The findings of the Initial survey, conducted 05/17/22 through 05/19/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.
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 revisit to the re-licensure survey on 05/20/22, conducted 08/23/22 through 08/25/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
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
A situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An immediate plan of correction was requested in the following area:
OAR 411-054-0028 (1-3) Reporting and Investigating Abuse
OAR 411-054-0034 (1-5) Resident Move in and Evaluation
OAR 411-054-0036 (1-4) Service Plan
OAR 411-054-0040 (1-2) Change of Condition and Monitoring
OAR 411-054-0055 (1) Systems: Treatment Orders
The facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the second re-visit to the re-licensure survey of 05/19/22, conducted 04/10/23 through 04/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 third re-visit to the re-licensure survey of 05/19/22, conducted 09/25/23 through 09/26/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 fourth revisit to the re-licensure survey of 05/19/22, conducted 01/10/24 to 01/11/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.
Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:
During the revisit survey, conducted 08/23/22 through 08/25/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.
1. A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following areas:
OAR 411-054-0028 (1-3) Reporting and Investigating Abuse
OAR 411-054-0034 (1-5) Resident Move in and Evaluation
OAR 411-054-0036 (1-4) Service Plan
OAR 411-054-0040 (1-2) Change of Condition and Monitoring
OAR 411-054-0055 (1) Systems: Treatment Orders
The facility put an immediate plan of correction in place during the survey and the situation was abated.
2. Refer to deficiencies in the report.
OAR 411-054-0025 - Facility Administration: Operation
Please refer to all citations in this report
Based on observation, interview, and record review, it was determined the facility failed to provide effective licensee oversight to ensure quality of care and services rendered in the facility. This is a repeat citation. Findings include, but are not limited to:
During the second revisit survey, conducted 04/10/23 through 04/12/23, licensee oversight to ensure adequate resident care and quality of services rendered in the facility was found to be ineffective based on the on-going non-compliance and severity of citations.
Refer to the deficiencies in the report.
C150
OAR 411-054-0025 (1) Facility Administration Operation
Refer to deficiencies in the report.
There are no detail notes for this visit.
3. Resident 5 was identified during the acuity interview as having multiple skin issues including an open wound on their left buttock and was observed during the survey to have their lower left leg wrapped due to multiple blisters and a rash.
A review of the resident's progress notes revealed the last entry of the resident's open wound on left buttock was on 07/23/22, and skin issue on lower left leg was on 08/13/22.
In an interview with Staff 20 (Administrator) and Staff 21 (Regional Nurse), they indicated there was no other documented evidence of the skin issues at least weekly until resolution. Staff 20 and 21 confirmed the facility RN did not conduct an RN assessment for the open wound on the left buttock of the resident.
In interviews, Staff 20 and Staff 21, confirmed they did not have signed physician's orders for Resident 5 in the facility. The physician's orders in the resident record did not match the MAR. The facility obtained the signed physician's orders on 08/25/22.
The failure to ensure complete and accurate records of the resident's status was shared with Staff 20 and Staff 21 on 08/25/22. They acknowledged the findings.
Refer to C 270.
Based on observation, interview, and record review, it was determined the facility failed to ensure resident records were complete and accurate for 3 of 4 sampled residents (#s 5, 6 and 7) whose records were reviewed. The facility failed to update Resident 6's records, which placed the residents health and safety at risk. Findings include, but are not limited to:
1. Resident 6 was re-admitted to the facility on 07/12/22 with diagnoses including traumatic brain injury, major neurocognitive disorder, and seizure disorder. Resident also had a history of physical altercations with staff and other residents.
Review of Resident 6's clinical records and interviews revealed the following documentation was incomplete or inaccurate:
*Resident eloped from the facility on 06/24/22 and did not return to the facility until 07/12/22. There was no documented evidence the facility investigated the elopement.
*Resident 6 was re-admitted to the facility on 07/12/22. There was no documented evidence the facility had completed a new move-in evaluation or service plan upon re-admission. Resident's previous service plan, dated 5/19/22, stated resident was not at risk for elopement.
*The facility had current signed physician orders from the residents psychiatrist, dated 07/12/22, however failed to obtain current signed physician orders for all other medications the resident had been prescribed, including medications for mood stabilization and seizures.
*In an interview on 08/24/22, Staff 36 (MT) reported Resident 6 had not been administered multiple medications because the resident was "not on cycle fill" with the pharmacy, so the medications had not been ordered. Also, multiple medications lacked signed physician orders. Staff 36 also confirmed the resident had engaged in several physical altercations with staff and other residents since his/her return to the facility.
The facilities failure to ensure the preparation, completeness and accuracy of resident's records placed the resident at risk for future elopement, continued physical altercations with other residents, and increased the residents risk of experiencing seizures.
On 8/24/22, the survey team requested an immediate plan of correction to update all of Resident 6's clinical records. The plan was received and accepted the same day, and the situation was abated.
Refer to C 231, C 252, C 260, C 270, and C 303.
On 08/25/22, the need to ensure resident records were complete and accurate was discussed with Staff 20 (Administrator). She acknowledged the findings.
2. Resident 7 was admitted in 11/2021 with diagnoses including schizophrenia and psychosis.
Review of Resident 7's clinical record and interviews revealed the following:
* The Residents record failed to have signed physician orders for all medications being administered on the MAR.
On 08/25/22, the need to ensure resident records were complete and accurate was discussed with Staff 20 (Administrator). She acknowledged the findings.
Please refer to the following citations for plan of correction: C231, C252, C260, C270, & C303.
Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:
During the survey, conducted 05/17/22 through 05/19/22, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID 19 and made available to all facilities, were not being followed by the facility.
On multiple occasions throughout the survey, staff were observed in common areas without protective facemask's properly worn, as current regulations require. The infractions included failure to cover the wearer's mouth or nose, or simply no mask at all.
On 05/17, 05/18, and 05/19/22 the need for proper wearing of required protective facemask's by all staff was discussed with Staff 1 (Administrator). S/he acknowledged the findings, and stated immediate plans for further staff training on infection control.
Staff failure to wear face mask properly or not at all:
1. Signs will be posted reminding staff of proper mask wearing procedure. Supervisors will complete rounds multiple times on every shift to audit staff wearing masks properly. Any staff found not wearing masks properly will be issued a disciplinary notice. All department heads will be tasked with ensuring every member of their department is in compliance with proper mask wearing.
2. Increased awareness will be made amongst staff, including signage and review of the policy regarding mask wearing. Increased audits will be completed to ensure compliance amongst staff.
3. This process will be evaluated monthly for effectiveness by Administration and the importance of mask wearing will be reviewed at monthly mandatory meetings for all staff.
4. Department heads will be responsible for members of their department, shift Supervisors will be responsible for floor staff on each shift and Administrator will be responsible for overall compliance.
Based on observation and interview, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. This is a repeat citation. Findings include, but are not limited to:
Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.
Upon entering the facility on 08/23/22, multiple direct care staff were observed not wearing face masks.
In an interview with Staff 20 (Administrator) on 08/23/22, she indicated all staff should be wearing face masks. She also stated she would provide immediate instruction to staff to wear face masks appropriately.
Throughout all three days of the survey, multiple facility staff were observed not wearing their masks as outlined by the Oregon Administrative Rule.
The need to ensure staff fully and consistently complied with masking requirements was discussed with Staff 20 and Staff 21 (Regional Nurse) during the exit meeting on 08/25/22. They acknowledged the findings.
OAR 411-054-0025 (4) Reasonable Precautions
1.) The following actions will be taken to correct each violation, per example(s) given:
a. Facility will designate one staff member to enroll & complete the required 'Infection Control Specialist Training' to ensure oversight & compliance for infection control standards.
b. Facility IDT will conduct 'spot-checks' of all staff members, randomly, to ensure that staff are wearing the required PPE (masks) and that staff are wearing PPE appropriately.
c. Facility will schedule a mandatory in-service for all staff members to include: Proper hand-hygiene with return demonstration, as well as, basic infection control practices.
2.) The system will be corrected to ensure this violation does not happen again, as follows:
a. Facility is creating a training grid that will be reflective of all required training(s) including standard precautions for infection prevention control.
b. Facility training grid will be updated with each new-hire, and will be reviewed/audited at least monthly to ensure accurate, up to date training for all staff.
3.) This system will be evaluated as follows: All training related to standard precautions for infection control will be reviewed & audited, during pre-service on-boarding, and annually thereafter. Facility IDT will review the training grid at least monthly, to identify any staff out of compliance for required training(s).
4.) Facility Administrator and Facility LN will be responsible for ensuring corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to immediately notify the local SPD office of any incidents of abuse or suspected abuse for 1 of 1 sampled resident (#2) who was involved in altercations in the community. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 10/2021 with diagnoses including stroke, alcohol abuse, psychosis and post traumatic stress disorder.
Review of Resident 2's behavior plan, dated 03/24/22, progress notes, dated 02/16/22 through 05/17/22, and incident reports, identified three physical altercations between Resident 2 and other residents. These were listed as:
*02/16/22- Resident 2 "threw a punch" at another resident, as a staff member attempted to intervene;
*02/23/22- Loud verbal altercation escalated to "grabbing and shoving" with another resident; and
*03/12/22- Resident 2 "grabbed another resident's glasses and pulled [his/her] hair", leading to "scratching and screaming" as a staff member worked to intervene.
There was no documented evidence the facility reported these incidents to the local SPD office.
In an interview on 05/18/22 Staff 1 (Administrator) stated no self-reporting to SPD had been completed for the incidents. Staff 1 was informed the incidents must be reported prior to survey team's exit from the building.
On 05/18/22, at 4:40 pm Staff 1 presented the surveyor documentation of self reporting the incidents, and acknowledged the need to report any future altercations. No further information was provided.
No documented evidence the facility reported three physical altercations involving resident 2:
1. Altercations happened in 2/22 and 3/22. Facility incident report procedure has since been improved and Med Tech training provided on how to properly document and report resident physical altercations. The facility procedure for a resident altercation includes:
a) Med Tech completes IR for each resident involved
b) Med Tech puts each resident on 72 hour alert charting and 15 minute checks
c) Med Tech reports incident to nurse on-call and QMHA on-call, completes chart note on each resident.
d)Nursing completes assessment on condition of each resident and documents on IR and in chart notes. Nursing completes any care plan updates needed.
e) QMHA reviews each resident's behavior plan and makes updates as needed.
f) Nursing and QMHA provide Administrator with copies of all documentation.
f) Administartor ensures all updates are in place and self-reports incident to APS.
This process should be completed within 48 hours of incident.
2. Med Tech's receive training on how to complete this process during their initial medication administration class and review of the process during quarterly Med Tech meetings. Ensuring Med Tech's complete all necessary documentation and reporting of incident guarantees nursing and QMHA staff are alerted to the incident. This means follow-up action can be completed and presented to Administrator for reporting. Section nurses will also review all chart notes for resident's in their section weekly to ensure nothing has been missed by Med Tech reporting.
3. All resident altercations will be reviewed quarterly during a care team census meeting to ensure thorough completion of all follow up and necessary documentation.
4. DON will be responsible for all nursing follow-up and care plan implementation. QMHA will be responsible for behavior plan implementation and Administrator will be responsible for reporting incidents of abuse or suspected abuse to APS.
Based on observation, interview, and record review, it was determined the facility failed to immediately investigate all incidents of possible abuse and neglect with all required components and immediately report abuse and suspected abuse for 1 of 2 sampled residents (#6). Resident 6 had eloped from the facility and was later admitted to the emergency department. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in 04/2022 with diagnoses including traumatic brain injuries, major neurocognitive disorder, and seizure disorder.
Resident 6's clinical records including evaluations, service plans, temporary service plans, incident reports/investigations and progress notes were reviewed during survey and interviews with staff and Resident 6 indicated the following:
*Resident 6's service plan, updated 05/19/22, indicated s/he was not an elopement risk.
*In an interview on 08/24/22, Staff 36 (MT) reported the resident was re-admitted to the facility after being gone for 18 days from a recent elopement.
*Progress notes on 06/24/22 reported the resident left for Walmart via taxi with a suitcase. The cab company reported the resident became physically aggressive and threatened to beat the driver up if she did not take the resident to Medford. Resident 6 was "excused from the cab and was last seen heading south." The facility then searched Resident 6's room and found all his/her personal belongings removed except a pair of pants and socks. Resident 6's case worker was notified and the Administrator phoned Resident 6's state guardian.
*A progress note on 07/12/22 indicated Resident 6 was being re-admitted to the facility after an 18 day elopement. The note further stated Resident had been sleeping on the streets, drinking alcohol, and traveled to Eugene Oregon with a destination of Medford. Resident 6 was admitted to the emergency department on 07/03/22 for suspected seizure "off Dilantin" (seizure mediation) for approximately two weeks. S/he was again admitted to the emergency department on 07/09/22 for seizures, noting again the lack of seizure mediation.
*In an interview on 08/24/22, Staff 21 (Regional Nurse) reported there was no documented evidence the facility had conducted an immediate investigation of the elopement or that the incident had been reported to the local SPD office.
The facilities failure to conduct an immediate investigation of the elopement and report the elopement to the local SPD placed the residents health and safety at risk.
On 8/24/22, the survey team requested an immediate plan of correction, which included reporting the incident to local SPD. The plan was received and accepted the same day and the situation was abated.
On 08/25/22, the need to immediately investigate all incidents of possible abuse and neglect with all required components, and the need to ensure incidents of abuse or suspected abuse were promptly reported to the local SPD office was discussed with Staff 20 (Administrator). She acknowledged the findings. At survey's request, the facility reported the incident to the local SPD office. Confirmation of the report was provided to survey prior to exit.
OAR 411-054-0028 (1-3) Reporting and Investigating Abuse-Other Action
1.) The following action(s) are being taken to correct violations, per each example given:
a. Resident #6 - Facility self-reported incident that occurred on 6/24/22, to local SPD prior to survey exit, on 8/24/22. Facility will ensure that appropriate interventions are in place, following the review/investigation of prior elopement(s).
2.) This system will be corrected as follows:
a. All employees will complete "Elder abuse
Prevention, Investigation and Reporting" provided by Oregon Care Partners, b. Facility IDT will review incident reports daily, during morning stand-up, to ensure all incidents are investigated & reported appropriately (when abuse and neglect cannot be ruled out, for injuries of unknown cause, & all instances of abuse & neglect or suspected abuse & neglect) to local SPD.
c. Facility administer will review, sign, & date all incident reports.
3.) This system will be evaluated as follows:
a. Facility Administrator & Facility LN will coordinate at least once monthly during Quality Improvement meetings to ensure that all staff have completed the required pre-service & on-going training 'Abuse & Reporting Requirements.'
b. Facility Administrator & Clinical IDT will review all incident reports at least 5 days per week (during morning stand-up) & will bring all data/trends related to incident reports to once monthly Quality Improvement Meeting.
4.) Facility Administrator and Facility LN will ensure completion and will continue to monitor this system.
Based on interview and record review, it was determined the facility failed to thoroughly investigate resident-to-resident altercations and failed to report the incidents to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (# 11) who experienced resident to resident altercations. This is a repeat citation. Findings include, but are not limited to:
Resident 11 was admitted to the facility in 02/2022 with a traumatic brain injury.
