The findings of the re-licensure survey conducted 11/15/21 through 11/18/21 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 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 11/18/21, conducted 02/22/22 through 02/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 second re-visit to the re-licensure survey of 11/18/21, conducted 05/18/22 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 implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

1. A review of Resident Council minutes dated 09/23/21 and 10/21/2021 revealed the following resident concerns:

* "The kitchen needs to let us know about changes in the menu ahead of time. Not when caregivers take orders to residents ...";

* "Too much frozen food, instant, high sodium foods";

* "Would like some fresh fruit on snack tray ...";

* "Clothes are coming up missing again ...";

* "Too much instant/frozen food still. Too much processed food";

* "Trouble getting help...seemed like hours...also meals late or not [delivered] frequently";

* "Caregivers on phone in my room is becoming an issue";

* "Shower curtain in shower rooms, need non-slip tiles in all bathrooms";

* "Patio/deck doors need to be locked at night.  All [three] of them are left open..";

* "How does the financial situation of the company affect residents ...is there a problem that has led to the changes in the care and services?":

* "Survey residents";

* "Caregivers should always answer the call buttons within [five] minutes";

* "Security, especially at night...smoking area is not safe at night"; and

* "Does anyone know CPR?";

There was no documented evidence the concerns identified during the meetings had been addressed, responded to or resolved.

2. The survey team conducted resident interviews with multiple alert and oriented facility residents between 11/15/21 and 11/18/21. Some residents voiced concerns regarding the facility including equipment failure, dissatisfaction with call light responses, staffing and lack response from the Administrator regarding concerns.

In an interview on 11/18/21, Staff 1 (Executive Director) stated she had not yet reviewed the Resident Council meeting notes from 10/21/21. The facility had no documented evidence showing follow-up to residents' concerns. She acknowledged the need to improve the facility's method for responding to and resolving resident complaints and concerns.

The need to implement effective methods of responding to and resolving resident complaints was discussed with Staff 1, Staff 5 (Resident Care Coordinator), and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Executive Director has created a grievance log and will begin documenting all grievances and will follow up in a timely manner.

Executive Director will read Resident Council Meeting notes within one week of the meeting and will meet with the Resident Council President monthly to follow up on issues at hand.

See above

Monthly

Executive Director is responsible for meeting with Resident Council President on a monthly basis.  

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 11/15/21 through 11/18/21, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

In an interview on 11/18/21, Staff 1 (Executive Director) confirmed the facility did not have a quality improvement plan in place.

Refer to the deficiencies in the report.

Quality Improvement meetings will occur on a quarterly basis moving forward.

Quarterly Improvement Meetings

Quarterly

Executive Director is responsible for meeting with the Quality Improvement Committee at least quarterly to identify and act on quality issues.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. This is a repeat citation. Findings included, but are not limited to:

During the survey, conducted 02/22/22 through 02/24/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

In an interview on 02/24/22, Staff 1 (Executive Director) acknowledged the facility did not have a quality improvement plan in place.

Refer to the deficiencies in the report.

1). A program for quality improvement has been developed and is currently in use.  The program reviews services provided, resident outcomes, and resident satisfaction with subsequent action taken as identified.

2). Formal quality improvement meetings including department heads and other individuals as appropriate will be conducted no less often than quarterly.  More informal gatherings will be conducted as the need arises.

3). The efficacy of the program and evidence of meetings being conducted will be monitored at least quarterly.

4). The Executive Director, Director of Operations, and nurse consultant are assuring compliance.   

Based on interview and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

Five residents resided on C-Hall during the survey.

In individual interviews on 11/15/21 and 11/18/21 with residents on C-Hall, they expressed concern that call lights were not answered in a timely manner, often exceeding 30 minutes.

One resident stated that during the evening shift on 11/17/21, s/he waited over an hour for staff to answer his/her call light. S/he said s/he felt "neglected" as his/her incontinence brief was "soaked". S/he added that "this happens frequently ...It's affecting my quality of life." S/he said s/he reported the incident to Staff 6 (Resident Care Director).

Review of the call log for the resident revealed s/he pressed the call button at 8:55 pm. It took 1 hour and 30 minutes before staff "resolved" or responded to the call.

Call light response logs, for the time period of 11/01/21 through 11/18/21, were reviewed. The following was revealed:

* Residents on C-Hall called 691 times for assistance; and

* 228 of the 691 calls exceeded 15 minutes (33% of the time), with 70 of those calls exceeding 30 minutes.

