The findings of the re-licensure survey conducted 05/23/22 through 05/26/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/26/22, conducted 09/20/22 through 09/21/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times

The findings of the second re-visit to the re-licensure survey of 05/26/22, conducted 01/25/23 through 01/26/23, 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.

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 third revisit to the re-licensure survey of 05/26/22, conducted 03/30/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to investigate an injury of unknown cause in order to rule out suspected abuse or neglect for 1 of 1 sampled resident (# 5), who experienced an injury of unknown cause. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2017 with diagnoses including dementia and multiple sclerosis.

Observations of Resident 5 throughout the survey and interview with staff revealed the resident was dependent on staff for most ADLs and used a Hoyer lift for transfers.

The resident's 07/16/22 through 09/06/22 progress notes and incident reports were reviewed and revealed the resident experienced an injury of unknown cause on 08/15/22.

On 08/15/22 facility staff noted the following:

* The resident was on alert charting for skin discoloration, red and purple, on left arm above wrist. Further documentation noted, "Resident doesn't know what happened".

There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the above physical injury was not the result of abuse and it was not reported to the local SPD office.

On 09/21/22 at 1:25 pm, Staff 11 (ED) confirmed the physical injury had not been thoroughly investigated nor reported to the local unit. The surveyor requested Staff 11 to report the incident to local SPD office. Confirmation the report had been sent to local APD office was provided.

C231 - OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

1.) The following actions will be taken to correct this violation for each example listed: Facility will investigate resident #5's injury of unknown cause from 8/15/22 and will document findings. Facility self-reported incident to local APS prior to survey exit. Facility will create interventions to mitigate future incidents of same, based on findings from investigation.

2.) This system will be corrected so violations do not happen again, as follows:

a. Facility will ensure that all employees receive mandatory training on 'Abuse Reporting & Investigation.'

b. Facility IDT will review incident reports each morning (on working days) as part of the 24hr process, to ensure all incident reports are: completed thoroughly, investigated within a timely manner with abuse & neglect being ruled out or reported to local APS when indicated, interventions implemented to mitigate future incidents of same, and reviewed and signed by facility administrator.

c. Facility will bring all incident reports to QA meetings to review data/trends related to incidents.

3.) This system will be evaluated as follows: Facility administrator and clinical IDT will review all incident reports each morning as a part of the 24hr process. Facility will collect data/trends related to incident reports to once monthly QA meetings for review and discussion.

4.) The facility administrator and facility LN will be responsible for monitoring this system and ensuring ongoing compliance.

Based on 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 for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2022 with diagnoses including dementia and Type II Diabetes.

Observations of the resident and interviews with staff from 05/23/22 to 05/26/22, review of the service plan, dated 03/02/22, and temporary service plans indicated the service plan was not reflective of the resident's current care needs and lacked specific instruction to staff in the following areas:  

* Increased confusion and exit seeking behavior;

* Memory, orientation, and decision making capability;

* Ability to understand or be understood;

* Full assist with ADL care;

* Toileting needs and incontinent care;

* Fall risk history or interventions;

* Ability to use the call system;

* Current skin condition and treatment; and

* Use of siderails.

The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Executive Director) on 05/26/22. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2018.

Observations of the resident, interviews with staff, review of the updated service plan from 04/28/22, and subsequent temporary service plans were reviewed during the survey and showed the plan was not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas:

* Use of side rails;

* Eating status; and

* Diet texture.

On 05/25/22, the need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Executive Director). She acknowledged the findings.

C260 - Service Plan; General

1 (a) - Resident 2's service plan will be updated to provide accurate, and clear information/instructions in the following areas: Increased confusion, exit seeking behaviors, memory, orientation, decision making abilities, ability to understand, or be understood, full assist with ADL care, toileting needs & incontinence care, fall risk history or interventions, ability to use call system, current skin condition and treatment, & use of side rails.