During the acuity interview on 04/10/23, Resident 11 was identified to be involved in resident to resident altercations.
Resident 11's facility progress notes indicated:
02/17/23 - "...[Resident 11] was involved in an altercation with another resident..."; and
03/17/23 - "...[Resident 11] threatened violence towards several individuals and punched a light fixture."
There was no documented evidence the altercations were reported to the local SPD.
On 4/11/23, the surveyor requested Staff 21 (Administrator) report the incidents to SPD. Verification the incidents had been reported was provided.
C231
OAR 411--54-0028 (1-3) Reporting & Investigating Abuse- Other Action
1. Action taken to correct this rule violation includes:
Resident #11- 2/17/23 resident to resident alertcation and 3/17/23 threatening violence towards several individuals and punching a light fixture was reported to the local SPD on 4/11/23 per the request of surveyor.
2. To ensure the system is correctedso this violation will not happen again; all incident reports will be reviewed daily in stand up. Each incident that has been identified will be fully investigated to ensure abuse and neglect can be ruled out. If abuse and neglect can not be ruled out, or for incidents of unknown origin or cause, community will self report to APS.
The community will also ensure all components are
completed related to identifying appropriate interventions to be put in place to reduce risk for this to happen again.
Abuse reporting and investigating guide for providers for Oregon will be reviewed with the management team and staff.
3. This area will be reviewed on a daily and quarterly basis. To ensure compliance with Company Policy and Oregon Administrative Rules.
4. The facility Administrator and Licensed Nurse will be responsible to that the corrections are completed and montiored.
Based on interview and record review, it was determined the facility failed to report incidents of resident to resident altercations to the local Seniors and People with Disabilities (SPD) office for 1 of 2 sampled residents (#15) who experienced resident to resident altercations. This is a repeat citation. Findings include, but are not limited to:
Review of Resident 15's progress notes, dated 09/05/23 through 09/25/23, and incident reports, identified two altercations between Resident 15 and another resident. These were listed as:
09/10/23 - "...[Resident 15] was involved in an altercation with a housemate today ...the residents were attempting to swing at one another but did not make contact..[Resident 15] was angry and yelling about how the other resident was a 'thief' and [s/he] was gonna 'kick [his/her] a** "; and
09/21/23 - "...[Resident 15] became physically aggressive with staff and housemate. He struck staff member two times with his walker and assaulted his housemate ...causing injury."
There was no documented evidence the facility immediately reported the incidents of resident altercations to the local SPD.
The altercation on 09/21/23 was not immediately reported to local SPD. It was reported on 09/25/23 when requested by survey.
On 9/26/23, the surveyor requested Staff 51 report the 09/10/23 incident to SPD. Verification the incident had been reported was provided.
On 09/26/23, the need to immediately report incidents of abuse to the local SPD office was discussed with Staff 51. She acknowledged the findings.
OAR 411-054-0028 (1-3) Reporting and Investigating Abuse- Other Action
1. Immidate action taken to correct the violation includes:
a. Resident #15's resident to resident alercation from 9/10/23 was reported to the local SPD office on 9/25/23 when requested by survey
b. Resident #15's resident to resident alercation from 9/21/23 was reported to the local SPD office on 9/26/23 when requested by survey.
2. This system will be corrected as follows so this violation will not happen again:
a. All employees will complete "Elder Abuse and Prevention, Investigation and Reporting" provided by Oregon Care partners.
b. Facility IDT will review incident reports daily, during morning stand-up, to ensure all incidents are investigated & reported appropriately.
If abuse and neglect can not be ruled out, or for incidents of unknown origin or cause, community will self report to SPD.
3.The area needing correction will be evaluated as follows:
a. Facility Administrator, Director of Nnursing or designee will coordinate at least once monthly during Quality Improvement meetings to ensure that all staff have completed the required pre-service & on-going training "Abuse & Reporting Requirements."
b. Facility administrator, Clinical IDT or designee will review all incident reports at least 5 days per week (during morning stand-up) & will bring all data/trends related to incident reports to once monthly Quality Imporvement Meeting.
4 Facility Administrator, Director of Nursing or designee will be responsible to ensure the system has been corrected and the system is monitored.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
The facility consisted of two buildings, Bachelor and Broken Top. Each had kitchens where food was stored and served. All food was prepared in the kitchen in Bachelor.
Observations of the kitchen, food storage, logs, prep, and service areas on 5/17/22 revealed:
* No evidence of monitoring temperatures of refrigerators or the dishmachine;
* Spills, splatters, and food debris inside all ranges and microwaves;
* Storage shelves, cabinets, and drawers throughout the kitchens had debris, splatters, spills, crumbs, hair, and drips;
* Garbage can in Broken Top near food prep area had no lid;
* Multiple dented cans of food were noted in the dry storage area;
* Staff were observed to not change gloves or sanitize hands between meal preparation and service tasks; and
* Caregiving staff assisting with meal service and delivery were not using aprons and restraining hair, beards were not restrained with hair nets.
The areas in need of cleaning and repair and infection control practices were reviewed with Staff 1 (Administrator) and Staff 5 (Dietary Manager/Cook) on 5/17/22. They acknowledged the findings.
Monitoring temperatures of refrigerators and dishwasher-
1. A new temperature log was created to be filled out after each meal. On the log we will record temps of all refrigerators including walk in, check to ensure freezer is at appropriate temperature and check check temp on the dishwasher to ensure temp is up to standards as indicated on the dishwasher plate.
2. Cooks will be trained to fill out the forms daily and Dining Director will be responsible for auditing them weekly.
3. The Dining Director will be responsible for performing audits every 2 -3 days to ensure these forms are being filled out correctly and done daily.
4. The Dining Director will be responsible for ensuring all corrections are completed.
Spills and splatters inside microwave and ranges/storage shelves, cabinets, and drawers had debris-
1. The deep clean schedule was reviewed and updated to operate on a weekly basis, as well as a daily cleaning log was created. Cabinets, fridges, ovens, small appliances and storage will be inspected daily for cleanliness and deep cleaned weekly on a schedule.
2. Cooks will sign daily and weekly logs to document completion of cleaning and they will be inspected by Dining Director for completion.
3. The Dining Director will be responsible for performing audits every 2 to 3 days to ensure forms are being filled out correctly and done daily.
4. The Dining Director will be responsible for ensuring all corrections are completed.
Garage cans in Broken Top had no lid-
1. Garbage can lids have been ordered for all kitchen garbage cans.
2. Dining Director will check weekly to ensure can lids are being used properly and are on garbage cans.
3. Dining Director will check cans weekly.
4. Dining Director is responsible for ensuring correction is complete.
Dented cans in dry storage area-
1. A weekly inspection of all foods in dry storage by cooks will be implemented, with special attention paid to any open cans or canned products to ensure they are stored safely with no signs of damage or spoilage.
2. Dining Director will train cooks in proper food storage procedures and audit dry storage inventory weekly to ensure compliance.
3. Inventory will be inspected weekly.
4. Dining Director is responsible for ensuring correction is complete.
Staff not changing gloves between meal preparation and service tasks-
1. Additional training was provided to cooks to make sure they understand and execute proper handwashing and glove usage when switching between tasks. Training will be provided in accordance with Oregon food handlers education.
2. A review of gloves usage and proper hand washing will be reviewed at weekly kitchen meetings. Dining Director will audit food preparation process for each cook during random intervals.
3. Glove usage and food preparation procedures will be reviewed and as needed with kitchen staff.
4. Dining Director is responsible for ensuring correction is complete.
Care staff assisting with meal service and delivery were not wearing aprons and hair restraints.
1. Aprons, hair nets and beard nets will be provided to all staff in the kitchen. All carestaff will be required to follow a routine process upon entering the kitchen before handling food, which includes putting on an apron, putting on a hair/beard net and washing hands.
2. Supplies will be maintained and made available to all staff. Cooks will monitor care staff compliance while in the kitchen and on-going training will be provided to care-staff regarding kitchen procedures.
3. Dining Director will maintain supplies weekly, as well as auditing staff while in the kitchen.
4. Dining Director will be responsible for ensuring corrections are complete. Administrator will ensure care staff are provided with quarterly training on food sanitation procedures.
Based on observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:
The facility consisted of three buildings, Bachelor, Broken Top, and Washington. Each had kitchens where food was stored and served. All food was prepared in the kitchen in Washington.
Observations of the kitchen, food storage, logs, prep, and service areas on 08/23/22 and 08/24/22 revealed:
* No evidence of monitoring temperatures of refrigerators or the dishmachine;
* Test strips for the sanitizer solution were not available in all kitchens and no evidence the solution was monitored to ensure it was at the correct levels;
* Spills, splatters, and food debris inside all ranges and microwaves;
* Storage shelves, cabinets, and drawers throughout the kitchens had debris, splatters, spills, crumbs, hair, and drips;
* Large wet spill noted in the dry storage area;
* Thawing hamburger was noted on a shelf above ready to eat food in the walk in refrigerator;
* Staff were observed to not change gloves or sanitize hands between meal preparation and service tasks;
* Caregiving staff assisting with meal service and delivery were not using aprons and restraining hair; and
* Plated food being delivered to resident rooms was noted to be uncovered on an open cart in the common hallway.
The areas in need of cleaning and repair and infection control practices were reviewed with Staff 20 (Administrator) and Staff 22 (Dietary Manager) on 08/23/22 and 08/24/22. They acknowledged the findings.
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule
1.) The following actions will be taken to correct the violations for each example given:
a. The following areas in the kitchen will be addressed immediately: The inside of all oven ranges, microwaves, storage shelves, cabinets, and drawers throughout the kitchen will be thoroughly cleaned.
b. Facility will implement a temp log for refrigerators, dishwashers, & freezers.
c. Facility will purchase appropriate test strips for sanitizer solution and a log will be maintained to ensure sanitizer is monitored for appropriate levels.
d. All meat products will be moved and stored on the bottom shelves of the walk-in refrigerator(s) & freezers, to avoid cross contamination.
e. All universal workers will wear required aprons when serving food, and will be required to have further training on appropriate infection control prevention and food sanitation.
f. Facility will ensure all meal trays are covered appropriately when food is being delivered to rooms.
2. This system will be corrected as follows:
a. Facility will implement daily, weekly, & monthly cleaning checklists to ensure all areas of the kitchen are clean & in good repair. As part of these checklists, facility will add an audit to review temp log and sanitizer log to ensure compliance.
b. All dining staff will be required to have further training on 'Infection Control in the Kitchen' & 'Proper Food Storage.' Facility will ensure all dining staff employees' have current food handlers cards.
c. All Universal workers will have on-going training on 'Infection Control in the Kitchen' and facility will ensure all employees' food handlers cards are current.
3. This system will be monitored as follows:
a. Facility Dietary Manager will ensure that the daily, weekly, & monthly cleaning checklists are completed. Dietary manager will bring all cleaning checklists to monthly quality improvement meetings to discuss concerns or areas of the kitchen that need repair.
b. Facility Administrator will review all staff training at least once monthly and with each new-hire orientation to ensure appropriate training is completed.
c. Facility Dietary Manager will review temp & sanitizer logs at least once weekly to ensure there are not any holes in log(s) and to ensure appropriate temps and sanitizer levels. Any discrepancies will be reviewed with administrator.
d. Facility Administrator and dietary manager will complete once weekly walk-throughs of the kitchen to ensure all food is stored safely, and the kitchen is clean & in good-repair.
4. Facility Administrator and facility dietary manager will be responsible for ensuring completion and monitoring on-going compliance.
Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations were completed, contained all required elements, and were reflective of resident current needs for 1 of 1 sampled resident (#6). The facility failed to evaluate Resident 6 upon re-admission after an 18 day elopement. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was re-admitted to the facility on 07/12/22 with diagnoses including traumatic brain injuries, major neurocognitive disorder, and seizure disorder. Record review and interviews with staff revealed the following:
*A progress note on 07/12/22, indicated the resident was re-admitted to the facility after an 18 day elopement. There was no documented evidence a new move-in evaluation had been completed prior to re-admission.
*In an interview on 08/24/22, Staff 36 (MT) reported Resident 6 was frequently involved in verbal altercations with other residents, and had "tried to fight two other residents within the last 24 hours." Resident 6 had thrown hot coffee in another residents face the morning of 08/24/22. Staff 36 also reported Resident 6 had been without his/her seizure and mood stabilizer medications for 42 days.
*In a subsequent interview, 08/24/22, Staff 21 (Regional Nurse) confirmed the facility had not re-evaluated the resident upon re-admission.
The facilities failure to evaluate the resident upon re-admission placed the resident at risk for future elopement, put Resident 6 and other residents at risk for physical harm, and increased the risk for seizures and negative behaviors.
On 08/24/22 the survey team requested and received an immediate plan of correction, at which time the situation was abated.
On 08/25/22, the need to ensure new move-in evaluations were completed, contained all required elements, and were reflective of resident current needs was discussed with Staff 20 (Administrator). She acknowledged the findings.
OAR 411-054-0034 (1-6) Resident Move-In and Eval: Resident Evaluation
1.) The following action(s) will be taken to correct violations for each example given:
a. Resident #6 - Facility will complete a thorough chart-review & lookback to ensure all resident needs, interventions, and incidents are appropriately documented in residents' evaluation, to include: Elopement hx and risk, verbal & physical aggression, interventions & triggers related to verbal & physical aggression.
b. Facility will ensure that all new-admissions and/or readmissions will be evaluated appropriately and per requirements.
2.) This system will be corrected as follows:
a. Facility IDT will receive training from Vanda Consultant on the required areas needed in each eval, as well as, general training on how to & when to complete (with date & signature)
evaluations.
b. Facility IDT will review current policies and procedures around completing evaluations, to ensure all evaluations are completed thoroughly and accurately, to reflect the current needs of the resident. Facility will ensure that all TSPs/ISPs from the last quarter are used as a tool to build each resident's evaluation(s).
c. Facility will review all upcoming resident evaluations & service plans, weekly, to ensure multiple staff members (service planning team) who are familiar with residents' care are involved with updating evaluations.
3.) This system will be monitored as follows:
a. Facility IDT will review all evaluations coming due at least once weekly during morning stand-up meetings. Facility will ensure that all new-admissions and/or re-admissions will be evaluated within 24hrs of admission. Facility will complete all evaluations in accordance with current OARs: Pre-admission, Admission, Within 30-days of admission, quarterly thereafter, and within any significant change of condition (including re-admission to facility.)
b. Facility admin will ensure that any staff member completing resident evaluations will have proper training, and administrator will monitor this once monthly via training grid.
4. Facility administrator will be responsible for ensuring completion and monitoring on-going compliance.
Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations contained all required elements and were the foundation used to develop the resident's service plan for 2 of 2 sampled residents (#s 8 and 12) whose move in evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 12 was admitted to the facility on 04/04/23 with diagnoses including schizophrenia.
a. Review of the initial evaluation dated 04/03/23 revealed the following elements were missing:
* Traditions;
* Interests, hobbies, leisure activities; and
* Recent losses.
b. The initial evaluation and service plan dated 04/03/23, "Juniper Canyon Living Evaluation and Service Plan" was not a separate and distinct document.