The above information was discussed with Staff 6 (Resident Care Director) on 11/18/21 at 2:55 pm.  He was aware of the incident that occurred on 11/17/21. He added he was in process of his investigation of why it took so long for staff to respond to the resident's call light. The surveyor reviewed the call log with Staff 6. He said staff should be answering calls within 10 minutes. He acknowledged that response times were too long. He stated that he did not routinely audit the call logs/response times and was unaware of the numerous call times exceeding 15 minutes.

The need to ensure call lights were answered in a timely manner was discussed with Staff 1 (Executive Director) on 11/18/21 at 3:10 pm. She reviewed the call logs and acknowledged the findings. She stated the system would be reviewed, audits performed and changes made to ensure calls were answered timely.

Resident Care Director will audit call lights on the C wing on a routine basis.

Resident Care Director will identify if any patterns are present in regards to longer wait times for call light response.

The system will be evaluated on a monthly basis.

Executive Director is responsible to correct any issues that arise with longer than average wait times on call lights.

Based on interview and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to:

During the survey conducted 2/22-2/24/22 five residents resided on the C-Hall.  

During the survey, call light response logs, for the time period of 02/01/22 through 02/23/22, were reviewed. The following was revealed:

* Residents on C-Hall called 853 times for assistance; and

* 362 of the 853 calls exceeded 15 minutes (42.4 % of the time), with 158 of those calls exceeding 30 minutes.

In an interview on 02/24/22, Staff 9 (MT) and Staff 11 (CG) explained the call system used in the facility. Staff 9 reported that when a resident activated a call pendant, the call signal activated the medication technician computers (used in C-Hall). The call signal was audible as well as visual. The other medication technician computer (used in Halls A and B), however, did not receive the call signal.  Staff 9 stated the MTs would use walkie talkies to communicate with staff if they saw a call had gone unanswered for an extended period. Staff 11 reported caregivers received call notifications on an "ipod" they would carry with them. The ipod did not have an audible tone. Caregivers were required to look at the ipod "every seven minutes" to check if a call pendant had been activated. Care givers also would carry walkie talkies to communicate with other staff to respond to call notifications.

The need to ensure call lights were answered in a timely manner was discussed with Staff 1 (Executive Director) on 02/23/21. She reviewed the call logs and acknowledged the findings. She stated the system would be reviewed, audits performed by Staff 17 (Business Office Manager) and changes made to ensure calls were answered timely.

1). The call light system is being evaluated to assure it consistently audibly notifies staff when a resident activates their call system.  This evaluation is known to the owners and they are prepared with capital funds if significant improvements are required.  Sufficient walkie talkies are available to staff to enhance communication for the safety and well-being of the residents.  

2). Random audits of call light response times are being conducted no less often than weekly to facilitate timely response and to assure the system functions properly at all times.  

3). Findings from #1 and #2 above will be reviewed in the quality improvement program at least quarterly and more frequently as needed.

4). Executive Director and Director of Operations are assuring compliance.

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 11/15/21 at 9:45 am, the facility 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:

* Wall, pipes and drain under dish machine;

* Caulking behind dish machine;

* Floor perimeter and tile edge in dish machine area; and

* Knobs of ovens.

b. The following areas needed repair:

* Doors, frames and jambs were scraped and gouged; and

* Walls in the dish machine area had several scraped areas.

The areas that required cleaning and repair were observed and discussed on 11/15/21 with Staff 3 (Dining Services Director) and discussed with Staff 1 (Executive Director) on 11/16/21. The findings were acknowledged.

Met with Maintenance on 11-30-2021 to address the issues.  Caulking was replaced on 11-15-2021.  Maintenance and kitchen staff will clean kitchen on a regular basis.

Maintenance will do routine walk through of the building on a routine basis and repair doors, frames and jams accordingly. Executive Director ordered corner protector for pillars throughout building.

Routine cleaning.

Weekly

Executive Director is responsible for ensuring cleanliness of kitchen and entire building.

2. Resident 1 moved into the facility in 07/2021.

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

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

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

The need to ensure move-in evaluations included all required elements was discussed with with Staff 2 (RN) and Staff 5 (Resident Care Coordinator) on 11/17/21, and with Staff 1 (Executive Director) on 11/18/21. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled resident (#s 1 and 3) and failed to complete 30-day evaluations for 1 of 2 sampled resident (#3). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2021.

The move-in evaluation failed to address the following:

* Environmental factors that impact a resident's behavior including noise, lighting and room temperature.

There was no documented evidence Resident 3's initial evaluation was updated and modified as needed during the 30 days following the resident's move into the facility.