(b) - Resident 1's service plan will be updated to provide accurate, and clear information/instructions in the following areas: Use of side rails, eating status, and diet texture.

Additionally, all resident service plans will be accessible for direct care staff.

2. Admin (or designee) and all applicable clinical staff, will review service plans quarterly or with change of condition, as well as, TSPs daily, during clinical drill-down, to ensure that all service plans are updated timely, and all resident specific care needs have clear directions to staff regarding the delivery of services. Service plans will be resident centered, with specific, individual needs.

3. Service plans will be reviewed as required: Prior to move-in, within 30 days of move-in, quarterly thereafter, and with any change of condition. Temporary service plans will be reviewed daily and made part of the resident's permenante service plan.

4. Facility administrator will be responsible for overseeing service plan compliance.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to caregiving staff regarding the delivery of services for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2021 with diagnoses including insulin-dependent diabetes.

Observations of the resident, interviews with staff, review of the current 08/05/22 service plan and clinical records during the survey, revealed Resident 4's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Transfer status;

* Use of plastic cup for coffee;

* Encouraging elevating legs; and

* Sign and symptoms of low and high blood sugar level.

The need to ensure the service plan provided clear instruction to staff and was reflective of Resident 4's needs was discussed with Staff 11 (ED) and Staff 13 (HR operation support manager) on 09/21/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 05/2017 with diagnoses including dementia and multiple sclerosis.

a. Observations of the resident, interviews with staff, review of the current 02/28/22 service plan and clinical records during the survey, revealed Resident 5's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Dressing status;

* Use of side rails including what to monitor and who to report if any;

* Checking blood pressure on the left side only; and

* Offering prune juice at breakfast daily.

b. Resident 5's service plan was last updated on 02/28/22, therefore not updated quarterly.

The need to ensure the service plan provided clear instruction to staff and was reflective of Resident 5's needs was discussed with Staff 11 (ED) and Staff 13 (HR operation support manager) on 09/21/22. They acknowledged the findings.

C260 - OAR 411-054-0036 (1-4) Service Plan: General

1.) The following actions will be taken to correct this violation for each example/resident given:

a.Facility will complete a thorough review of resident #4's service plan and ensure that the service plan is reflective of resident's needs and provides clear instructions for staff, including: Transfer Status, Use of Plastic coffee cup, Encouragement of elevating legs, and s/s of low & high blood sugars.

b. Facility will complete a thorough review of resident #5's service plan and ensure that the service plan is reflective of resident's needs and provides clear instructions for staff, including: Dressing status, Use of Side rails - including what to monitor and who to report to, Checking blood pressure on the left side only, and offering prune juice daily at breakfast.

2.) This system will be corrected to ensure this violation does not happen again, as follows:

a. Facility will provide updated training to direct-care staff related to writing interim service plans when resident care needs change.

b. Facility IDT will review interim service plans each morning (during working days) to ensure that all changes to residents care is reflective of residents' needs, and clear instructions for staff to follow.

c. Service plans will be reviewed and updated by IDT in accordance to current OARs: Prior to admission, at admission, within 30 days of admission, quarterly thereafter, and with any changes of condition. All other changes to resident care needs that occur between service plan updates will be written as an interim service plan. Resident care needs that are secondary to a significant change of condition will have interim service plans written by facility RN and will include clear instructions and interventions for staff to follow.

d. Facility IDT will review service plans coming due as the 'service planning team' to ensure all service plans are reflective of resident care needs as indicated by evaluation and interim service plans, once weekly.

3.) This system will be evaluated as follows:

a. Interim service plans will be reviewed daily as part of the 24/72hr process (during working days.)

b. Service plans will be reviewed and updated as follows: Prior to admission, at admission, within 30-days of admission, quarterly thereafter, and with any changes of condition,

c. IDT will review all upcoming service plans at least once weekly.