The need to ensure the initial evaluation included all of the required elements and was the foundation used to develop the resident's service plan was discussed with Staff 21 (Administrator) and Staff 51 (Assistant Administrator) on 04/12/23 at 10:30 am. The findings were acknowledged.
2. Resident 8 was admitted to the facility in 03/2023 with diagnoses including stroke, anxiety and depression.
a. Review of the initial evaluation dated 03/14/23 identified the following required elements were missing:
* Customary routines;
* Interests, hobbies and social activities;
* Cultural preferences and traditions;
* Mental Health: including the history of treatment and effective non-drug interventions;
* Nutrition habits including fluid preferences;
* Complex medication regimen;
* History of dehydration;
* Recent losses; and
* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.
b. The initial evaluation and service plan titled "Juniper Canyon Living Evaluation and Service Plan", dated 03/14/23, was not a separate and distinct document from future evaluations.
During an interview on 04/10/23 at 2:40 pm. Staff 21 confirmed the initial evaluation was not a separate and distinct document from future evaluations. Staff 21 further stated, the facility was working with a consultant to come up with a form that was a separate document and had all the required elements.
The need to ensure the initial evaluation included all of the required elements and was a distinct and separate document was discussed with Staff 21, Staff 45 (Director of Nursing), and Staff 51 (Assistant Administrator) on 04/1123 at 3:30 pm. They acknowledged the findings.
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OAR 411-054-0034 (1-6) Resident Move-In and Eval: Res Evaluation
1. Action taken to correct this rule violation include:
a. Resident #12's evaluation has been updated to reflect the following: traditions, interests, hobbies, leisure activities, and recent losses.
b. Resident #8's evaluation has been updated to reflect the following: traditions, interests, hobbies, leisure activities, and recent losses.
c. The evaluation and service plan 'Juniper Canyon Living Evaluation and Service Plan has been separated and are two distinct documents.
2. To ensure the system is corrected so this violation will not happen again; evaluations including all required factors will be completed per company policy and Oregon Administrative Rule prior to move-in, updated with 30 days, quarterly thereafter and with a signifcant change of condition. The document will be signed to indicate who completed the evaluation.
3. The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of evaluations will be reviewed in daily clinical stand-up meeting prior to each new move-in to ensure all components are reflective and all areas are complete with appropriate information.
4. The Administrator, Licensed Nurse or designee are responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's needs and provided clear direction regarding the delivery of services for 1 of 3 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 03/2022 with diagnoses including a history of stroke.
Resident 3's bed was observed with bi-lateral 1/2 side rails in the up position.
Resident 3 had a history of aspiration and speech therapy had instructed staff to provide "intermittent observations" while Resident 3 was eating.
Resident 3's service plan, dated 05/01/22, did not provide direction for:
* The use of bi-lateral 1/2 side rails, including the risks and precautions; and
* Directions for staff to observe Resident 3 while eating and drinking related to the risk of aspiration.
The need for service plans to provide clear direction regarding the delivery of services was discussed with Staff 1 (Administrator). She acknowledged the findings.
Service plan was not reflective of resident's needs and provided clear direction regarding the delivery of service:
Resident 3 service plan did not include use of and risks of side rails, direction for staff to observe while eating for risk of aspiration.
1. The use of side rails, including risks and precautions for use will be added to the service plan. Direction for staff to observe resident 3 while eating, including risks for aspiration will be added to service plan.
2. RN will assess all residents who have side rails with community ancillary side rail assessment.
Instructions to staff will be noted in the service plans of each resident with side rails on the correct use and precautions of the device(s).
Inservice to take place on safety and risks of side rails as well as proper maintenance.
3. Side rails will be evaluated on a quarterly basis. Accuracy of care plans will be evaluated at 30 days after admit, every 90 days, after a significant change in conditions or other significant incident/change.
4. Director of Nursing, Maintenance Director and Administrator will be responsible for ensuring that corrections are completed and monitored.
3. Resident 5 was admitted to the facility in 12/2021 with a history of falls.
Observations of the resident, interviews with staff on 08/23/22 through 08/25/22, and a review of the current service plan dated 06/06/22 indicated the service plan was not reflective of the resident's care needs and lacked clear instructions to staff in the following areas:
* Use of side rails;
* Oral care;
* Use of Commode; and
* Skin issues related to left leg and bottom.
The need to ensure service plans were reflective of residents' current needs and provided specific instruction to staff was discussed with Staff 20 (Administrator) and Staff 21 (Regional Nurse) on 08/25/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of current resident care needs, provided clear direction to staff regarding the delivery of services, and ensured the implementation of services identified on the service plan for 2 of 3 sampled residents (#s 5 and 6) whose service plans were reviewed. Resident 6 had previously eloped from the facility and had physical altercations with other residents. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was re-admitted to the facility on 07/12/22 with diagnoses including traumatic brain injuries, major neurocognitive disorder, and seizure disorder.
A review of the resident's clinical records for the period 06/01/22 through 08/24/22, indicated the resident had eloped from the facility for 18 days from 06/24/22 until 07/12/22. There was no documented evidence the facility had updated the residents service plan upon re-admission on 07/12/22.
In an interview on 08/24/22, Staff 21 (Regional Nurse) confirmed the facility had not completed a current service plan for Resident 6 upon re-admission.
The service plan available to staff at the time of survey, last updated on 05/19/22, indicated the the resident was not an elopement risk.
In an interview on 08/24/22, Staff 36 (MT) reported Resident 6 was frequently involved in verbal altercations with other residents, and had tried to fight two other residents within the last 24 hours. Resident 6 had thrown hot coffee in another residents face the morning of 08/24/22.
On the morning of 08/24/22, resident was observed sitting outside in front of the facility and stated "some guy tried to kick my ass last night, that's why I'm sitting outside right now."
The facilities failure to update the residents service plan, placed the resident at risk for future elopement and continued aggressive behaviors.
On 8/24/22, the survey team requested and received an immediate plan of correction, and the situation was abated.
On 08/25/22, the need to ensure service plans were completed at time of move-in, accurately reflected residents care needs, and provided clear instruction to staff on the delivery of services was discussed with Staff 20 (Administrator). She acknowledged the findings.
OAR 411-054-0036 (1-4) Service Plan: General:
1. The following actions will be taken to correct violations per each example given:
a. Resident #6 - Facility is completing a thorough chart-review and lookback of resident's care needs and will update resident #6's service plan to ensure it is reflective of resident's current needs, including but not limited to; elopement hx & risk, verbal & physical aggression interventions and triggers, and current behaviors that may put resident and others at risk.
b. Resident #5 - Facility is completing a thorough review of resident's chart & will update resident's service plan to ensure all care needs are reflective, with specific, clear instructions for staff. Resident #5's service plan will be updated with the following: Use of side rails, oral care, use of commode, and skin issues related to L leg & buttocks. Due to resident requiring nursing oversight, facility LN will be a part of updating resident's service plan, & will provide appropriate interventions and staff instructions.
2. This system will be corrected as follows:
a. Facility IDT will review all upcoming evaluations and service plans for the week, to ensure they are completed timely and thoroughly.
b. Facility will implement a 24hr audit system to ensure that any resident w/a short-term or significant change of condition has appropriate documentation, including TSPs/ISPs, in an attempt to ensure all skin events, falls, and/or any change to resident care is addressed & made a part of the resident's care plan. All audit findings will be brought to morning stand-up meeting by RCM(s) for IDT to review.
c. TSPs/ISPs will be used as a tool to build resident evaluations and service plans, to ensure resident centered care, interventions, & appropriate staff instruction.
d. All service plans will be reviewed & completed in accordance with current OARs: Prior to admission, upon admission, within 30-days of admission, quarterly thereafter, and with any significant change of condition (including re-admission to facility.) Facility administrator will oversee and ensure that all service plans are reflective of resident needs, as identified in resident(s) evaluation.
3.) This system will be monitored as follows:
a. All TSPs/ISPs will be reviewed daily as part of the 24hr process, b. Service plans will be reviewed and updated prior to admission, at time of admission/readmission, within 30 days of admission, quarterly thereafter, and with any significant change of condition.
c. All upcoming service plans will be reviewed once weekly during morning stand-up with IDT. Facility administrator will ensure that service plans are being reviewed and updated on the appropriate schedule, during weekly review with IDT.
4. Facility administrator and facility LN will be responsible for ensuring completion and ensuring on-going compliance.
2. Resident 8 was admitted to the facility in 03/2023 with diagnoses including stroke, anxiety, and depression.
Observations, interviews, and review of Resident 8's clinical records including service plans, MARs dated 04/01/23 through 04/10/23 and progress notes dated 03/14/23 through 04/10/23, was completed during the survey.
The service plan dated 03/14/23 and temporary service plans dated 03/14/23 through 04/10/23, were not reflective and/or did not provide clear direction to staff related to the following care areas:
* Use of assistive devices including bilateral side rails, trapeze, and over the bed table;
* Tray service for meals;
* Assistive devices for dietary needs including use of divided plate, cup with lid and straw, and weighted utensils;
* Mobility limitations;
* Two person ADL care needs for bladder and bowel management;
* Communication including expressive aphasia and the ability to understand and to be understood;
* Cognition including short term memory loss and orientation to time;
* Staff instructions for precautions and monitoring related to history of seizures; and
* History of drug use.
The need to ensure service plans were reflective of the resident's care needs, status, and provided clear instructions for direct care staff was discussed with Staff 21 (Administrator), Staff 45 (Director of Nursing) and Staff 51 (Assistant Administrator) on 04/11/23 at 3:30 pm. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 9 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease.
Observations, interviews, and review of Resident 9's clinical records including service plans, health provider notes, MARs dated 04/01/23 through 04/10/23 and progress notes dated 10/09/22 through 04/10/23, identified the following:
The service plan dated 03/26/23 and temporary service plans dated 10/09/22 through 04/10/23, were not reflective of the resident's care needs and/or did not provide clear direction to staff related to the following care areas:
* Home health services;
* Foley catheter;
* Side-rail placed on the resident's bed;
* Weight fluctuations;
* Tray service for meals;
* Fall risk interventions; and
* Staff instructions for precautions related to use of Warfarin (a blood thinning medication).
During observations on 04/10/23, staff provided Resident 9 with room tray service for the lunch meal.
During an interview on 04/10/23, Resident 9 was observed using a quarter length side rail to assist with bed mobility and repositioning.
During an interview on 04/10/23 Staff 49 (CG) stated staff provided catheter bag changes and assisted the resident with perineal care care related to placement of a new Foley catheter.
The need to ensure service plans were reflective of residents' care needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 21 (Administrator), Staff 51 (Assistant Administrator) and Staff 45 (Director of Nursing) on 04/12/23. They acknowledged the findings.
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OAR 411-054-0036 (1-4) Service Plan: General
1. Action taken to correct this rule violation include:
a. Resident #9 service plan has been updated to reflect home health services; foley catheter; side-rail placement on resident's bed; weight fluctuations; tray service for meals; fall risk interventions; and staff instructions related to use of an anticoagulant.
b. Resident #8 service plan has been updated to reflect use of assistive devices including bilateral side rails, trapeze, and over the bed table; tray service for meals; assistive divices for diatary needs including use of divided plate, cup with lid and straw, and weighted utensils; mobility limitations; two person ADL care needs for bladder and bowel management; communication including expressive aphasia and the ability to understand and be understood, cognition including short term memory loss and orientation to time; staff instructions for precautions and monitoring related to history of seizures; and history of drug use.
2. The system will be corrected so this violation does not happen again by ensuring that the service plan is updated with any acute or signifcant change of condition, as well with pre-scheduled updates (initial, 30-day and ongoing quarterly updates) to reflect the residents current status per Oregon Administrative Rule.
Clinical Services and Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative.
3. The area needing correction will be evaluated at time of move-in, 30-day review, quarterly and as needed if a change of condition occurs.
4. The Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed 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 preferences and provided clear direction to staff regarding the delivery of services for 1 of 2 sampled residents (#15) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 15 was admitted to the facility in 09/2023 with diagnoses including Huntington's disease.
During observations on 9/25 and 9/26/23, Resident 15's bed was noted to have one 1/2 length side rail in the down position. During lunch, Resident 15 was served pureed steak, pureed scalloped potatoes, a berry smoothie, and a cup of yogurt.
Resident 15's current service and behavioral plan, dated 09/20/23, were reviewed, observations were made and interviews were conducted between 09/25/23 through 09/26/23.
Staff stated offering Resident 15 a smoothie or turning on his preferred music were interventions for his agitation and aggression.
Resident 15's service plan was not reflective and did not provide clear instruction to staff in the following areas:
* Use of 1/2 side rail, including the risks and precautions;
* Food preferences; and
* Behavioral interventions.
The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 51 (Administrator) on 09/26/23. She acknowledged the findings.
OAR 411-054-0036 (1-4) Service Plan: General:
1. Immediate action taken to correct the rule violation was
Resident #15 beahvioral plan & service plan was updated on 10/2/23 and to identify resident needs and clear directions to staff in the following areas:
* Use of 1/2 side rail, including the risks and precautions.
* Food preferences.
* Behavioral interventions.
2.This system will be corrected as follows so this violation will not happen again:
a. Facility IDT will review all upcoming evaluations and service plans for the week, to ensure they are completed timely and throughly.
b. Facility will implement a 24 hr audit system to ensure that any resident with a short-term or significant change of condition has appropriate documentation, including TSP/ISP's, in an attempt to ensure all changes to resident care is addressed & made a part of the resident's care plan. All audit findings will be brought to morning stand-up meeting by RCC's for IDT review.
c. TSP/ISP's will be used as a tool to build resident evaluations and service plans to ensure resident centered care, interventions & appropriate staff instructions.
d. All service plans will be reviewed & completed in accordance with the current OAR's: Prior to admission, upon admission, within 30-days of admission, quaterly thereafter, and with any significant change of condition (including re-admission to facility). Facility administrator will oversee and ensure that all service plans are reflective of resident needs, as identified in resident's evaluation.
3. The area needing correction will be monitored as follows:
a. All TSPs/ISPs will be reviewed daily as part of the 24 hour process.
b. Service plans will be reviewed and updated prior to admission, at time of admission/readmission, within 30-days of admission, quarterly thereafter, and with any significant change of condition.
4. Facility Administrator, Director of Nursing or designee will be responsible for ensuring completion and ensuring on-going compliance.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition monitored, for 2 of 2 sampled residents who experienced short term changes of condition (#s 1 and 3). Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 03/2022 with diagnoses including a history of stroke.
The resident's 05/01/22 service plan, 03/31/22 through 05/17/22 Progress Notes, and temporary service plans were reviewed. The resident experienced short-term changes without documented monitoring at least weekly until resolution, in the following areas:
* UTI; and
* Bowel issues.
The need to ensure changes of condition were evaluated, had documentation to reflect monitoring to resolution at least weekly, and provided clear resident specific directions to staff, was discussed with Staff 1 (Administrator) on 05/18/22. She acknowledged the findings.