The failure to address all required areas in the move-in evaluation and to update or modify the evaluation within 30 days after move-in was discussed with Staff  2 (RN) on 11/17/21 and with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Oregon Assessment will include all required components and will be completed prior to move in and again after 30 days after admission. Move in assessment to be completed by qualified staff. RN will double check assessment for accuracy. 30 day assessment will be completed by a qualified staff, double checked by RN and 3rd check completed by Executive Director.

Triple check system put into place.

At every assessment.

Executive Director is responsible for ensuring all assessments are completed accurately.

Based on observation, 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 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2021 with diagnoses including insulin dependent diabetes, a history of falls, skin breakdown and a urinary catheter.

Review of Resident 1's clinical record, interviews with care staff and observations during the survey revealed s/he had a ½ siderail on the left side of the bed. Additionally, the resident needed assistance with ADL care, including emptying his/her catheter bag, but often refused the help.

Resident 1's service plan, dated 11/10/21, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Siderail use, including correct use and precautions related to the use of the device; and

* Interventions when s/he refused care.

The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 2 (RN) and Staff 5 (Resident Care Coordinator) on 11/17/21, and with Staff 1 (Executive Director) on 11/18/21. The findings were acknowledged.

2. Resident 3 was admitted to the facility in 2021 with diagnoses including cerebrovascular accident.  

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's 11/11/21 service plan, temporary service plans, and 8/4/21 through 11/15/21 progress notes were reviewed.

The resident's current service plan was not reflective of the resident's needs and preferences and did not offer clear instruction for the staff in the following areas:

* Mobility - regarding the resident's use of manual wheelchair, electric wheelchair and walker;

* Sleeping routine-regarding the resident's preference to sleep in his/her electric wheelchair frequently; and

* Siderail use-including associated risks.

The need to ensure service plans were reflective of the resident's current needs and  status and provided clear instruction to staff was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator), and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

RCC/RCD retrained on care plans by Executive Director. Care plans will be reviewed by Executive Director upon completion and prior to care plan being finalized. All resident needs will be listed accurately and will have clear directions/interventions.

Executive Director will review all care plans before the finalization of the care plan.

Quarterly

Executive Director is responsible for ensuring all care plans are complete and accurate.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff regarding the delivery of service for 1 of 3 sampled residents (#5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 2021 with diagnoses including chronic peripheral venous insufficiency and urinary tract infection.

Observations of the resident, interviews with staff and review of the service plan and clinical records during the survey, from 02/22/22 thru 02/24/22, showed the service plan was not reflective of the resident's current care needs and failed to provide clear direction in the following:

* Use of oxygen including setting;

* Toileting status including use of a bedpan;

* Transfer status;

* Use of glasses; and

* Use of side rails.

On 02/24/22, service plans were discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director). They acknowledged the service plan was not reflective of the resident's status and lacked clear instructions.

1). Resident #5 returned to the community the evening of 02.21.2022 following a lengthy hospital stay related to COVID which resulted in a terminal condition.  The resident's service plan was under review at the time of the re-survey.

2). All resident service plans are currently under review to assure accuracy and personalization.  Temporary service plans are available for use to notify all staff of changes as those changes occur.  

3). Resident service plans are reviewed and revised quarterly and more often if needed.

4). Compliance is assured by the Resident Care Coordinator, the SNC Program Director and the Excutive Director.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

Resident 1, 2 and 3's current service plans were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

RCC/RCD retrained by Executive Director on what a Service Planning team consists of.

All care plans will consist of a Service Planning team.

Quarterly

Executive Director is responsible for ensuring that all care plans consist of a Service Planning team.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 3 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to:

Resident 5 and 6's most recent service plans were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director) on 02/23/22. They acknowledged the findings.

1). Resident #5 expired 02.24.2022.  The service plan for resident #6 is under review with the service planning team and will be finalized with the resident.

2). A service planning team is in place and will include other individuals as requested by each resident for each revision.  

3). Use of the service planning team will be reviewed quarterly during the quality improvement program meetings.

4). Executive Director and SNC Program Director are assuring compliance.  

Based on interview and record review, it was determined the facility failed to ensure short term changes of condition were monitored until resolution for 2 of 4 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted in 2021 and had diagnoses which included a urinary catheter, history of urinary tract infections (UTIs), falls and skin injuries.