4.) The facility administrator and Facility RN will be responsible for ensuring all corrections and overseeing this system to ensure ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, and included a written description of who shall provide the services, and what, when, how, and how often the services shall be provided for 2 of 2 sampled residents (#s 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 12/27/22 with diagnoses which included Parkinson's disease.

During the entrance conference acuity interview on 01/25/23, Staff 16 (RCC) said Resident 6 needed assistance with ADLs, had fallen multiple times, needed meal cues and assistance, and had bilateral side rails.

Observations of the resident, interviews with staff, and review of the resident's clinical record during the survey revealed s/he required staff assistance for several ADL care needs, needed meal assistance, had a history of falls, used ½ bilateral side rails, and was on hospice services.

Resident 6's current service plan, dated 01/20/23, was not reflective, did not provide clear direction regarding the delivery of services, or failed to include a written description of who shall provide the services, and what, when, how, and how often the services shall be provided in the following areas:

* Bladder/incontinence care;

* Life Enrichment;

* Siderail use;

* Falls;

* Cognition;

* Housekeeping;

* Laundry services;

* Personal hygiene, oral care;

* Personal shopping;

* Technology use; and

* Transfer assistance.

The need to ensure the service plan was reflective of Resident 6's current needs, provided clear direction to staff, and included a written description of who shall provide the services, and what, when, how, and how often the services shall be provided was discussed with Staff 15 (Executive Director) on 01/26/23 at 10:45 am. Staff 15 acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided.

2. Resident 7 was admitted to the facility in 2020 and had diagnoses which included Alzheimer's.

Observations of the resident, interviews with staff, and review of the resident's clinical record during the survey revealed s/he required staff assistance for all ADL care needs, was on hospice services, needed meal assistance, had a history of falls, and was currently bed bound.

Resident 7's current service plan, dated 12/08/22, was not reflective, did not provide clear direction regarding the delivery of services, or failed to include a written description of who shall provide the services, and what, when, how, and how often the services shall be provided in the following areas:

* Evacuation assistance;

* Life Enrichment;

* Elopement Risk;

* Bathing;

* Housekeeping;

* Cognition;

* Dressing assistance;

* Laundry;

* Eating/Meals/Nutrition;

* Hearing;

* Vision;

* Ambulation;

* Assistive Devices;

* Toileting assistance; and

* Transfer assistance.

The need to ensure the service plan was reflective of Resident 7's current needs, provided clear direction to staff, and included a written description of who shall provide the services, and what, when, how, and how often the services shall be provided was discussed with Staff 15 (Executive Director) on 01/26/23 at 10:45 am. Staff 15 acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided.

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 #7 - Facility is completing a thorough chart-review and lookback of resident's care needs and will update residents #7 service plan to ensure it is reflective of resident's current needs, with specific, clear instructions for staff including but not limited to; Evacuation assistance; Life enrichment, Bathing, Cognition, Dressing assistance, Eating/Meals/Nutrition, Hearing, Vision, Ambulation, Assistive devices, toileting and transfer assistance.  Due to resident requiring nursing oversight, facility LN will be part of updating the 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 24hr audit system to ensure that any resident with a short term or significant change of condition has appropriate documentation including TSPs/ISPs in an attempt to ensure all falls, decline in ADLs and/or any change to resident care is addressed and made a part of the resident's care plan.  All audit findings will be brought to the morning stand-up meeting by RCC for IDT review.

c.  TSPs/ ISPs will be used as a tool to build resident evaluations and service plans, to ensure resident centered care, interventions, and appropriate staff instruction.

d.  All service plans will be reviewed and completed in accordance with OARs: Prior to admission, upon admission, within 30-days of admission, quarterly thereafter, and with any significant change of condition.  Facility administrator will oversee and ensure that all service plans are reflective of resident needs, as identified in the resident(s) evaluation.

3.  This system will be monitored as follows:  

a.  All TSPs/ISP. 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 at the appropriate schedule, during weekly review with IDT.