2. Resident 1 was admitted to the facility in 11/2021 and had diagnoses which included diabetes.
Resident 1's clinical record and charting notes, reviewed from 02/14/22 through 05/17/22, revealed the following:
a. On 04/11/22, Resident 1 was admitted to the hospital. Resident 1 returned to the facility with a diagnosis of acute septic shock resulting in mesenteric stenosis which required a stent to resolve. S/he also returned with edematous extremities and gonads. There was no documented evidence the facility monitored Resident 1 after his/her return to the facility.
b. On 04/02/22 Resident 1 received a cut on his/her right index finger near the knuckle. There was no documented evidence the facility monitored the cut weekly until the cut was resolved.
The need to ensure the facility monitored and documented on the progress of short-term changes in condition at least weekly until resolved and monitor the resident consistent with his/her evaluated needs was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing) on 05/18/22. They acknowledged the findings.
Short term changes in condition monitoring-
Resident 3 had changes related to UTI and bowel issues without weekly documentation until resolved.
1. Nursing will follow facility procedures for changes in condition, which includes an initial nursing assessment of the COC after Med Tech completes incident report, resident put on alert charting for 72 hours, a TSP started in care plan, adding the COC to the nursing follow-up spreadsheet with frequency of needed follow-up, then completing the needed follow-up until resolved. When resolved, nursing will document the resolution.
2. DON and Admin will complete monthly audits of documentation in the EMAR to ensure every COC documented in an incident report was assessed, monitored and resolved.
3. All documentation in resident EMAR will be reviewed weekly by DON and monthly by Administrator.
4. DON and Administrator are responsible for corrections being completed.
Resident 1 returned from hospital with no documented evidence of monitoring after return.
1. After a resident returns from the hospital nursing will complete an initial assessment of resident's condition, put resident on 72 hour alert charting, initiate a TSP, enter follow-up needed and frequency on nursing follow-up spreadsheet and complete follow up until resolved.
2. DON and Admin will complete monthly audits of documentation in the EMAR to ensure every COC is assessed, monitored and resolved.
3. All documentation in resident EMAR will be reviewed weekly by DON and monthly by Administrator.
4. DON and Administrator are responsible for corrections being completed.
Resident 1 received a cut on his finger, there was no documentation of monitoring the cut until resolved.
1. Nursing will follow facility procedures for changes in condition, which includes an initial nursing assessment of the COC after Med Tech completes incident report, resident put on alert charting for 72 hours, potentially a TSP started in care plan, adding the COC to the nursing follow-up spreadsheet with frequency of needed follow-up, then completing the needed follow-up until resolved. When resolved, nursing will document the resolution.
2. DON and Admin will complete monthly audits of documentation in the EMAR to ensure every COC documented in an incident report was assessed, monitored and resolved.
3. All documentation in resident EMAR will be reviewed weekly by DON and monthly by Administrator.
4. DON and Administrator are responsible for corrections being completed.
2. Resident 5 was admitted to the facility in 12/2021 with a history of skin issues.
Observations of the resident, interviews with staff on 08/23/22 through 08/25/22, a review of the current service plan dated 06/06/22, and review of the progress notes dated 07/18/22 through 08/23/22 indicated a lack of monitoring of Resident 5 for changes of condition in the following areas:
*A progress note dated 07/22/22 revealed Resident 5 had been attending a wound clinic twice weekly for scattered blistering on lower left extremity. The next progress note following up with the scattered blistering was on 08/13/22 noting the appearance is unchanged. Interview with Staff 20 (Administrator) revealed there was no other documentation regarding the blistering on Resident 5's lower left extremity.
* A progress note dated 07/23/22 revealed Resident 5 had an open wound on his/her left buttock. In an interview with Staff 20 and 21 (Regional Nurse) there was no documented evidence of any other follow up monitoring for the open wound.
The need to ensure the facility monitored changes of condition at least weekly until resolution was discussed with Staff 20 and Staff 21 on 08/25/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to evaluate, monitor, and develop resident specific interventions for 2 of 3 sampled residents (#s 5 and 6) who experienced changes of condition. Resident 6 had an elopement from the facility and behaviors that negatively impacted themselves or other residents. This is a repeat citation. Findings include but are not limited to:
1. Resident 6 was re-admitted to the facility on 07/12/22 with diagnoses including traumatic brain injuries, major neurocognitive disorder, and seizure disorder.
Resident 6's clinical records were reviewed during the survey and revealed the following:
*07/12/22 Resident 6 was re-admitted to the facility after an 18 day elopement. There was no documented evidence the facility had determined actions or interventions to address the resident's elopement risk upon re-admission, determined and documented what actions and interventions were needed for the resident, communicated them to staff on all shifts, updated the service plan or monitored the resident.
*07/14/22 Resident 6 reported feeling agitated and did not have any medications to address his/her pain. There was no documented evidence the resident was monitored for pain and lack of pain reducing medications.
*07/15/22 Resident 6 and an un-sampled resident were involved in a verbal altercation and had verbally threatened one another. There was no documented evidence the facility determined what actions or interventions were needed to minimize further occurrences.
*In an interview on 08/24/22, Staff 36 (MT) reported Resident 6 was frequently involved in verbal altercations with other residents, had tried to fight two other residents within the last 24 hours, and had thrown hot coffee in an unsampled residents face. Staff 36 also reported the resident had been without his/her seizure or mood stabilizing medication since re-admission on 07/12/22.
On 08/24/22 the resident was observed sitting outside the facility smoking cigarettes and drinking coffee.
The facility failed to evaluate the resident elopement risk and history, obtain resident medications, and implement interventions to reduce behaviors which resulted in Resident 6 having repeated altercations with other residents and put resident at risk for future elopements.
On 8/24/22, the survey team requested and received an immediate plan of correction and the situation was abated.
On 08/25/22, the need to ensure the facility evaluated, monitored, and develop resident specific interventions for all residents who experienced changes of condition was discussed with Staff 20 (Administrator). She acknowledged the findings.
OAR 411-054-0040 (1-2) Change of Condition and Monitoring:
1.) The following actions are being taken to correct violations per each example given:
a. Resident #6 - Facility LN will begin weekly significant change of condition assessments for resident #6. Facility LN will assess hx of elopement & elopement risk, medications, and resident behaviors. Facility LN will include interventions and clear instructions for staff to follow via TSP/ISP. Facility LN will continue to monitor and assess resident weekly, until resident is back to baseline or LN can reasonably establish a new baseline.
b. Resident #5 - Facility LN will assess all of resident #5's current & ongoing skin events/wounds. All findings will be documented via TSP/ISP, with clear instructions for staff to follow. All current skin events will be assessed by LN, with weekly updates, until resolved.
2.) This system is being corrected as follows:
a. Facility is implementing a 24hr audit/process to ensure that all resident changes of condition are evaluated at onset, that appropriate interventions are put in place via TSP/ISP, & that all changes of conditions are monitored until resolved. The 24hr audit/process will include a lookback of the last 24hrs (or 72hrs on Mondays) of chart notes, incident reports, alert log, and reviewing the 24hr binder. This audit will ensure that all appropriate care paths are followed in a timely manner. The 24hr audit and findings will be brought to daily stand-up for IDT to review.
b. Facility will ensure that a skin log & significant change of condition log is maintained in the 24hr binder to ensure appropriate oversight, interventions, and communication to staff.
c. Facility staff will receive training related to the 24hr process and will include ensuring all skin events, or changes of condition are added to either the skin log or the significant change of condition log.
d. Facility nurse will review the skin log, significant change of condition log, and resident alerts, daily during morning stand-up. LN will also ensure that all new skin events and/or treatments are entered into the resident's chart with clear instructions for staff to follow.
e. Facility nurse will ensure that all interventions and/or staff instructions secondary to change of condition are implemented via TSP/ISP and made a part of the resident's record.
3.) This system will be evaluated as follows:
a. The 24hr audit will be completed and reviewed daily, during morning stand-up by IDT, and a 72hr audit will be completed and reviewed on Mondays (or upon return from 2 days off.)
b. Facility LN will review skin log and change of condition log, daily, and will provide once weekly resident assessments with weekly documentation, until resolved.
c. Facility will ensure that all TSPs/ISPs (temporary service plans) are made a part of the resident's service plan/evaluation as they are updated per scheduling requirements: Initial, within 30 days of admission, quarterly thereafter, & with significant change of condition or readmission.
d. Facility Administrator will ensure that all applicable staff (those writing, reviewing, and updating TSPs/Service plans) will have on-going training as required. Facility administrator will review training grid at least once monthly, and with each new-hire orientation, as applicable.
e. Facility Administrator will ensure that the 24hr audit and review is done daily, and reviewed by IDT, during morning stand-up.
4.) The facility administrator, and the facility LN will be responsible to ensure correction and oversee ongoing compliance.
2. Resident 8 was admitted to the facility in March 2023 with diagnosis including stroke, hypertension, and history of seizures.
A review of the resident's 03/14/23 through 04/10/23 progress notes, MARs and temporary service plans for the same time period indicated the following changes of condition:
* 03/14/23 through 03/21/23, missed medications including Eliquis, Keppra, Atrovastatin, and Protonix;
* 03/17/23 loose stool; and
* 03/28/23 C-diff lab order due to ongoing loose stool.
There was no documented evidence the facility had evaluated these changes to determine actions and interventions needed, provided written instructions to staff, and/or monitored the above documented changes of condition to resolution.
The need to ensure changes of condition were evaluated, action or interventions communicated to staff and monitored through resolution was discussed with Staff 21 (Administrator), Staff 45 (Director of Nursing) and Staff 51 (Assistant Administrator) on 04/11/23 at 3:30 pm. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to document monitoring of short term changes of condition until resolution and failed to document monitoring of residents consistent with their evaluated needs for 4 of 5 sampled residents (#s 1, 8, 9, and 10) who experienced falls and short term changes of condition. This is a repeat citation. Findings include but are not limited to:
1. Resident 10 was admitted to the facility in 09/2021 with a traumatic brain injury and was identified to be evaluated as a fall risk and to have a behavior of lying on the floor. A specific behavior plan was developed for these instances.
Resident 10's service plan included interventions to reduce falls.
Review of Resident 10's service plan and interviews with staff identified Resident 10 was independent with transfers and mobility, and had a cane for ambulation.
a. Resident 10's clinical record revealed s/he fell, was found on the floor, and Resident 10 reported having fallen and gotten up independently, 20 times between 01/01/23 and 04/10/23.
Staff 45 (Director of Nursing) had a record of each fall, documenting the instance and conclusions about the situation, including if it was a behavior or an actual fall.
Incident Investigation Forms were completed for each fall and temporary service plans were developed.
There was no documented evidence the service planned fall interventions were monitored and reviewed to determine effectiveness with each incident.
b. Resident 2's facility charting notes indicated:
*On 1/26/23 - "... skin tear to right great toe..." following a fall
*On 01/27/23 - "...right eye bleeding..." following a fall; and
*On 03/21/23 - a head laceration and ER visit following a fall.
There was no documented evidence the injuries had been monitored at least weekly until resolved.
The need to monitor residents per their evaluated needs and to monitor changes in condition to resolution was discussed with Staff 21 (Administrator). She acknowledged the findings.
3. Resident 9 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease.
Observations, interviews, and review of Resident 9's clinical records including service plans, home heath provider notes, MARs dated 04/01/23 through 04/10/23 and progress notes dated 10/09/22 through 04/10/23, identified the following:
a. During the acuity interview on 04/10/23, Staff 21 (Administrator) stated Resident 9 required two staff members to assist with all transfers. On 01/09/23, staff documented Resident 9 was found on the floor after s/he slid out of his/her wheelchair. A temporary service plan dated 01/09/23, instructed staff to monitor the resident's ability to transfer. The temporary service plan lacked resident specific interventions related to Resident 9's fall risk and there was no documented evidence the resident's ability to transfer was monitored consistent with his/her evaluated needs.
b. On 03/30/23, a home health provider documented placement of a Foley catheter and instructed staff to provide "cath care daily, daily peri care and orange cream." There was no documented evidence the facility RN was notified of the significant change in condition and there was no documented evidence the facility provided written communication of the change in condition, with required interventions, to caregivers on each shift.
During interviews on 04/12/23, Staff 21 and Staff 45 (Director of Nursing) stated they had not been notified that Resident 9 had a Foley catheter placed on 03/30/23.
The facility's failure to monitor changes in condition consistent with residents' evaluated needs, develop resident specific interventions, provide written communication of residents' changes of condition, with required interventions, to caregivers on each shift, and refer significant changes in condition to the facility nurse was discussed with Staff 21, Staff 51 (Assistant Administrator) and Staff 45 on 04/12/23. They acknowledged the findings.
4. Resident 1 was admitted to the facility in November of 2021 with diagnoses including diabetes mellitus and depression.
A review of the resident's clinical records dated 10/10/22 through 04/10/23, indicated the following changes of condition:
* 12/17/22 - MT documented Resident 1 "has stated that s/he has had many suicidal thoughts and cries daily.";
* 01/13/23 - Resident had a fall with cut to right hand; and
* High/low blood sugar episodes on 01/15/23, 04/06/23, 04/07/23 and 04/10/23.
There was no documented evidence the facility had evaluated these changes to determine actions and interventions, provided written instructions to staff, and/or monitored the above documented changes of condition to resolution.
The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was updated was discussed with Staff 21 (Administrator) and Staff 45 (Director of Nursing) on 04/12/22. They acknowledged the findings.
C270
OAR 411-054-0040 (1-2) Change of Condition and Montioring
1. Action taken to correct this rule violation include:
a. Resident #10 will have an RN assessment and root cause analysis related to repeat falls with and without injuries will be conducted to identify appropriate
interventions to minimize injuries related to the
resident high risk of falls.
AND
Will have a comprehensive skin evaluation
and service plan update conducted related specifically
to resident skin condition. Current and relevant
historical skin conditions will be added to the service
plan with appropriate interventions for staff to be made
aware of and to follow as applicable.
b. Resident #8 will have have a focused assessment completed by RN for 3/14/23 through 3/21/23, missed medications including Eliqus, Keppra, Astrovastatin and Protonix; 3/17/23 loose stool; and 3/28/23 C-Diff lab order due to ongoing loose stool.
c. Resident #9 will have an RN assessment completed to address that following: resident specific interventions related to fall risk and ability to transfer.
AND
RN will complete signifcant change of condition assessment for placement of foley catheter.
A service plan addendum was completed to provide appropriate interventions for staff to be made aware of and to follow as applicable.
d. Resident #1 will have a comprehensive assessment completed by the RN related to suicidal thoughts and crying daily; falls with injury, and hypo / hyperglycemia. Current and relevant suicidal thoughts; crying daily; falls with injury; and hypo / hyperglycemia will be added to the service plan with appropriate interventions for staff to be made aware of and to follow as appliable.
Based on observation, interview, and record review, it was determined the facility failed to ensure actions or resident-specific instructions or interventions were identified, implemented, and communicated to staff for 1 of 2 sampled residents (#15) reviewed for changes of condition. This is a repeat citation. Findings include, but are not limited to:
Resident 15 was admitted to the facility in 09/2023 with diagnoses including Huntington's disease.