Resident 1's clinical record and charting notes, reviewed from 08/01/21 through 11/15/21, revealed the following:

a. On 09/02/21, a MT charted in progress notes that the resident "shows signs of possible UTI." No further information, including documented monitoring until resolution, was noted.

b. On 09/13/21, the resident sustained a "deep cut between [his/her] fourth toe and little toe on [his/her] left leg." Documentation indicated the facility treated the injury and initiated short-term change monitoring. However, no monitoring until resolution was documented for the change in condition.

c. A progress note, dated 09/30/21, indicated the resident "hurt [his/her] foot on door, was bleeding ..." Although treatment was provided, there was no specific information about the wound or monitoring until resolution.

d. On 10/06/21, staff noted that the resident had a small abrasion on top of the fourth toe on his/her right foot. The record revealed no documented monitoring of the wound at least weekly until resolved.  

In an interview on 11/17/21 at 4:30 pm, Staff 2 (RN) and Staff 5 (Resident Care Coordinator) stated they were unable to find documentation that the short-term changes in condition were monitored until resolved.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) on 11/18/21. She acknowledged the findings.

2. Resident 2 moved into the facility in 2019.

His/her clinical record and charting notes, reviewed from 08/01/21 through 11/15/21, revealed the following:

* On 08/15/21, the resident was "throwing up on this shift with diarrhea." Documentation indicated the facility initiated short-term change monitoring. However, no monitoring until resolution was documented.

* On 09/30/21, staff reported that the resident had a "pale or lighter pigmented skin on [his/her] left inner thigh." Documentation indicated "care staff will continue to monitor." There was no documented on-going monitoring of the resident's skin condition until either resolved or it was determined that monitoring was no longer needed.

In an interview on 11/18/21 at 8:20 am, Staff 6 (Resident Care Director) stated he was unable to find documentation that the conditions were monitored until resolved.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) on 11/18/21. She acknowledged the findings.  

Upon resident COC, RCC will complete COC documentation and initiate alert charting. Qualified staff will monitor routinely and will document observations. Documentation will continue until resolution of COC.

COC documentation will be reviewed routinely by RCC/RCD and by Executive Director until resolved.

Monthly

Executive Director is responsible to ensure all short term changes of condition have completed and accurate documentation until resolution.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were assessed by a facility RN in accordance with their conditions, findings documented, and interventions developed and implemented as a result of the assessment for 1 of 2 sampled residents (#1), who experienced a significant change of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 2011 with diagnoses including cerebral palsy. The resident was receiving hospice services at the time of survey.

The resident's 08/01/21 through 11/15/21 progress notes, 02/2021 through 11/2021 weight records, 09/14/21 service plan, multiple temporary service plans, 11/01/21 through 11/18/21 MAR and 11/04/21 evaluation were reviewed and revealed the following:

The facility weight records noted the following:

* 08/18/21-138.3 pounds.

* 09/2021-no weight listed;

* 10/13/21-121.8 pounds;

* 10/14/21-130 pounds; and

* 11/14/21-120.2 pounds.

.

Between 8/2020 and 11/2021 Resident 4 lost 18.1 pounds in three months or 13.8% of his/her body weight constituting a severe weight loss. There was no documented evidence the facility RN completed an assessment including findings, resident status, and interventions made as a result of the assessment.  

Observations of the resident during lunch on 11/17/21 and 11/18/21 showed the resident was able to partially feed him/herself.  Staff would then assist him/her with the resident consuming 80% of the meal on 11/17/21 and 100% on 11/18/21.

In an 11/18/21 interview with Staff 2 (RN), she confirmed she did not complete a thorough RN assessment regarding Resident 4's severe weight loss.

The failure to ensure an RN assessment was completed for significant changes of condition was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator), and Staff 6 (Resident Services Director) on 11/18/21. They acknowledged the findings.

Maintenance will ensure that the scale is calibrated for accuracy. Staff will be educated on proper use of the scale. Routine weight meeting to review changes with the RN, RCC and Executive Director. Review and discuss changs and utilize a team approach to address changes.

Routine meetings.

Monthly

RN is responsible for ensuring weights are accurate and appropriate COC is 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 1 of 1 sampled resident (#1) 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 11/15/21, Resident 1 was identified to be administered insulin injections by non-licensed staff.

Resident 1's MARs, reviewed from 11/01/21 through 11/15/21, revealed insulin had been given by Staff 9, 14 and 15 (MTs) on multiple occasions.

Delegations for Staff 9 (MT) completed 09/16/21, Staff 14 (MT) completed 09/15/21, and Staff 15 (MT) completed 10/21/21, lacked documentation in the following areas:

* A current nursing assessment and condition of the client;

* The skills, ability and willingness of the unlicensed person;

* That the unlicensed person was competent to safely perform the task of nursing care; and  

* That the RN took responsibility for delegating the task to the unlicensed person, and ensured that supervision would occur for as long as the RN was supervising the performance of the delegated task.