4.  Facility administrator and facility RCC will be responsible for ensuring completion and ensuring ongoing compliance.

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

Resident 1, 2 and 3's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 05/26/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director). She acknowledged the findings.

C262 - Service Plan; Service Planning Team

1. Resident 1, 2, & 3 will have service plans developed/reviewed by service planning team. The service planning team will include: The resident, the resident's legal representative (if applicable) any person of the resident(s) choice, the facility administrator (or designee,) and at least one other staff who is familiar with, or who is going to provide services to the resident. Service plans will be signed and dated by service planning team at time of review.

2. All service plans will be developed and reviewed by appropriate service planning team. Additionally, the service planning team will document when and who participated in service planning team via signatures and dates.

3. The system will be reviewed as followed: With new admissions, at 30 days, quarterly, and with any change of condition.

4. The administrator (or designee) and Licensed Nurse will be responsible for overseeing compliance with the service planning team.  

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 2 sampled residents (#s 6 and 7) whose service plans were reviewed. Findings include, but are not limited to:

Resident 6 and 7's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 15 (Executive Director) on 01/26/23 at 10:45 am. He reviewed the record and acknowledged the findings.

OAR 411-054-0036 (5) Service Plan:

Service Planning Team

1.  The following actions are being taken to correct violations per example given:

a.  Resident #7 - Facility will coordinate with resident, resident's legal representative, if applicable, any person of the residents choice, the administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident.

b. Service plan meeting will be scheduled including evidence all pertinent parties have been notified of meeting and, in the case any one or multiple members of the above are unavailable to attend; means will be offered/coordinated for remote participation.

c.  Documented evidence of invitation, involvement and acceptance of Service plan will be obtained with the completion of Service Plan meeting and kept with the service plan in the resident record.

2.  The system is being corrected as follows:  

a.  Each resident record will be updated with residents preference and or legal representative(s) in which the resident prefers to have involved in the development of their service plan.  This information will be included in the resident evaluation and service plan portion of Point Click Care.

3. The system will be monitored as follows:

a. The Service Plan populated within Point Click Care will reflect the individuals involved in development of the residents service plan.

4.  The administrator will be responsible for ensuring compliance with this system.

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

1. Resident 2 was admitted to the facility in 02/2022 with diagnoses including dementia and Type II Diabetes.

Interviews with staff during the survey from 05/23/22 through 05/26/22 indicated Resident 2 was incontinent of bowel and bladder, had a skin wound on his/her bottom, and staff applied barrier cream "as needed" on the resident's bottom.

Resident 2's 02/23/22 through 05/23/22 progress notes, quarterly evaluation dated 04/24/22, service plan dated 03/02/22, additional temporary service plans, and 04/01/22 through 05/23/22 MARs and TARs were reviewed.

There was no documented evidence the facility evaluated the resident's skin condition, determined and documented what action or interventions were needed for the resident's wound, and had communicated to staff on each shift. There was no documentation the wound on the bottom was being monitored weekly to resolution.

During conversations with Staff 1 (Executive Director) on 05/25/22, she confirmed there was no documentation describing the initial status of the wound, no documented weekly monitoring indicating whether the wound was improving or not, and no documentation that the wound had resolved. The surveyor asked Staff 3 (Care Partner/Med Tech) to observe the resident's skin.

On 05/25/22 at 3:17 pm, Staff 3 observed resident 2's skin and reported there was one area on the right buttock that was approximately the size of a nickel that was unopened and scabbed.

The need to ensure the facility had a system for documenting changes of condition and monitoring until resolved was reviewed with Staff 1 on 05/26/22. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2018.

Resident 1's record was reviewed for changes of condition and identified the following:

*A progress note on 03/25/22 indicated that the resident had "...bruising on top of right hand, small area adjacent to thumb/index finger ..." and "Staff alerted and will monitor and apply ice pack if necessary".

There was no documented evidence the resident's skin issues were monitored weekly and were resolved.