Review of Resident 15's service and behavioral plan, dated 09/20/23, progress notes dated 09/05/23 through 09/25/23 and incident investigations were reviewed and found the following:
a. On 09/10/23 Resident 15's progress notes stated " ...[Resident 15] was involved in an altercation with a housemate today ...the residents were attempting to swing at one another but did not make contact ...Staff will perform frequent checks and attempt to keep resident's separated."
Then on 09/21/23 - "...[Resident 15] became physically aggressive with staff and housemate. [S/he] struck staff member two times with his walker and assaulted his housemate [Same resident as incident on 09/10/23] ...causing injury."
On 09/26/23 at 12:35 pm, a surveyor observed Staff 55 (CG) seat the housemate, whom Resident 15 had altercations with, next to Resident 15 for lunch.
On 09/26/23 in an interview with Staff 54 (CG) and Staff 55 they stated they "just pay attention to where all the residents are" but were not aware of any specific information related to keeping Resident 15 and the housemate away from one another.
There was no documented evidence the intervention to keep Resident 15 and the housemate separated was communicated to staff.
b. An incident report from 09/13/23 noted Resident 15 was in the backyard and using his/her chair to "attempt to break down the fence ...[Resident 15] was alternating between attempting to climb the fence and banging [his/her] head on the gate."
Progress notes dated 09/13/23 stated "TSP to open front door for [Resident 15] during violent outburst and maintain distance for a few minutes until emotionally reactivity dissipates. Also, you can phone Mom/guardian to calm [Resident 15] or encourage [him/her] to take meds."
On 09/26/23 at 9:00 am, during an interview with Staff 45 (Director of Nursing) she stated Resident 15 "is super violent when agitated" and the plan was to open the front door and staff would follow the resident "with the idea that [he/she] will wear himself out."
On 09/26/23 at 9:10 am with Staff 54 (CG) stated "opening the front door is all new to me" and was not aware of the plan to open the front door when Resident 15 was having violent behaviors.
There was no documented evidence the determined action or intervention was communicated to staff on each shift.
The need to ensure actions or resident-specific instructions or interventions were identified, implemented, and communicated to staff was reviewed with Staff 51 (Administrator) on 09/26/23. She acknowledged the findings.
OAR 411-054-0040 (1-2) Change of Condition and Monitoring:
1. The following actions have been taken to correct this rule violation
a. Resident #15 had his behavioral plan updated by the behavioral specialist on 10/5/23 to reflect residnet specific instructions / interventions and communicated to and reviewed by staff.
b. Resident #15 had a sevice plan team meeting with update to his service plan on 10/2/23 to reflect resdient specific instructions / interventions and communicated to and reviewed by staff.
2. The system will be corrected so this violation will not happen again as follows:
a. Facility is implementing a 24hr audit/process, to be led by RCC's, to ensure that all resident changes of condition are evaluated at onset, that appropriate interventions are put in place via TSP/ISP and all changes of conditions are monitored until resolution. The 24hr audit/process will include a lookback of the last 24hrs (or 72hrs on Mondays) of chart notes, incident reports, alert log and reviewing the 24hr binder. This audit will ensure that all appropriate care paths are followed in a timely manner. The 24hr audit and findings will be brought to daily stand-up for IDT review.
b. Facility will ensure that a skin log & significant change of condition log is maintained in the 24hr binder to ensure appropriate oversight, interventions and communication to staff.
c. Facility nurse will review the skin log, significant change of condition log and resident alerts, daily during monring stand-up. LN will also ensure that all new skin events and/or treatments are entered into the resident's chart with clear instructions for staff to follow.
d. Facility nurse will ensure that all interventions and/or staff instructions secondary to change of condition are implemented via TSP/ISP and made a part of the residents record.
3. The area needing correction will be evaluated as follows:
a. The 24hr audit will be completed and reviewed daily, during morning stand-up by IDT, and 72hr audit will be completed and reviewed on Mondays (or upon return from days off).
b. Facility will ensure that all TSPs/ISPs (temporary service plans) are made a part of the residents service plan/evaluation as they are updated per scheduleing requirements: Initial, within 30-days of admission, quarterly thereafter & with significant change of condition or readmission.
c. Facility administrator or designee will ensure that all applicable staff (those writing, reviewing, and updating TSPs/service plans) will have on-going training as required. Facility administrator will review training grid at least once a month, and with each new-hire orinetation, as applicable.
d. Facility administrator or designee will ensure that the 24hr audit and review is done daily, and reviewed by IDT, during morning stand up.
4. The facility Administer, Director of Nursing or designee will be responsible to ensure correction and oversee ongoing compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN for 1 of 1 sampled resident (# 5) reviewed for significant changes of condition. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 12/2021 with a history of skin issues.
Interviews with staff from 08/23/22 through 08/25/22, a review of the current service plan dated 06/06/22, and review of the progress notes dated 07/18/22 through 08/23/22 indicated the following significant change of condition:
A progress note dated 07/23/22 revealed Resident 5 had an open wound on his/her left buttock. In an interview with Staff 20 (Administrator) and 21 (Regional Nurse) on 08/24/22, they reported there was no RN assessment of the wound.
In an interview with Staff 20 and Staff 21, they stated the facility RN was on vacation and there was no documented evidence of the current status of the wound. Staff 20 stated there were no outside provider notes to determine the current status of the wound.
The need to ensure an RN assesses significant changes of condition was discussed with Staff 20 and Staff 21 on 08/25/22. They acknowledged the findings.
OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services:
1.) The following actions are being taken to correct violations for each example given:
a. Resident #5 - Facility LN will assess all current and on-going skin events and wounds for resident #5. LN will complete a significant change of condition assessment for resident #5 to include: current status of residents' wound(s), on-going treatment plan, and clear instructions for staff to follow. LN will continue to assess resident #5 once weekly, with thorough weekly documentation of assessment(s).
2.)This system will be corrected as follows:
a. Facility will ensure RN coverage of the building when facility nurse is on vacation or away from the building for an extended amount of time.
b. Facility is implementing a 24hr process to include: Updating the 24hr binder with skin log, change of condition logs, and instructions for staff on when to call the nurse. Facility RCM(s) will run the 24/72 hr audit each morning (5 days a week on regular scheduled days, and 72hr audit on Mondays or upon return from 2 days off) to identify any changes of condition noted. This audit will be ran using current EHR system ( ) and will allow RCM(s) to have a 24/72 hr look back at everything that has happened within the last 24/72hr time frame. This audit will ensure that all notable changes in a resident's condition are identified in a timely manner, and that all assessments are initiated and then maintained until resolution.
c. Facility administrator will review assessment logs once weekly to ensure all changes of condition and nursing assessments are being completed timely, thoroughly, and with all required components.
d. Facility RN will complete "The Role of the RN" through OHCA and will submit a certificate of completion to The Dept.
3.) This system will be evaluated as follows:
a. The 24/72 hr audit will be completed daily (5 days a week, and 72hr audit on Mondays, or upon RCM(s) return from 2 days off.)
b. Skin logs & change of condition logs will be reviewed daily during morning stand-up with IDT, which will include facility nurse(s).
c. To ensure ongoing compliance with nursing oversight and resident assessments', facility administrator will review all active assessments, at least once weekly.\
4.) Facility Administrator, Facility RCM(s), and Facility RN will be responsible for ensuring completion and ongoing compliance.
Based on observation, interview, and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, or updated the service plan for 2 of 3 sampled residents (#s 9 and 11) who experienced significant changes in condition. Resident 11 experienced on-going severe weight loss. This is a repeat citation. Findings include, but are not limited to:
1. Resident 11 was admitted to the facility in 02/2022 with a traumatic brain injury.
Resident 11 was not observed to leave his/her room during the survey. Staff advised the Surveyor to not disturb the resident as it could possibly trigger aggressive behavior.
Review of facility resident service notes, weight records, MARs, physician communications, and current service plan, from 10/2022 through 04/10/23, revealed the following:
* Weight records indicated the resident weighed 147.8 lbs. on 02/01/2023. On 03/01/23, the resident's weight dropped to 137.0 lbs.
Between 02/2023 and 03/2023, s/he lost 10.8 lbs. or 7.3 % of his/her weight in one month, which constituted a severe loss and significant change in condition for which an assessment by the facility RN was required.
* Weight records indicated the resident weighed 133.0 lbs. on 04/02/23, an additional 4 lb loss.
Resident 11's weight on 4/10/23 was 130 lbs., an additional 3 lbs loss.
From 02/01/23 to 03/2023 Resident 11 experienced a severe weight loss. There was no documented evidence of an RN assessment documenting resident status, findings and interventions made as a result. Resident 11 continued to lose weight.
On 03/24/23, Staff 45 (Director of Nursing) documented in facility Progress Notes the weights of Resident 11, indicating a change of condition. Staff 45 noted the physician had been notified and a supplement was requested. No further information, including an assessment of the resident's status and interventions made as a result of the assessment, was documented.
During an interview on 04/11/23 at 9:30 am, Staff 45 acknowledged the lack of a documented RN assessment including documentation of findings, the resident's status, and interventions made as a result of the assessment for the significant change in condition.
The need to ensure documented RN assessments for significant changes in condition was discussed with Staff 21 (Administrator) and Staff 45 on 04/11/23. They acknowledged the findings.
2. Resident 9 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease.
Observations, interviews, and review of Resident 9's clinical records including service plans, home health provider notes, MARs dated 04/01/23 through 04/10/23 and progress notes dated 10/09/22 through 04/10/23, identified the following:
On 03/30/23, a home health provider documented new placement of a Foley catheter and instructed staff to provide "cath care daily, daily peri care and orange cream."
There was no documented evidence the facility RN assessed the resident's significant change in condition related to placement of a Foley catheter.
The need to ensure residents' significant changes in condition were assessed by the facility RN was discussed with Staff 21 (Administrator), Staff 51 (Assistant Administrator) and Staff 45 (Director of Nursing) on 04/12/23. They acknowledged the findings.
C280
OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services
1. Actions to correct this rule violation include a comprehensive health assessment by RN for
a. Resident #11will be assessed by the RN to ensure probable casuative factors for weight loss are identified and appropriate interventions and montioring are in place until weight stabilizes.
b. Resident #9 will be assessed by the RN for the placement of foley catheter and will be added to the service plan with appropriate interventions for staff to be made aware of and to follow as applicable.
2. To ensure the system will be corrected so this violation does not happen again, the community will follow 24-hour communication system. The 24-hour binder has been set up to include:
a. Shift to shift communication log
b. Alert charting log / audit log
* Staff will follow Short Term Monitoring / Communication System for any resident identified to have an acute change of condition such as UTI, missed medication, return from the hospital, fall for example.
* When a change of condition is identified, staff add the resident name to the alert log to ensure monitoring of the resident, and identify when to report concerns to the licensed nurse or MD per the temporary service plan (TSP) that has been put in place, which cooralates with the resident change of condition.
* The TSP has specific directions for staff including what to look for, interventions to put in place, signs / symptoms to report and staff signature lines to sign once they have read and understand the TSP.
* Staff should monitor resident status until resident condition resolves and they are back at their baseline.
* 24-hour book / process will be reviewed daily during stand up meeting as a means of identification of potential signifcant change that needs to be assessed by the RN.
3. The area needing correction will be reviewed daily, weekly, monthly and quarterly to ensure compliance is maintained.
4. The Administrator and Registered Nurse will be responsible to ensure the corrections are completed and monitored.
There are no detail notes for this visit.
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 05/17/22, Resident 1 was identified as a diabetic with prescribed sliding scale insulin, who received injections by non-licensed staff.
Review of Resident 1's delegation documentation during the survey revealed the following:
* Staff 8 (MT) was initially delegated to perform insulin injections on Resident 1 on 7/7/21, Staff 11 (MT) was initially delegated to perform insulin injections on Resident 1 on 01/17/22 and Staff 12 (MT) was initially delegated to perform insulin injections on Resident 1 on 12/07/21. Re-evaluation of Staff 8, 11 and 12's delegation duties was not completed within 60 days of initial delegation;
* There was no documented evidence the facility documented individual observation/return demonstration of competence of the MT;
* There was no documented evidence a facility RN assessed Resident 1's condition to determine his/her condition was and remained stable and predictable; and
* There was no documented evidence the facility included frequency the client should be reassessed including a rationale.
The need to ensure delegation and supervision of special tasks of nursing care was completed in accordance with OSBN Division 47 rules was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing) on 05/18/22. They acknowledged the findings.
Delegations, re-evaluation of 3 staff was not done within 60 days of initial delegation
1. DON will review delegation requirements and make adjustments to re-evaluation schedules for all delegated staff. Re-evaluations will happen at 30, 60, 90, and 120 days after initial delegation. DON will create a delegation calendar to ensure all re-evaluations are completed on time.
2. DON will schedule each delegated staff on a delegation calendar to remind her when people are due for re-evaluation. Administrator will audit delegations quarterly for completion.
3. DON will audit delegation schedule monthly and Administrator will audit delegations quarterly.
4. DON will be responsible for correcting delegations and Administrator is responsible for on-going compliance.
No documented evidence of individual observation/return demonstration of MT
1. DON will review delegation regulations and follow all requirements. Every MT that is delegated for insulin will have an observation/return demonstration form completed and filed in the delegation binder.
2. DON will audit delegation binder monthly and Administrator will audit delegations quarterly for compliance.
3. Delegation binder will be audited monthly and quarterly.
4. DON is responsible for making corrections and Administrator is responsible for on-going compliance.
No evidence of RN assessed resident 1 was and remained stable and predictable. No evidence RN documented frequency with which resident 1 should be reassessed, including rationale.
1. DON will review all delegation regulations and follow all requirements. DON or RN will complete an initial diabetic assessment upon move-in of residents who are diabetic. This assessment will include a documented frequency and rationale for when they will be assessed next. Then DON or RN will complete re-assessments based on documented frequency to determine if resident is stable and predictable.
2. DON will put residents who require diabetic assessments on the nursing follow-up spreadsheet so nursing is alerted when they are due to be completed.
3. DON will audit resident assessments monthly and Administrator will audit resident charts quarterly.
4. DON is responsible for ensuring corrections are completed and Administrator is responsible for on-going compliance.
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 2 sampled residents (#4) who received insulin injections by unlicensed facility staff. This is a repeat citation. 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.
Resident 4 was admitted to the facility in 07/2022 with diagnoses including insulin dependent diabetes.
Resident 4 was identified to be administered insulin injections by non-licensed staff.
There was no documented evidence the facility RN had completed an assessment of Resident 4 to determine his/her condition was stable and predictable. There was no determination of the frequency of re-assessment, including rational.
Review of Resident 4's insulin administration record from 07/25/22 through 8/23/22 revealed Staff 29, 30, 31, 34, 35, 39, 40, 41 (MTs), and Staff 32 and 33 (Agency MT) had administered insulin to Resident 4.
1. Staff 34 was delegated to administer insulin to Resident 4 on 7/25/22. The delegation lacked:
*Rational the task could be safely delegated to the staff; and
*Documentation the facility RN accepted responsibility for delegating the task and would ensure supervision.