The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 11/17/21 at 4:00 pm. Staff 2 acknowledged the findings.

Prior to medication administration delegation by a RN to unlicensed staff, RN will ensure that a complete assessment of resident is in place in the resident's chart. RN will ensure that unlicensed delegated staff is willing, competent, and trained to safely perform the delegated task. RN will assume responsibility for delegation of the task to unlicensed staff and will continue to supervise the performace of the delegated staff.

See above

Upon every delegation.

RN is responsible for ensuring all delegations are done properly and accurately.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system ensuring adequate professional oversight. Findings include, but are not limited to:

1.  Refer to C 303 and C 310.

2. In interviews on 02/22/22 and 02/23/22, Staff 2 (RN) stated the facility had a special needs contract which covered one area of the facility. The RN was providing oversight of the clinical needs primarily for the residents in the contracted section of the facility. There was no other licensed nurse providing services at the facility. An interview with Staff 9 (MT) revealed the facility had a triple check system for medication orders and administration of medications. The MT who received orders from the physician would be the "first check" and was responsible for faxing the orders to the pharmacy. The MT who was on duty for the next shift would be the "second check" and the RCC would be the "third check". Staff 9 verified there was currently a vacancy in the RCC position and the "second check" was not being completed consistently. Furthermore, the medication orders were being forwarded to the RN, however, this system was not effective in producing a "third check".

The need to have a medication administration system that was receiving professional oversight was discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Manager) on 02/24/22. They acknowledged the findings.

1). Nurse oversight and a triple check system for the medication and treatment systems are in use.  

2). Routine oversight and daily use of a triple check system will remain in place indefinately to prevent a repeat occurrence.  

3). The safety of the medication and treatment systems, including professional oversight and the use of the triple check system will be reviewed quarterly, or more often if needed, via the quality improvement program.

4). Executive Director and Nurse are assuring compliance.

2. Resident 5 moved into the facility in 2021 with diagnoses including deep vein thrombosis (a blood clot in a deep vein) and hypertension.

a. Resident 5 had a physician's order, dated 12/03/21, to administer Carvedilol 6.25 mg for hypertension two times daily.

Resident 5's 02/01/22 through 02/20/22 MAR revealed staff documented 25 mg of the medication was administered to the resident, not 6.25 mg.

b. Resident 5 had a physician's order, dated 12/03/21, to administer Eliquis 2.5 mg two times daily.

Resident 5's 02/01/22 through 02/20/22 MAR revealed staff documented 5.0 mg of the medication was administered, not 2.5 mg.

c. Resident 5 had a physician's order, dated 12/03/21, to administer Gabapentin 100 mg at night daily.

Resident 5's 02/01/22 through 02/20/22 MAR revealed staff documented 300 mg of the medication two times daily was administered, not 100 mg of the medication daily.

d. Resident 5 had returned to the facility on 02/21/22 with a new order of Eliquis to administer 5.0 mg two times daily.

Resident 5's 02/21/22 through 02/22/22 MAR revealed staff documented 2.5 mg of the medication was administered, not 5.0 mg.

e. Resident 5 had returned to the facility on 02/21/22 with a new order of Gabapentin to administer 300 mg two times daily.

Resident 5's 02/21/22 through 02/22/22 MAR revealed staff documented 100 mg of the medication two times daily was administered, not 300 mg.

On 02/24/22, the physician orders and the MARs were reviewed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director). They acknowledged the findings.

Surveyor: Gill, Lauren K.

3. Resident 7's current physician's orders, dated 02/18/22, and MARs, dated 02/01/22 through 02/22/22, revealed the following medications were not given to the resident as ordered:

a. Aspirin 81 mg, one time daily;

* Levothyroxine 50 mg, one time daily;

* Mirtazapine 15 mg, one time daily; and

* Pantoprazole 40 mg, one time daily.

b. Staff documented on the MAR Omeprazole and Trazadone was administered to the resident without a written order in the record.

In an interview with Staff 9 (MT) at 1:15 pm on 02/23/22, s/he verified the current orders were not followed as prescribed and verified the lack of written orders.

The need to ensure facility staff carried out all orders as prescribed was discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director) on 02/24/22. They acknowledged the findings. A request for order clarification and signed, written orders was sent to the physician on 02/23/22.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 3 sampled residents (#s 5, 6 and 7) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted in 2020 with diagnoses including schizophrenia and neurocognitive disorder.

