenance Department will be contacted by the auditor for repair.

c- check the entire home to make sure there is no foam or duct tape being used. If noted, the auditor will remove.

d- check all lighting to make sure covers are clean, in good repair and functioning properly. If any issues are noted, the auditor will notify the Maintenance Department for repair.

e- check all grab bars throughout the home to make sure there is no rust or buildup present. If issues are noted, the auditor will notify the Maintenance Department for repair.

f- check all walls, furniture, cabinets, drawers and all other furniture to make sure there is no exposed wood, any scratches, gouges, missing paint or other issue that would render the surface uncleanable and if any issues are noted the auditor will contact the Maintenance Department for repair.

g- check all furniture to make sure there are no tears, gouges, exposed wood, scratches, missing paint or finish, stains or buildup. If noted, the auditor will work with the supervisor for the home (if the issue is a cleaning issue) and the Maintenance Department for repair.

h- check each shower stall to make sure they are clean and in good repair. If any issues are noted, the auditor will work with the supervisor for the home (if the issue is a cleaning issue) and the Maintenance Department for repair.

i- check each garbage can to make sure they are clean and in good repair. If they need to be replaced or cleaned, the auditor will work with the supervisor for the home.

j- check all flooring throughout the home to make sure they are clean, free from scratches, gaps, gouges, chips or any other issue that would render them uncleanable. If issues are noted, the auditor will work with the supervisor for the home (if the issue is a cleaning issue) and the Maintenance Department for repair.

4- An updated Quality Assurance Auditing schedule has been created by the Administrator to assure each home is being thoroughly audited for environmental issues at least quarterly. The auditing team which consists of the Administrator, Assistant Administrator and Staffing Coordinator, was trained on the new additions to the auditing tool as well as the updated schedule on 10/26/22.

5- The Administrator and Assistant Administrator shall oversee and ensure these changes and updates are completed and implemented.

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:

Refer to C240, C372 and C513.

Refer to tag C240, C372 and C513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff demonstrated competency in all required areas within 30 days of hire and 3 of 4 long-term staff completed a total of 16 hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed on 10/04/22 and 10/05/22. The following was identified:

1. There was no documented evidence Staff 21 (CG/MT), Staff 31 (CG), and Staff 32 (CG/MT), hired 07/05/22, 07/20/22, and 08/02/22, respectively, demonstrated competency in the following areas within 30 days of hire:

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition; and

* Conditions which require assessment, treatment, observation, and reporting.

Staff 3 (HR Coordinator), in an interview on 10/05/22, reported these three new hires were unable to attend a scheduled new hire orientation class in which these topics were covered, and she neglected to schedule them for individual training.

The need to ensure all new hires demonstrated competency in all required areas was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. They acknowledged the findings.

2. There was no documented evidence Staff 17 (Resident Coordinator/MT), hired 06/20/12; Staff 34 (CG/MT), hired 08/11/20; or Staff 35 (CG/MT), hired 07/19/18, completed the required number of hours of annual in-service training in 2021 through 2022. Training records reviewed were 6/2021 - 6/2022, 8/2021-8/2022, and 7/2021-7/2022, respectively.

The need to ensure staff completed a total of 16 hours of annual in-service training was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. They acknowledged the findings.

Plan of Correction:

1-An audit for each employees annual training hours has been completed by the HR Coordinator. As a result of this audit, a list has been compiled of every employee who is needing additional annual training hours. A plan is now in place to get each employee caught up on their required annual training hours.

2- The HR Coordinator will now complete montly audits for each employee to ensure the requirement for annual training hours is met.

3- We will now begin using Oregon Care Partners training as a suppliment to our current training program if an employee misses one of their scheduled training classes or if they are needing additional training hours in order to maintain compliance for requirements for annual training hours.

4- The Administrator, Assistant Administrator and HR Coordinator shall oversee and ensure these changes are implemented and monitored.

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:

Refer to C260, C270, C280, C282 and C340.

Refer to tags C260, C270, C280 and C340.