2. Staff 29, 30, 31, 32, 33, 35, 39, 40, and 41 lacked evidence of delegation to administer insulin to Resident 4.
A plan to ensure only staff delegated per the OSBN Division 47 rules or a licensed nurse would administer insulin to Resident 4 was requested and accepted on 08/24/22.
The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 20 (Administrator) and Staff 21 (Regional Nurse) on 08/24/22. They acknowledged the findings.
OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching:
1.) The following actions are being taken to correct violations per each example given:
a. Resident #4 - Facility RN has completed an assessment of resident #4 to determine that his/her condition was stable and predictable.
b. Facility RN will determine and document the frequency of re-assessment for resident #4, and will include the rationale.
c. Facility RN has appropriately delegated all direct care staff who are responsible for administering insulin, and delegations will include all required components outlined in division 47, including but not limited to:
Rationale that the task can be safely delegated to staff, documentation that RN has accepted responsibility for delegating the task, and would ensure supervision, providing initial direction by teaching the task of nursing care, observing the non-licensed staff member perform the task, and leaving procedural guidance for performance of the task for staff to reference.
2.) This system will be corrected as follows:
a. Facility RN will attend 'The Role of the RN' through OHCA, and will submit a certificate of completion to The Dept.
b. Facility RN will implement a delegation spreadsheet with all residents who require delegations, and all staff members who will be administering insulin. This document will include the date of initial delegation for each staff member to ensure re-delegation at appropriate dates, ongoing.
c. Vanda Consultant will provide facility RN with further training and training material related to delegations, and from division 47.
d. Facility administrator will review/audit all delegation documentation to ensure thorough and timely assessment and delegation.
3.) This system will be evaluated as follows:
a. Facility RN will review delegation task sheet at least bi-weekly to ensure appropriate oversight and assessment.
b. Facility administrator will review/audit delegations at least once monthly to ensure appropriate requirements are in place and being followed per the regulations and division 47.
4.) Facility Administrator and Facility RN will be responsible for corrections and ensuring ongoing compliance.
Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were added to the service plan and communicated to staff for 1 of 2 sampled residents (# 1) who were receiving home health services from outside providers. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 11/2021 and had diagnoses including bilateral edema in lower extremities.
A Home Health RN left a note on 05/11/22 recommending Resident 1 wear Ted Hose to help reduce the swelling in his/her legs. In an interview on 05/18/22 with Staff 2 (Director of Nursing) and Staff 3 (RN) revealed the facility did not update the service plan to include the recommendations of Ted Hose or communicate the recommendation to staff.
The need to ensure the facility coordinate care with outside providers and ensure recommendations were added to the service plan and communicated to staff was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 05/18/22. They acknowledged the findings.
Documentation and monitoring of outside provider directions:
Resident 1 had new orders for TED hose, which were not added to service plan with instructions for staff.
1. DON will ensure TED hose instructions have been added to resident 1's care plan. Section nurse will collect all communications from outside providers, implement the recommendations by adding to care plan, EMAR or elsewhere and document recommendations in resident chart.
2. DON will track which residents have outside providers and audit resident charts to ensure documentation on regular provider visits is being completed. When completing quarterly care plan updates RCM will check with DON for updates related to outside providers that may need to be included in updated care plan.
3. DON will audit outside provider notes being documented monthly by reviewing chart notes and outside provider communication log.
4. DON is responsible for ensuring corrections are made.
Based on interview and record review, it was determined the facility failed to ensure the coordination care with outside service providers for 1 of 1 sampled resident (# 5) who received outside services. This is a repeat citation. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 12/2021 with a history of skin issues.
Interviews with staff on 08/23/22 through 08/25/22, a review of the current service plan dated 06/06/22 and review of the progress notes dated 07/18/22 through 08/23/22 indicated the following:
A progress note dated 07/22/22 revealed Resident 5 had been attending a wound clinic twice weekly for scattered blistering on lower left extremity The next progress note following up with the scattered blistering was on 08/13/22 noting the appearance was unchanged. Interview with Staff 20 (Administrator) and Staff 21 (Regional Nurse) revealed they had no outside provider notes from the wound clinic.
The need to ensure written recommendations made by outside service providers were made available to staff for provision of supplemental care was discussed with Staff 20 and Staff 21 on 08/25/22. They acknowledged the findings.
OAR 411-054-0045 (s) Resident Health Services: On and off site Health Services:
1.) The following actions are being taken to correct violations per each example given:
a. Resident #5 - Facility will coordinate with wound clinic to obtain all previous records and recommendations given by outside provider. All recommendations will be made a part of the resident record.
2.) This system is being corrected as follows:
a. Facility is implementing an outside provider binder for each house. Outside provider binder will be kept near the med-room(s).
b. All outside provider notes will be stamped with the triple check stamp, and will be processed as 'orders' through the triple check process. This process will include: Each medication-aide will check outside provider binder at least once during shift and will process all notes, including implementing all recommendations via TSP/ISP. Med-tech will sign/date the completed outside provider note(s) indicating that it has been reviewed and resident's TSP updated. The next med-tech to come on shift will be the second review to ensure all appropriate documentation was completed and will sign/date indicating so, and the final check will be completed by facility LN/RN.
3.) This system will be evaluated as follows:
a. Med-techs will check outside provider binders at least once per shift, and will process all outside provider notes prior to their shift ending, through the triple check system.
b. Facility LN will review triple checks at least once daily (on workdays) to ensure appropriate follow-up, coordination of care, and implementation of recommendations and/or interventions.
c. All significant changes will be reviewed during daily morning stand-up by IDT.
4.) Facility LN and Facility Administrator will ensure completion and will oversee ongoing compliance.
Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:
During the initial licensure survey, conducted 05/17/22 through 05/19/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:
C 282: RN Delegation and Teaching;
C 303: Systems: Medication and Treatment Orders;
C 305: Systems: Resident Right to Refuse;
C 310: Systems: Medication Administration;
C 325: Systems: Self Medication; and
C 372: Training within 30 days: Direct Care Staff.
Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 05/19/22.
1. All Medication Techs and Nurses will go through a training course to review the medication policies and procedures.
2. Procedures will be reviewed by Vice President of Operations and changes will be amended as needed and triaged to Pharmacy for consult.
3. Med Tech training will be audited by DON and HR monthly to ensure complaince.
4. DON, Administrator and HR will be responsible for corrections.
Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was not administered medications from 07/12/22 to 08/23/22, including seizure and mental health medications.
Refer to C 303.
2. During the re-visit to the initial relicensure survey, conducted 08/23/22 through 08/25/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:
C 282: RN Delegation and Teaching;
C 303: Systems: Medication and Treatment Orders; and
C 310: Systems: Medication Administration; and
Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was reviewed with Staff 20 (Administrator) and Staff 21 (Regional Nurse). They acknowledged the findings.
OAR 411-054-0055 (1)(a) Systems: Medications and Treatments:
Please refer to C282, C303, and C310 for plans of correction.
Based on interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to:
Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:
C 303: Physician's Orders; and
C 310: Systems: Medication Administration.
The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 21 (Administrator) and Staff 45 (Director of Nursing) on 04/12/23. They acknowledged the findings.
C300
OAR 411-054-0055 (1)(a) Systems: Medications and Treatments
Please refer to the following deficiencies in the Plan of Correction under C300 to ensure a safe medication system and adequate professional oversight:
*C303 Medication and Treatment Orders
*C310 Medication Administration
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed or notified the physician when blood sugars were outside parameters for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:
Resident 1 had diagnoses which included diabetes, was prescribed sliding scale insulin with direction to notify the physician with blood sugars over 401.
Resident 1's 05/01/22 through 05/17/22 was reviewed and revealed the following:
* On 05/03/22, Resident 1 had a blood sugar reading of 353 and received 4 units of insulin aspart 100u/ml flexpen. The sliding scale parameters called for 6 units of insulin for blood sugars between 301-400;
* On 05/10/22, Resident 1 had a blood sugar reading of 488 and received 5 units of insulin aspart 100u/ml flexpen. The sliding scale insulin parameters called for 6 units for blood sugars over 401;
* On 05/17/22, Resident 1 had a blood sugar reading of 367 and received 4 units of insulin aspart 100u/ml flexpen. The sliding scale parameters called for 5 units of insulin for blood sugars between 301-400; and
*In an interview on 05/18/22 with Staff 2 (Director of Nursing), she revealed there was no documented evidence the physician was notified when Resident 1's blood sugars measured above 401.
The need to ensure the facility carried out medication orders as prescribed and notified the physician when blood sugars were outside parameters was discussed with Staff 1 (Administrator) and Staff 2 on 05/18/22. They acknowledged the findings.
Systems:Treatment orders-
Resident 1 received incorrect dose of sliding scale insulin and no documentation was found of notifying MD when CBG was above 401.
1. All Medication Techs and Nurses will go through a training course to review the medication policies and procedures. Procedures will be reviewed by Vice President of Operations and changes will be amended as needed and triaged to Pharmacy for consult. Nursing will issue medication errors for dates that incorrect insulin was given, along with MT education on how to properly give sliding scale insulin.
2. DON will audit insulin orders on MAR monthly to ensure proper doses are being given in accordance with sliding scale. If errors are found a med error will be issued along with MT education.
3. Insulin and CBG orders on the EMAR will be audited monthly to ensure compliance.
4. DON is responsible for completion of corrections. Administrator is responsible for on-going complaince.
4. Resident 5 was admitted to the facility in 12/2021 with a history of skin issues.
Review of Resident 5's 07/23/22 through 08/22/22 MAR and current physician's orders revealed the following:
Interview with Staff 20 (Administrator) and Staff 21 (Regional Nurse) revealed there were not signed physician's orders in the facility. Staff 20 contacted the pharmacy to retrieve the most current signed physician's orders for Resident 5. On 08/25/22, the surveyor received a signed copy of the most current physician's orders.
The need to ensure the facility has a copy of the most recent signed physician's orders was discussed with Staff 20 and Staff 21 on 08/25/22. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 07/2022 with diagnoses including chronic pain and insulin dependent diabetes.
Resident 4's 07/25/22 through 08/23/22 MARs and current physician orders were reviewed.
Resident 4 had physician orders for:
* Methadone 10 mg one tablet by mouth three times daily for 14 days signed 07/25/22 (14 days ending on 08/07/22); and.
* Methadone 5 mg one tablet by mouth as needed every eight hours signed 07/25/22.
Resident 4 was being administered the Methadone three times daily from 08/07/22 through 08/23/22.
The physician orders and current MARs were reviewed with Staff 20(Administrator) and Staff 21 (Regional Nurse). They acknowledged there was no current order to administer the routine Methadone.
Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the residents record, and/or to ensure signed orders were carried out as prescribed for 4 of 4 sampled residents (#s 4, 5, 6 and 7) whose orders and MAR/TAR's were reviewed. Resident 6 was not administered seizure and psychotropic medications as prescribed which put the residents health at risk. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was re-admitted to the facility on 07/12/22 with diagnoses including traumatic brain injuries, major neurocognitive disorder, and seizure disorder.
Review of Resident 6's 07/12/22 through 08/24/22 MAR and current medication orders revealed the following:
*A signed physician order, dated 07/12/22, for Quentiapine 100 mg nightly for psychotic agitation, Topiramate 50 mg twice daily for anxiety and alcohol cravings, Dilantin 60 mg daily for seizure disorder, and Depakote 250 mg nightly for seizure disorder and agitation were not administered as prescribed. Staff 36 (MT) reported the facility had not had these medications in stock since the resident was readmitted to the facility, and confirmed the medications had not been administered to the resident;
*Resident's record contained signed physician orders for Venlafaxine XR 25 mg every morning for depression and pain. The MAR indicated the resident was receiving 75 mg and an additional 150 mg for a total of 225 mg every morning. Staff 36 confirmed the dosage on the MAR was the amount being administered to the resident since readmission; and
*Thiamine Mononitrate 100 mg daily for supplementation, Acetaminophen 1000 mg as needed for pain, Calcium 500 mg as needed for dyspepsia, and Ibuprofen 200 mg as needed for pain were noted on the resident MAR without signed physician orders.
The facilities failure to carry out signed physician orders as prescribed placed the Resident's health at serious risk for adverse reactions from medications administered over the prescribed dose, for failing to administer medications prescribed, or for administering medications without signed physician orders.
On 08/25/22, the facility was asked to develop an immediate plan of correction to obtain medications s/he was prescribed and current signed physician orders for Resident 6. A plan of correction was provided and approved and the situation was abated.
On 08/25/22, the need to ensure physician's orders were carried out as prescribed and written, signed physician or other legally recognized practitioners orders were documented in the resident's record for all medication and treatments the facility was responsible to administer was discussed with Staff 20 (Administrator). She acknowledged the findings.
2. Resident 7 was admitted in 11/2021.
Residents 7's physician's orders and 08/01/22 through 08/24/22 MARs were reviewed. Resident 7's MAR included the following medications without a signed physician order:
*Culturelle-10B every day for probiotic;
*Invega 234 mg/1.5 ml injection every 3 weeks for psychosis;
*Lantus solostar 100u/ml inject 29 units nightly for diabetes;
*Therapeutic multivitamin every day for supplement;
*Trulicity injection 1.5 mg/0.5 ml every 7 days for diabetes;
*Clotrimazole 1% cream topically as needed for itching;
*Eucerin topically as needed for dry skin;
*Hydrocortisone 2.5% topically as needed for itching;
*Milk of magnesia 10 ml as needed for constipation; and
*Polyethylene glycol 3350 as needed for constipation;
On 08/25/22, the need to ensure signed provider orders were documented in the resident's record for all medications, was discussed with Staff 20 (Administrator). She acknowledged the findings.
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders:
1.) The following actions are being taken to correct violations per each example given:
a. Resident #6 - Facility is completing a thorough medication reconciliation with a chart to MAR to Cart review and will send updated physician orders' to resident #6s provider(s) for signature. Facility will ensure that resident #6 has all medications in stock, by coordinating with resident's physician and facility pharmacy.
b. Resident #7 - Facility is completing a thorough medication reconciliation for resident #7, and will send updated physician orders to residents' provider(s) for signature.
c. Resident #4 - Facility is completing a thorough medication reconciliation for resident #4, and will send updated physician orders to residents' provider(s), including resident's methadone order, for signature.
d. Resident #5 - Current physician orders will be kept in resident's chart at all times.
2.) This system is being corrected as follows:
a. Facility is auditing all resident charts to ensure up to date physician orders for all residents.
b. Facility will ensure that all resident's physician orders are reviewed by the nurse at least every 90 days and sent to residents' providers for updated signatures and refills.
c. Facility administrator will ensure that a schedule is created for each resident to ensure the timely processing of physician orders and nurse review.
d. Upon return of all physician orders, facility nurse will review and ensure that all orders are carried out as written by provider(s).
e. Facility nurse will be the last (3rd) review of all physician orders to ensure accuracy of MAR, and to oversee that all medication is in facility in a timely manner and being administered as prescribed.
3.) This system will be evaluated as follows:
a. All physician orders will be reviewed by facility LN at least every 90 days, with updates sent to providers for signature.
b. Facility RCM(s) will complete a daily missed medications audit to identify medications not available. This audit will be brought once weekly to morning stand-up to be reviewed by IDT. Facility LN will ensure coordination of care with physicians and pharmacy when a medication is not in facility to ensure the appropriate follow-up.
c. Facility Administrator will review MAR audits and physician order schedule, at least once weekly to ensure appropriate oversight and correction when needed.