Resident 6 had physician's orders to titrate Clozapine for schizophrenia. The orders from 02/02/22 through 02/22/22 were reviewed.

Resident 6's MARs, reviewed from 02/01/22 - 02/22/22, revealed the following orders were not followed:

* On 02/08/22 and 02/09/22: orders were for 50 mg of Clozapine and staff administered 125 mg;

* On 02/11/22 and 02/12/22: orders were for 75 mg of Clozapine and staff administered 125 mg;

* On 02/13/22, 02/14/22, and 02/15/22: orders were for 100 mg of Clozapine and staff administered 125 mg; and

* On 02/20/22: orders were for 125 mg of Clozapine and staff administered 100 mg.

The need to ensure physician orders were followed as prescribed was reviewed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director) during the survey. They acknowledged the findings.

1). The medication/treatment orders for residents #6 and #7 have been reviewed, revised, and verified by their providers.  

2). All medication/treatment orders for each resident have been reviewed/revised and verified by their provider; this review will continue quarterly.  All new orders are reviewed/verified upon receipt via a triple check process.  

3). Medication/Treatment orders will be reviewed quarterly by an RN or Consultant Pharmacist and verified by the responsible provider.

4). Compliance is assured by Nurse, SNC Program Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 2021.

Resident 1's MARs, reviewed from 11/01/21 - 11/15/21, revealed the following inaccuracies:

* The MAR lacked parameters for PRN bowel medications bisacodyl suppository, Fleet enema, Milk of Magnesia and Miralax powder, regarding the sequential order of use;

* PRN bisacodyl suppository and PRN Fleet enema lacked administration frequency;

* Staff were instructed to apply hydrocortisone cream to rash area twice a day, and nystatin cream to red skin areas twice a day. The MAR lacked specific information indicating where the creams were to be applied; and

* On 11/06/21, staff failed to document that medications were not administered because the resident was out of the facility.

On 11/18/21, the need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed Staff 2 (RN) and Staff 5 (Resident Care Coordinator) on 11/17/21, and with Staff 1 (Executive Director) on 11/18/21. The findings were acknowledged.

2. Resident 2 moved into the facility in 2019 with diagnoses which included anxiety and a history of skin breakdown.

Review of Resident 2's MAR, dated 11/01/21 to 11/15/21, indicated the following deficiencies:

* The resident had an order for Coloplast Brava powder to be applied under the arm twice a day for yeast infection. The MAR lacked the name of the medication; and

* S/he had an order for Buspirone 10 mg one tablet three times a day PRN anxiety. The MAR failed to note the frequency and also instructed staff to give one "swab orally" versus one "tablet" as ordered.

On 11/16/21, the need to maintain an accurate MAR for all medications administered by the facility was discussed with Staff 6 (Resident Care Director). He reviewed the MAR and acknowledged the findings.

Bowel protocols were created by Executive Director. RCC/RCD instructed to fax "Standing Orders" to all PCP's to have them signed. After signature is obtained, the orders will be sent to the pharmacy to be placed on the MAR.

PCP's will sign the Standing orders and the orders will be placed on all resident MAR. RN will check all new orders for accuracy and clarify with Provider as needed. RCC/RCD will perform second check for accuracy and call Provider for clarification as needed.

Quarterly review by RCC/RCD/RN and Executive Director.

Executive Director is responsible for having MAR's that are accurate and that provide clear instrustions.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications for 1 of 3 sampled residents (#5) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 moved into the facility in 2021.

Resident 5's MARs, reviewed from 02/01/22 - 02/22/22, revealed the following inaccuracies:

* PRN bisacodyl suppository lacked administration frequency;

* Staff documented they administered multiple medications to the resident on 02/09/22, 02/07/22, 02/08/22, 02/10/22, 02/11/22, 02/13/22, 02/15/22 and 02/16/22 when the resident was at the hospital, not in the facility; and

* The MAR revealed to administer "Medication Order" 2 tablets orally as needed for constipation. The MAR lacked specific information indicating what medication was to be administered.

On 02/24/22, the need to maintain an accurate MAR for all medications administered by the facility and to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director). The findings were acknowledged.

1). The staff member identified has been interviewed.  Further investigation reveals probability of an EHR transcription error related to documentation.  

2). All staff involved in the management of medications and treatments have received additional training regarding accuracy, documentation requirements, improved overall communication.  Medication/Treatment administration records will be randomly reviewed by the Resident Care Coordinator and the SNC Program Director to identify errors in documentation.  As of 03.01.2022 and in conjunction with a change in management, all MAR's are completed on paper for the time being.  