An observation of the Resident 1, on 05/25/22, indicated that the bruising had been resolved and was no longer present.

On 05/25/22, the failure to monitor the skin issues weekly until resolution was discussed with Staff 1 (Executive Director). She acknowledged the findings.

C270 - Change of Condition and Monitoring

1. (a) Resident #2 will have a thorough nursing assessment related to skin event on Right Buttocks. Facility Nurse will implement and document interventions for skin event and ensure all interventions are communicated to staff on each shift. Facility nurse will monitor and document weekly on status of skin event, until resolved.

(b) Resident #1 skin event has since resolved, however facility will ensure that all skin events are documented weekly, until resolved, and staff instructions/interventions related to skin events will be communicated to all staff, on each shift.

2. Facility nurse and administrator will ensure that an active skin-event log is in place and updated/reviewed during clinical drill down. Facility nurse will ensure all active skin events are being monitored weekly, until resolution, as well as, implementation of interventions/instructions for staff to follow.

3. All active skin events will be reviewed at least weekly by facility administrator (or designee) and facility LN.

4. Facility LN will be responsible for ensuring nursing oversight documentation, and facility administrator will be responsible for overseeing compliance for all change of conditions.    

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted in 02/2022 with diagnoses including insulin-dependent diabetes.

Resident 2 had physician orders to administer Humalog sliding scale insulin to be given TID subcutaneously after meals in varying amounts based on results of the CBGs (blood sugars).

The MAR reviewed from 05/01/22 through 05/23/22, showed the resident's CBGs, site of injections, and staff signed insulin was given; however, the MAR lacked documentation of the amount of insulin administered, which was based on the resident's CBG.  

On 05/24/22, in separate interviews with Staff 1 (Executive Director) and Staff 3 (Care Partner/Med Tech) the resident's MAR was reviewed.  Staff 1 and Staff 3 confirmed there was no documentation of the amount of sliding scale insulin administered.  

The need to ensure physician orders were followed and the amount of sliding scale insulin administered based on the CBG recorded was documented on the MAR was reviewed with Staff 1 (Executive Director) on 05/26/22. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2018.

Physician orders and MARs for Resident 1, reviewed from 05/01/22 through 05/23/22, identified the following orders were not being administered as prescribed:

*A signed physician order for Miralax 17gm every 3 days (for bowel care), was not administered every 3 days on two occasions.

On 05/26/22, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Executive Director). She acknowledged the findings.

C303 - Systems; Treatment Orders

1. (a) Resident #2's Insulin order (Humalog sliding scale) will be updated to reflect amount of insulin given based on resident's CBG, for each administration.

(b) Facility will ensure physician order(s) for resident #1 are carried out as prescribed; Miralax 17gm every 3 days.

2. Facility Licensed Nurse and Administrator (or designee) will provide additional training to care partners regarding the 7 rights of medication administration, and appropriate policy/procedure for missed medications. Additionally, facility will audit medication administration(s) at least once weekly to ensure there are no holes in MAR and verify follow-up for any missed medications.

3. Facility will audit medication administration(s) and/or missed medications at least once weekly, to ensure that all orders are carried out as prescribed, and/or that the appropriate care path for missed medications is followed.

4. Facility Administrator (or designee) and facility LN will be responsible for ensuring that all physican orders are carried out as prescribed.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 2 sampled residents (#s 4 and 5) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2021 with diagnoses including hypertension and peripheral artery disease.

a. Resident 4 had a physician order to administer Carvedilol (to treat high blood pressure) 12.5 mg twice daily and hold if the resident's pulse was below 55.

Resident 4's 09/01/22 through 09/20/22 MAR revealed one occasion on 09/10/22, the medication was held when the pulse was 55 without clear documentation of why the medication was not administered as prescribed.

b. Resident 4's 09/01/22 through 09/20/22 MAR revealed staff documented they provided Santyl (to remove dead tissue from wounds) ointment treatment to wounds twice weekly. There was no signed physician order for the treatment.