4.) Facility Administrator, Facility RN, and Facility RCM will be responsible for correction and ongoing compliance.
2. Resident 1 was admitted to the facility in November of 2021 with diagnosis including diabetes mellitus.
Resident 1's signed physician's orders, dated 03/28/23 and 04/11/23, and MAR, dated 04/01/23 through 04/10/23, were reviewed during the survey.
Resident 1 had an order for glucose 4 GM chews which were to be administered if glucose (blood sugars) were less than or equal to 70.
The facility failed to administer the medication on 04/06/23, 04/07/23 and 04/10/23 when the resident's blood sugars were below 70.
During an interview on 04/12/23 at 09:30 am, Staff 44 (LPN) reviewed the MARs with the surveyor. She confirmed, the above medication was not administered to the resident.
The need to ensure orders were followed was reviewed with Staff 21 (Administrator) and Staff 45 (Director of Nursing) on 04/12/23. They acknowledged the findings.
3. Resident 12 was admitted to the facility on 04/04/23 with diagnoses including chronic obstructive pulmonary disease (COPD).
Review of Resident 12's 04/04/23 through 04/11/23 MAR and signed physician's orders for medications dated 04/03/23 were reviewed during the survey.
Resident 12 had an order for albuterol sulfate nebulizer twice daily for COPD.
The facility failed to administer the 8:00 am dosage on 04/05/23 and 04/07/23.
On 04/12/23 at 9:20 am, Staff 45 (Director of Nursing) reported the facility had not obtained the inhaler for administration of the albuterol sulfate nebulizer and confirmed the medication had not been administered to the resident on 04/05/23 and 04/07/23.
The need to ensure physician's orders were carried out as prescribed was discussed with Staff 21 (Administrator) and Staff 51 (Assistant Administrator) on 04/12/23 at 10:35 am. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 6 sampled residents (#s 1, 8 and 12) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the facility in 03/2023 with diagnoses including stroke, history of seizures, and hypertension.
Resident 8's signed hospital admission orders, dated 03/14/23, and MAR, reviewed from 03/14/23 through 04/10/23, identified the following medication orders were not administered from 03/14/23 through 03/21/23:
* Atrovastatin ( an oral medication for hypertension);
* Eliquis (an oral anticoagulant to reduce the risk of stroke);
* Keppra (an oral anticonvulsant to reduce the risk of seizures); and
* Protonix (an oral medication to reduce acid reflux).
During an interview on 04/11/23 at 10:35 am, Staff 44 (LPN) and Staff 46 (Care Manager) reviewed the MARs and physician orders with the surveyor. They confirmed, the above medications were not received from the pharmacy and the medications were not administered to the resident until 03/22/23.
The need to ensure orders were followed was reviewed with Staff 21 (Administrator), Staff 45 (Director of Nursing) and Staff 51 (Assistant Administrator) on 04/11/23 at 3:30 pm. They acknowledged the findings.
C303
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders
1. Immediate actions taken to correct this rule violation include a full audit of physician orders for Resident #8, Resident #1 and Resident #12 has been completed to ensure physician orders are carried out per MD order and that all medications are available to be administered as per the MD order.
2. The system will be corrrected so this violation will not happen again by all resident and treatment orders will be reconciled to ensure medications and treatments are dispensed as ordered.
3. Medication reconcilations will be completed upon resident move-in, and quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of three staff, Further daily audits to review missing medications, ommissions and PRN usage will be completed.
4. The Nurse, Administrator or trained designee will be responsible to ensure the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include, but are not limited to:
Resident 1's 05/01/22 through 05/17/22 MARs were reviewed. Resident 1 was noted to refuse Insulin on multiple occasions.
In an interview with Staff 2 (Director of Nursing) on 05/18/22, Staff 2 stated Resident 1 often refused his/her insulin if blood sugar reads below 100. Staff 2 confirmed the physician was not notified of Resident 1's refusal of insulin.
The need to ensure the facility notified the physician/practitioner when a resident refused to consent to orders was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.
Resident right to refuse-
Resident 1 refused insulin multiple times and had no documentation of notifying MD of refusal.
1. Section nurse will review insulin orders on EMAR weekly and report any refusals to resident's MD. If a resident refuses frequently, nurse will request an order to allow resident to self-direct insulin doses.
2. By reviewing the weekly delivery hx of insulin, nursing will be able to gain insight into refusals in order to report to MD.
3. The insulin orders will be reviewed weekly.
4. DON is responsible for ensuring corrections are completed.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 1 of 3 sampled resident (# 3) whose MAR was reviewed. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 03/2022 with diagnoses including a history of stroke.
The resident's 04/01/22 through 05/17/22 MARs were reviewed and revealed:
* PRN bowel medications (Senna 8.6, MiraLax 17 gram, and Bisacodyl Suppository 10 mg) lacked clear instruction to staff regarding the order of administration.
Both the Senna 8.6 and the MiraLax 17 gram had been administered in 05/2022.
The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 2 (Director of Nursing) on 05/19/22. She acknowledged the findings.
Medication Administration-ensuring resident MAR's are accurate.
Resident 3 had bowel medications that lacked clear instruction to staff regarding order of administration.
1. DON will request clear bowel care orders from resident 3's MD, including order in which to give medications. Any resident who has more than one bowel medication will get clarification on when and in what order to give medications from MD.
2. DON will audit resident EMARs monthly for compliance and get clarification from MD's when needed. The pharmacy will audit EMAR quarterly.
3. EMAR orders will be audited monthly and as needed to ensure compliance.
3. DON is responsible for ensuring corrections are made and Administrator is responsible for on-going compliance.
Based on observation, interview, and record review, it was determined the facility failed to ensure an accurate and complete MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications, for 4 of 4 sampled residents (#s 4, 5, 6, and 7) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 4 was admitted to the facility in 07/2022 with diagnoses which included chronic pain.
Resident 4 had orders for:
* Methadone 5 mg every eight hours as needed for severe pain; and
* Morphine 15 mg every 8 hours as need for severe pain.
There were no resident specific parameters and instructions to guide the unlicensed staff which medication to use.
The lack of resident specific parameters for multiple PRN pain medications was reviewed with Staff 20 (Administrator) and Staff 21 (Regional Nurse). They acknowledged the findings.
2. Resident 5 was admitted to the facility in 12/2021 with a history of skin issues.
Review of Resident 5's 07/23/22 through 08/22/22 MAR and current physician's orders revealed the following:
* Blanks on the MAR for checking oxygen levels on 08/02/22, 08/12/22 and 08/22/22;
* Blanks on blood pressure checks for Diltiazem ER 180 mg for hypertension on 08/18/22 and 08/19/22;
* No documentation on location and removal of lidocaine 5% patch for pain;
* No sleep monitoring on 08/14/22; and
* No documentation of use of supplemental oxygen on 08/14/22.
The need to ensure the facility documented accurately on the MAR and did not leave blanks was discussed with Staff 20 (Administrator) and Staff 21 (Regional Nurse) on 08/25/22. They acknowledged the findings.
3. Resident 7 was admitted in 11/2021.
Review of the 07/12/22 through 08/24/22 MAR/TAR, identified the following deficiencies:
a. Furosemide 20 mg lacked reason for use;
b. Resident was prescribed the following PRN medications for diarrhea:
*Pepto-bismol 262 mg/15 ml; and
*Loperamide HCL 2 mg.
Resident was prescribed the following PRN medications for itching:
*Hydrocortisone 2.5%; and
*Clotrimazole 1% cream.
The MAR failed to include clear parameters and instructions to unlicensed staff for when each medication should be administered.
c. The MARs/TARs contained multiple blank spots in the documentation for the following routine treatments and medications:
*CBG checks;
*Elevate feet;
*Levothyroxine 125 mcg for thyroid;
*Metformin HCL 1000 mg for diabetes;
*Omeprazole 20 mg for GERD; and
*Trulicity 1.5 mg/0.5 ml for diabetes;
d. The MAR failed to document effectiveness for the following PRN medications after they were administered:
*Acetaminophen 650 mg on 08/15/22;
*Pepto-bismol 262 mg/15 ml on 08/03/22;
*Flexeril 5 mg on 08/17/22; and
*Oxycodone 5 mg on seven separate occasions from 08/01/22 through 08/06/22.
e. PRN Oxycodone 5 mg ½ to 1 tablet every 4 hours as needed for pain lacked clear dosage for administration.
On 08/25/22, the need to ensure MARs were accurate and included parameters for PRN medications was discussed with Staff 20 (Administrator). She acknowledged the findings.
4. Resident 6 was re-admitted to the facility on 07/12/22.
The MAR failed to document effectiveness for the following PRN medications after they were administered:
*Acetaminophen 1000 mg on 08/04/22, 08/19/22, and 08/20/22.
In an interview on 08/24/22, Staff 36 (MT) reported Resident 6 was receiving Gabapentin 300 mg three times daily and Venlafaxine 225 mg every morning as prescribed since re-admission on 07/12/22. Staff reported Resident 6's other routine medications were being documented as administered on the MAR while not actually being administered due to lack of medication supply since re-admission.
On 08/25/22, the need to ensure MARs were accurate was discussed with Staff 20 (Administrator). She acknowledged the findings.
OAR 411-054-0055 (2) Systems: Medication Administration:
1.) The following actions are being taken to correct each violation per example given:
a. Resident #4, #5 #6 & #7 orders will be thoroughly reviewed to ensure the following: Specific parameters and instructions for unlicensed staff, holes in MARs, reason for use of each medication, efficacy of all PRN medications, clear dosage for administration for unlicensed staff, and accurate medication administration for medications given or not given.
2.) This system is being corrected as follows:
a. Facility will implement a parameter audit to ensure all orders have appropriate parameters for unlicensed staff, as well as instructions for staff to follow. Facility LN will review parameter audit and update each order identified that is lacking parameters and clear instructions.
b. Facility will implement a daily MAR audit to identify any holes in the MAR for the last 24hrs, and will ensure staff correct holes in a timely manner.
c. Facility will ensure that all orders are processed through the triple check system, using a triple check stamp, to ensure all orders are processed timely and that the facility LN reviews orders for required components. Facility LN will ensure that all orders have reason for use, appropriate dosage instructions for non-licensed staff, & parameters for PRN medications with the same indications of use.
d. All medication-aides will receive updated training on the 7 rights of medication administration, as well as, training on medication administration standards, including following up on all PRN medications given for efficacy.
3.) This system will be evaluated as follows:
a. Facility RCM(s) will complete a parameter audit at least once weekly, that is then given to the facility LN for review and correction.
b. Facility RCM(s) will complete a daily MAR audit and will bring audit to morning stand-up meeting to be reviewed by IDT and facility administrator.
c. Facility LN will review all orders in triple check process at least once daily, on workdays, and will correct or clarify any orders with missing required components.
d. Facility administrator will review all med-tech training at least once monthly and PRN for repeat medication errors or holes in MAR. Facility administrator will ensure appropriate medication administration system by reviewing all medication audits during daily stand-up.
4.) The facility administrator, facility LN, and facility RSC(s) are responsible for correction and ongoing compliance.
3. Resident 12 was admitted to the facility in April 2023 with diagnoses including schizophrenia and chronic constipation.
Resident 12's physician orders and 04/2023 MARs were reviewed and revealed the following:
a. The following medications were missing reasons for use:
* Albuterol sulfate nebulizer (breathing treatment);
* Budes/Formot inhaler (breathing treatment);
* Lactase; (for digestion)
* Lactulose (for constipation);
* Lansoprazole (for heartburn);
* Paliperidone (for schizophrenia); and
* Zaleplon (for insomnia).
b. The following medications for anxiety lacked resident specific parameters or instructions to direct non-licensed staff on which PRN medication should be administered and in what order:
* Hydroxyzine;
* Lorazepam; and
* Diphenhydramine.
c. There was no documented evidence the MAR was accurate related to administration of magnesium citrate on 04/05/23.
In an interview with Staff 45 (Director of Nursing) at 9:28 am on 04/12/23, she acknowledged the missing reasons for use, lack of parameters and clear instructions to staff for PRN anxiety medications and blank on the MAR.
On 04/12/23 at 9:40 am, Staff 52 (MT) confirmed on the electronic MAR the magnesium citrate was blank for 04/05/23.
The need to ensure an accurate MAR, medications had a reason for use, resident specific parameters and clear instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 21 (Administrator), Staff 51 (Assistant Administrator) on 04/12/23 at 10:28 am. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate related to administration, contained reasons for use of medication, resident-specific parameters for PRN medications, and clear instruction to staff for 3 of 6 sampled residents (#s 1, 8 and 12) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in November of 2021 with diagnosis including diabetes mellitus.
Resident 1's physicians orders and 04/2023 MAR were reviewed and revealed the following:
There was no documented evidence the facility completed an accurate MAR for the administration of medications for:
* Lantus solostar 100U/ML (given for diabetes) for Resident 1's blood sugars;
* Midodrine (for hypotension) lacking blood pressure on 04/04/23 and 04/06/23; and
* Novolog 100u/ML Flexpen (for diabetes) amount given and/ or blood sugars on 04/04/23, 04/05/23, 04/07/23 and 04/1023.
In an interview with Staff 44 (LPN) at 9:30 am on 04/12/23, she acknowledged the blanks and the MARs were not accurate related to administration.
The need to ensure an accurate MAR was reviewed with Staff 21 (Administrator) and Staff 45 (Director of Nursing) on 04/12/23. They acknowledged the MAR was not accurate.
2. Resident 8 was admitted to the facility in March 2023 with diagnoses including stroke and hypertension.
Resident 8's physician orders dated 03/14/23 and 03/01/23 through 04/10/23 MARs were reviewed and identified the following medications lacked medication specific instructions:
* Voltaren gel (for pain); and
* Lidocaine patch (for pain).
The need to ensure medication specific instructions were included on the MARs was discussed with Staff 21 (Administrator), Staff 45 (Director of Nursing) and Staff 51 (Assistant Administrator) on 04/11/23 at 3:30 pm. They acknowledged the findings.
C310
OAR 411-054-0055 (2) Systems: Medication Administration
1. Actions taken to correct this rule violation include:
a. Resident #1 medication administration record was reviewed and recording of blood glucose; amount of insulin administered and site was added to the orders for Lantus Solostar and Novolog. To take and record blood pressure prior to administration with blood pressure parameters was added to the order for Midodrine.
b. Resident #8 medication administration record was reviewed and specific instructions has been added to the order for Voltaren Gel for pain. Lidocaine Patch for pain was discontinued by physician on 4/13/23.
c. Resident #12 medication administration record was reviewed and the reason for use was added to the following medications Albuterol Sulfate Nebulizer; Budes / Formot Inhaler; Lactase; Lansoprazole; Paliperidone; and Zeleplon. Albuterol Sulfate Nebulizer was discontinued by physician on 4/13/23.