3). Any errors identified will be reviewed timely with the employee and will be reviewed, in depth, at least quarterly via quality improvement program for patterns and the need for additional training.

4). Compliance is assured by Resident Care Coordinator, SNC Program Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 3 of  3 newly-hired direct care staff (#s 12, 13 and 15) completed all required pre-service orientation including pre-service dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were reviewed on 11/17/21.

Staff 12, 13 and 15 (CGs), hired on 09/07/21, 09/07/21 and 08/30/21 respectively, lacked documented evidence of completing all required elements for pre-service orientation including pre-service dementia training prior to assuming job duties.

The need to ensure required pre-service orientation was completed prior to newly hired direct care staff beginning their job responsibilities was reviewed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Executive Director has inquired with Relias on setting up "Pre-service trainings". There is now a sign up sheet for staff to reserve the computer to complete the required trainings.

All newly hired staff will complete pre-service training prior to working on the floor with residents.

At every new hire.

Business Office Manager is responsible for having all pre-service trainings completed by staff prior to working solo on the floor with residents.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 13 and 15) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of staff training records on 11/17/21 revealed Staff 12, 13 and 15 (CGs), hired on 09/07/21, 09/07/21 and 08/30/21 respectively, lacked the following documentation of demonstrated competencies 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; and

* First aid and abdominal thrust.

The need to ensure all newly hired staff demonstrated competency in all required training topics within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Services Director) on 11/18/21. They acknowledged the findings.

Executive Director has inquired with Relias on setting up "Training within 30 days of hire."

Newly hired staff will complete the training required and demonstrate compenticies before 30 days of hire.

Within 30 days of a new hire.

Business Office Manager is responsible for making sure all trainings and demonstrated compenticies are completed on time.  

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 10 and 11) completed 12 hours of annual in-service training including 6 hours of training in dementia care. Findings include, but are not limited to:

Annual in-service training records were reviewed on 11/17/21. Staff 10 (CG/Med Tech) and Staff 11 (CG) lacked documentation of a minimum of 12 hours annual in-service training, which included six hours of dementia care training.

The need to ensure long term staff had 12 hours of annual in-service training, including six hours of dementia care training, was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Manager) on 4/21/21. They acknowledged the findings.

Staff will complete at least 12 hours of annual in-service training including 6 hours of dementia training.

Staff will complete 1-2 trainings per month upon hire to stay in compliance with annual trainings.

Bi-annually.

Business Office Manager is responsible for ensuring all staff have at least 12 hours of annual in-service training.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month at different times of the day, evening and night shifts, failed to include required components on fire drill records, and failed ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records, reviewed between 05/2021 - 10/2021, revealed the following:

* One fire drill had been completed during the six-month time frame reviewed;

* Fire drill records lacked the following components:

- Escape route used;

- Number of occupants evacuated; and

* Fire and life safety instruction was not consistently provided to staff on alternate months.

The requirements regarding fire drills and fire/life safety instruction for staff was reviewed with Staff 1 (Executive Director) on 11/16/21 at 2:45 pm. She acknowledged the findings. No further information was provided.

One fire drill will happen every other month and Fire and Life Safety will be reviewed every other month. Maintenance Director was trained by Executive Director.

Maintenance Director will have fire drills pre-planned and will be put on a schedule. Maintenance will work with Executive Director on Fire and Life Safety topics.

Every other month.

Maintenance Director is responsible to ensure all fire drills are completed on time and that the fire drill record is completed. Maintenance Director also responsible to ensure all Fire and Life Safety trainings are completed on time.

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 were requested during the survey. The following deficiencies were identified:

* Documentation that fire and life safety training was provided to residents within 24 hours of move-in;

* Documentation that annual fire and life safety training was provided to residents, including all required training topics; and

* Alternate exit routes were used during fire drills.

The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, and alternate exit routes were used during fire drills was discussed with Staff 1 (Executive Director) on 11/16/21 at 2:45 pm. She acknowledged the findings. No further information was provided.

When a resident is being admitted, Fire and Life Safety training will be done within 24 hours of admittance. Annual Fire and Life Safety will be completed on an annual basis.

Care plans will have a section for Fire and Life Safety which will be reviewed quarterly.

Upon new admissions.

Maintenance Director is responsible for ensuring that Fire and Life Safety is reviewed with all residents upon admission and annually there after.