AND
Medication administration record was reviewed and resident specific parameters or instructions to direct non-licnesed staff was added to the medication Diphenhydramine. Hydroxyzine and Lorazepam was discontinued by physiciam on 4/7/23.
Review also included ensuring all medications and treatments are being administered as per the MD order.
All residents will have a medication reconcillation completed to ensure all medications and treatments area accurate to signed physician order, reflect reason for use, appropriate directions / parameters for use and when to notify nurse or MD. Once reconciled quarterly physician orders will be sent out for all residents for MD review and signature.
2. The system will corrected so this violation will no happen by ensuring trained community staff perform daily MAR audit to ensure no holes / missed medication. All new physician orders go through a triple check where the order is initially processed by the receiving med tech / RCC to ensure no delay of treatment. Second check is the next oncoming med tech / RCC to verify orders are accurate, and appropriate directions and parameters for staff to follow are in place. Nursing to be the final check to verify all components are in place, and to make updates as indicated.
Trained staff will complete weekly and monthly MAR aduits to ensure any concerns with medication decrepancy, omissions, PRN effectiveness, and parameteres are followed up on timely.
3. The area needed correction will be reviewed daily, weekly, and monthly basis with triple check MAR audits and monthly continuous quality improvement program. All orders will be reconciled quarterly prior to physician orders sent to MD for review.
4. The Administrator, Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure self-administration of medication evaluations were completed quarterly for 1 of 1 sampled resident (#1) who self-administered medications. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 11/2021 with diagnoses including Diabetes.
Review of Resident 1's MAR dated 05/01/22 through 05/17/22 revealed multiple refusals of insulin. Interview with Staff 2 (Director of Nursing) on 05/18/22 revealed Resident 1 monitored his/her blood sugar and told staff whether s/he wanted to receive insulin. S/he often refused his/her sliding scale insulin if his/her blood sugars were below 100. There was no documented evidence the facility evaluated Resident 1's ability to direct his/her own medications.
The need to ensure self-administration of medication evaluations were completed quarterly was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.
Self-administration of medication-
Resident 1 had hx of insulin refusal and directed his own insulin usage when CBG was below 100. No evidence of evaluating resident's ability to self-direct own medications.
1. When a resident requests to self-direct their medication orders DON will complete a nursing assessment to determine resident's ability to do so. If it is determined resident has ability to self-direct then DON will request approval from resident's MD.
2. Through auditing resident chart notes weekly and EMAR quarterly nursing will be able to identify which resident's prefer to self-direct and can reach out to MD's for approval.
3. Resident chart notes will be reviewed weekly and EMAR will be audited quarterly.
4. DON is responsible for ensuring corrections are made and Administrator is responsible for on-going compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:
In an interview with Staff 20 (Administrator) she revealed the facility has an ABST but they have not completed an ABST assessment for each resident.
In an interview on 08/24/22, Staff 1 stated she would follow up to ensure the ABST was implemented as required as part of their plan of correction.
The need to ensure the facility is documenting all areas into the ABST was discussed with Staff 20 on 08/25/22. She acknowledged the findings.
OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool:
1.) The following actions are being taken to correct violations per each example given:
a. Facility administrator is currently completing acuity-based staffing tool for the community.
b. Facility RCM(s) will receive training on acuity-based staffing tool to ensure appropriate staff scheduling.
2.) This system is being corrected as follows:
a. Facility will ensure that policies and procedures are in place for the required acuity-based staffing tool.
b. Facility IDT will receive training related to the requirements of the acuity-based staffing tool, c. Facility will maintain ABST and update resident care needs in the ABST at time of each resident evaluation and/or with any change of condition.
d. Facility administrator will review staffing schedule to ensure that the schedule is reflective of staffing requirements based on ABST.
3.) This system will be evaluated as follows:
a. The ABST will be updated with each resident evaluation: initial, within 30 days of admission, quarterly, and with significant change of condition.
b. Facility administrator will review monthly schedule to ensure the schedule is reflective of staffing needs based on resident care needs, per the ABST, at least once monthly.
4.) Facility administrator and facility RCM(s) will be responsible for correction and ongoing oversight.
Based on interview and record review, it was determined the facility failed to ensure food handler's certification and pre-service dementia training was completed prior to beginning job responsibilities, including meal preparation, for 3 of 3 newly hired staff (#s 9, 10, and 14) whose training records were reviewed. Findings include, but are not limited to:
Staff training records were reviewed on 05/18/22.
Staff 9 (MT) hired 02/27/22, Staff 10 (MT) hired 02/13/22, and Staff 14 (MT) hired 02/02/22, lacked documented evidence of having completed the required pre-service dementia training.
Staff 9, 10 and 14 served, and at times, prepared food.
All staff lacked evidence of Food Handler's certification.
The need for staff to complete required pre-service dementia training and Food Handler's certification, before beginning job responsibilities, was reviewed with Staff 1 (Administrator) and Staff 3 (Assistant Administrator). They acknowledged the findings.
Training requirements
Staff were missing documentation of pre-service dementia training and evidence of food handler certification.
Staff training-
1. An audit of all staff files will be completed to determine which staff need to complete food handler certification and pre-service dementia training. Assistant Admin will send notices to all staff listing what trainings need to be completed and how to get them completed. Assistant Admin will follow-up and ensure completion of all required training by July 18th. Facility will also hire an HR Generalist to assist in the tracking of staff training requirements.
2. Additional staffing will be added by hiring an HR Generalist to ensure required tasks are completed. HR will track all new hires monthly and ensure complaince with training is met. Regular audits of staff files will e completed.
3. Staff files, including staff training will be audited quarterly for compliance.
4. Assistant Admin will be responsible for ensuring all required staff training is completed until the HR Generalist is trained to complete the task. At that time the HR Generalist will take over tasks and Administrator will oversee that requirements are being met.
Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to beginning job duties for 2 of 3 newly-hired staff (#s 28 and 34), and Pre-Service Infectious Disease Prevention training was completed prior to 07/01/22 for 2 of 2 staff (#s 24 and 38). This is a repeat citation. Findings include, but are not limited to:
Staff training records were reviewed on 08/24/22. The following deficiencies were identified:
a. There was no documented evidence Staff 28 (CG), hired 06/04/22, completed the following elements of pre-service orientation:
*Written job description; and
*Pre-service dementia training.
b. There was no documented evidence Staff 34 (MT), hired 06/08/22, completed the following elements of pre-service orientation:
* Resident rights and values of community based care;
* Abuse reporting requirements;
* Infectious disease prevention;
* Fire safety and emergency procedures;
* Written job description; and
* Pre-service dementia training.
c. There was no documented evidence the following employees had completed infectious disease training:
*Staff 24 (Activities), hired 08/23/21; and
*Staff 38 (Maintenance), hired 08/10/21.
On 08/25/22, the need to ensure all newly hired staff had completed all required pre-service orientation and all staff completed the required Infectious Disease Prevention training by 07/01/22 was discussed with Staff 20 (Administrator). She acknowledged the findings.
OAR 411-054-0070 (3-4) Staffing Requirements and Training: Caregiver Requirements:
1.) The following actions are being taken to correct violations per each example given:
a. Staff member #28 will complete pre-service dementia training, and a written job-description will be given to staff member and kept in staff members file.
b. Staff member # 34 will complete all pre-service training and orientation, to include:
* Resident rights and values of community based care; * Abuse reporting requirements;
* Infectious disease prevention;
* Fire safety and emergency procedures;
* Written job description; and
* Pre-service dementia training
c. Staff members #24 & #38 will complete infection disease training.
2.) This system is being corrected as follows:
a. Facility is implementing a staff training grid that will include all required pre-service, within 30 days, and annual on-going training, for all staff, with dates of completion and dates that next training is due.
b. Facility is completing an audit for all staff members to ensure each staff member has completed the required training(s).
3.) This system will be evaluated as follows:
a. Facility HR will review staff training grid at least once monthly.
b. Facility administrator will review all new-hire orientation and training, at least once monthly, to ensure timely completion.
c. Facility will schedule new-hire orientation at least once monthly to ensure all new-hires have required training and documents in their files.
4.) Facility administrator and facility HR will be responsible for completion and ongoing compliance.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 10 and 14) had documented demonstration of competency in all required areas and been trained in First Aid within 30 days of hire. Findings include, but are not limited to:
Review of the facility's training records on 05/18/22 indicated the following:
Staff 9 (MT) hired 02/27/22, Staff 10 (MT) hired 02/13/22, and Staff 14 (MT) hired 02/22/22, lacked documented evidence observations and evaluations of competency had been completed within the first 30 days of hire for topics including:
* Providing assistance with activities of daily living; and
* Medication and treatment administration.
Staff 9 was scheduled and working 05/18/22. It was requested a demonstration of competence was immediately observed prior to Staff 9 passing medications. The competence demonstration was documented and provided to the survey team on 05/18/22.
Staff 9, 10 and 14 lacked documented evidence of First Aid training within 30 days of hire.
The need to document demonstrated competency in job duties and to complete First Aid training within 30-days of hire was discussed with Staff 1 (Administrator) and Staff 3 (Assistant Administrator). They acknowledged the findings.
Staff training-
3 staff lacked documentation of competencies observed within first 30 days of hire including assistance with ADL's an medication and treatment administration. 3 staff lacked documentation of First Aid training.
1. An audit of all staff files will be completed to determine which staff need to complete First Aid and observes competencies. Assistant Admin will send notices to all staff listing what trainings need to be completed and how to get them completed. Assistant Admin will follow-up and ensure completion of all required training by July 18th. Facility will also hire an HR Generalist to assist in the tracking of staff training requirements.
2. Additional staffing will be added by hiring an HR Generalist to ensure required tasks are completed. HR will track all new hires monthly and ensure complaince with training is met. Regular audits of staff files will e completed.
3. Staff files, including staff training will be audited quarterly for compliance.
4. Assistant Admin will be responsible for ensuring all required staff training is completed until the HR Generalist is trained to complete the task. At that time the HR Generalist will take over tasks and Administrator will oversee that requirements are being met.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 27, 28 and 34) demonstrated competency of skills in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:
Training records were reviewed on 08/24/22 and revealed the following:
a. Staff 34 (MT), hired on 06/08/22, lacked documented evidence of competency within 30 days of hire in the following required topics:
*Role of service plans in providing individualized care;
*Providing assistance with ADLs;
*Changes associated with normal aging;
*Identification, documentation, and reporting changes of condition;
*Conditions that require assessment, treatment, observation, and reporting;
*General food safety, serving, and sanitation; and
*Other duties as applicable (Med pass and treatments).
In an interview on 08/24/22, Staff 21 (Regional Nurse) reported Staff 34 would be pulled from passing medications until competency was demonstrated.
b. Staff 27 (CG), hired on 06/12/22, Staff 28 (CG), hired on 06/04/22, and Staff 34, failed to have documented evidence of First Aid and abdominal thrust training within 30 days of hire.
On 08/25/22, the need to ensure staff had documented evidence of competency demonstration in assigned duties, within 30 days of their hire date, was with Staff 20 (Administrator). She acknowledged the findings.
OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff:
1.) The following actions are being taken to correct violations for each example given:
a. Staff #34 has been pulled from the schedule as medication tech while completing competency checklist and return demonstration.
b. Staff #27 is completing first-aid and abdominal thrust training.
2.) This system is being corrected as follows:
a. Facility is completing an audit to ensure all direct care staff have appropriate competency checklists, with return demonstration.
b. Facility is implementing a training grid, to include all required trainings within 30 days, and dates of completion, as well as, date of next training required.
3.) This system is being evaluated as follows:
a. Facility HR will review training grid at least monthly and with each new-hire orientation to ensure staff are receiving required trainings in a timely manner.
b. Facility administrator will review all competency checklists, at least once monthly to ensure all required components are in place, and staff completed return demonstration.
c. Facility HR will brind training grid at least once monthly to morning stand-up for IDT to review and ensure their staff are up to date with trainings.
4.) Facility administrator and facility HR will be responsible for completion and ongoing compliance.
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 160, C 231, C 240, C 260, C 270, C 282, C 290, C 300, C 303, C 310, C 370, and C 372.
OAR 411-054-0105 (2-4) Inspections and Investigations: Insp Interval:
Please refer to C 160, C 231, C 240, C 260, C 270, C 282, C 290, C 300, C 303, C 310, C 370, and C 372 for plans of correction.
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. This is a repeat citation. Findings include but are not limited to:
Refer to C 150, C 231, C 252, C 260, C 270, C 280, C 300, C 303 and C 310.
Refer to C150, C 231, C 252, C 260, C 270, C 280, C 300, C 303 and C 310.
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. This is a repeat citation. Findings include but are not limited to:
Refer to C 231, C 260 and C 270.
OAR 411-054-0105 (2-4) Inspections and Investigations: Insp Interval:
Please refer to C 231, C 260 and C 270 for plans of correction.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the RCF's common-use areas were maintained in good repair, and the grounds were kept orderly and free of refuse. Findings include, but are not limited to:
The exterior grounds were toured on 05/17/22 at 12:35 pm. There were drop-offs of up to two inches from the pavement to the bark dust beds along the edges of multiple pathways around the perimeter of the building. These drop-offs created potential tripping or fall hazards for residents.
In multiple areas around the facility grounds there were large numbers of cigarette butts observed, as well as general litter and refuse. The butts were especially thick in the courtyard smoking areas (which did have appropriate ash and butt dispensers), but these problems were widespread throughout the campus.
On 05/17/22 the surveyor toured the outdoor grounds with Staff 1 (Administrator), observing the drop-offs and the general refuse, while explaining the need to properly maintain the building's exterior. She acknowledged the findings, and stated immediate plans to fix the issues.
General building exterior
Drop off's of up to 2 inches from pavement to barkdust beds, creating potential fall hazard.
1. Secure a date and time for the landscaper to return and blow in more bark dust around the pathways. To be completed before 07/18/2022.
2. The weekly to-do list for Facilities employees will be amended to include inspection of all pathways for drop-offs, and to rake back the areas that are found to be not in compliance.
3. The occurrence of the inspection will be once a week, but also as often as an area is found to be deficient, it will be addressed regardless of the day.
4. Facilities Manager or Facilities Lead will assign the task every week to a Facilities employee. After the task has been performed, the Facilities Manager or Facilities Lead will walk the pathways with the employee to ensure the work was done properly. Any missed areas will be fixed during the walk.
Large number of cigarette butts observed, especially in courtyard areas, as well as litter and refuse.
1. Better functioning and more stations for disposal of cigarette butts will be placed in areas designated for resident smoking, as well as in locations for employees to be better equipped for disposal of their cigarette butts. Amended weekly to-do list for Facilities employees will list the cleaning of all smoking areas twice weekly with what actions should be taken to complete this task.
2. Facilities employees will be assigned to clean the smoking areas, followed by inspection by the Facilities Manager or Facilities Lead to ensure the activity was performed.
3. The task of maintaining the smoking areas will be assigned twice weekly to a Facilities employee, followed by inspection by the Facilities Manager or Facilities Lead to make sure the task was performed within expectations.
4. The Facilities Manager and the Facilities Lead will be responsible for making sure the smoking areas are kept at an acceptable level of cleanliness.
There are no detail notes for this visit.