Based on interview and record review, it was determined the facility failed to have an emergency preparedness plan that included analysis and response to emergency hazards in event of a prolonged power failure, and failed to conduct a drill of the emergency preparedness plan at least twice a year. Findings include, but are not limited to:

During individual interviews with residents on 11/15/21 and 11/18/21, they expressed concern that the facility did not have an emergency plan in the event of a power outage.

In an interview with Staff 1 (Executive Director) on 11/18/21 at 11:30 am, the survey team requested:

* The facility's emergency preparedness plan in the event of a prolonged power outage; and

* Documentation of facility emergency preparedness drills.

Staff 1 reviewed the facility's Emergency Preparedness binder and reported the following:

* The plan/steps staff were to follow for utility outage was blank; and

* The facility had not conducted emergency preparedness drills.

The need to ensure the facility developed an emergency preparedness plan that included analysis and response to emergency hazards in event of a prolonged power failure, and to conduct a drill of the emergency preparedness plan at least twice a year was reviewed with Staff 1. She acknowledged the findings.

Emergency Preparedness binder will be updated to include steps for staff to follow in a power outage. The Maintenance Director will schedule 2 Emergency Preparedness drills twice annually.

Trainings to be scheduled and put on the calendar.

Semi annually.

Maintenance Director is responsible for ensuring Community Disaster drills are held semi annually.

Based on observation, 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 C 156, C 160, C 260, C 262, C 310 and C 513.

1). The re-survey plan of correction is in place.

2). All cited deficiencies have or will be corrected on or before the alledged compliance date.  

3). Any portion of this plan of correction deemed to be in jeopardy of not being completed by the compliance date will be submitted to the State of Oregon Department of Human Services APD Safety, Oversight and Quality Unit for consideration for an extension.

4). Executive Director and Director of Operations are assuring compliance.

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

Observations of the facility on 11/15/21 through 11/18/21 revealed the following areas were in need of cleaning and/or repair:

* The handrail between Resident Rooms 25 and 26 had a patch of rough exposed wood and was not a cleanable surface;

* Multiple walls, doors and door frames throughout the facility and pillars in the dining area were gouged, scrapped and chipped;

* There was extensive damage to the wall outside of Resident Room 5 as well as interior walls, bathroom door, door frame and bathroom walls;

* Window sills throughout the facility were in need of cleaning;

* Cabinets in the dining area were in need of cleaning with dust on the outer surfaces and food particles and other debris on the shelves;

* The carpet throughout the facility was stained in multiple areas;

* There was a pervasive unpleasant odor of urine in the hall near Resident Room 30 throughout the day on 11/18/21; and

* Resident Room 15 had scrapes and gouges in the bathroom door and frame, a black stained area was visible on the carpet next to the bed, and the room had a strong urine odor.

The need to ensure the environment was clean, in good repair and free from unpleasant odors was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Executive Director met with our maintenance team and retrained on completing routine checks of the environment and ensuring that the environment is clean, in good repair and is free of unpleasant odors.

Routine check of the building from Maintenance and Housekeeping as well as Executive Director.

Daily.

Maintenance Director is responsible for ensuring the building is clean, in good repair and free of unpleasant odors.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean, maintained in good repair, and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 02/22/22 and 02/23/22 revealed the following areas were in need of cleaning and/or repair:

* There was extensive damage in Resident Room 5 to the bathroom door frame;

* The carpet throughout the facility was stained in multiple areas; and

* Resident Room 15 had scrapes and gouges in the bathroom door and frame, a black stained area was visible on the carpet next to the bed, and the room had a strong urine odor.

The need to ensure the environment was clean, in good repair and free from unpleasant odors was discussed with Staff 1 (Executive Director) and Staff 18 (Maintenance Director) on 02/24/22. They acknowledged the findings.

1). The areas identified have been corrected or professional services have been contracted to assist in their correction.  

2). A log has been established to track the timely repair and/or cleaning of surfaces to assure a safe and healthy environment.

3). The log will be reviewed weekly to identify any outstanding items.  Recurring items of concern will be reviewed via the quarterly quality improvement program.

4). Executive Director to assure compliance.  

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

Observations during the survey revealed exit doors in the facility lacked alarms or other acceptable systems to alert staff when residents exited.

In an interview on 11/15/21, Staff 1 (Executive Director) confirmed the facility lacked an alarming device or other acceptable system to alert staff when all residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1, Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Executive Director to meet with the owner group of the property to ensure all main exit doors have a chime that will alert staff as to when a door is open and/or closed.

Will ensure that exits have a chime and that batteries are checked on a quarterly basis if needed

Quarterly

Maintenance Director will add exit alarms to ensure that batteries are working properly if batteries are needed for the door alert system.