In an interview on 09/21/22 at 2:00 pm, Staff 11 (ED) confirmed that she was not able to locate the treatment order for Resident 4.

On 09/21/22, the physician orders and the MARs were reviewed with Staff 11 (ED) and Staff 13 (HR operation support manager). They acknowledged the findings.

2. Resident 5 was admitted to the facility in 05/2017 with diagnoses including pressure ulcer and acute respiratory failure.

a. Resident 5 had two separate physician orders to provide treatment for skin tear and abrasions as needed.

Resident 5's 09/01/22 through 09/20/22 MAR revealed there was no indication these orders were transcribed to the MAR.

b. Resident 5's 09/01/22 through 09/20/22 MAR directed staff to provide DuoNeb (to prevent shortness of breath) every 6 hours as needed. There was no signed physician order for the treatment.

In an interview on 09/21/22 at 2:00 pm, Staff 11 (ED) confirmed that she was not able to locate the treatment order for Resident 5.

c. Resident 5 had physician orders to provide zinc ointment three times daily as needed.

Resident 5's 09/01/22 through 09/20/22 MAR revealed there was no indication the order was transcribed to the MAR.

d. Resident 5 had physician orders to apply oxygen for one hour if oxygen saturation was less than 95 %.

Resident 5's 09/01/22 through 09/20/22 MAR revealed there was no indication the oxygen order was transcribed to the MAR.

On 09/21/22, the physician orders and the MARs were reviewed with Staff 11 (ED) and Staff 13 (HR operation support manager). They acknowledged the findings.

C303 - OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

1.) The following actions will be taken to correct this violation for each example/resident listed: Facility will complete a thorough chart audit for residents #4 & #5 and will reconcile all medications and treatments, and send updated physician orders to each residents' respective physician to ensure all orders are current and correct in the MAR. Facility will investigate incident on 9/10/22 for resident # 4, to indentify why medication (Carvedilol) was held and will document as a med-error if indicated. Facility will ensure that staff are only administering medications and treatments if there are physician orders to do so.

2.) This system will corrected to ensure this violation does not occur again, as follows:

a. Facility will audit all physician orders to ensure they have been reviewed and signed by either facility RN, or pharmacist, and all recommendations sent to residents' physician, within the last 90 days.

b. All direct care staff responsible for administering medications will receive updated training related to medication administration, parameters, and order entry.

c. Facility LN will complete a parameter audit on medications and treatments to ensure clear instructions for staff to follows.

d. Facility will ensure that all orders are procressed through a triple check system, including the final check by facility LN, to ensure all orders are input correctly, with clear staff instructions.

e. Facility IDT will review skin log each morning (on working days) to ensure that each resident with a skin event has the appropriate monitoring/treatment transcribed into the MAR.

3.) This system will be evaluated as follows:

a. All residents' medications and treatments will be reconciled to ensure accuracy and physician signature via P.O's, at least quarterly.

b. Facility will complete a parameter audit at least bi-weekly to ensure accurate administration of medications secondary to parameters, and to identify potential med-errors.

c. Facility LN will review all triple checks (orders) at least once daily (on working days) and will ensure that orders are transcribed correctly, with appropriate parameters.

d. Facility LN will review skin log each day (on working days) to ensure all skin events have the appropriate monitoring/treatment in the MAR.

4.) Facility Administrator and facility LN will be responsible for overseeing these corrections and ongoing oversight to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 2 sampled residents (#s 6 and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 moved into the facility on 12/27/22 with diagnoses which included Parkinson's disease, constipation, anxiety and pain.

Physician orders and MARs for Resident 6, reviewed from 01/01/23 - 01/25/23, revealed the following orders were not followed:

* Tylenol 325 mg 2 tablets three times a day for pain: the 9:00 pm dose was not administered on 01/11/23;

* Carbidopa/Levo 25-100 mg 1 tablet three times a day for Parkinson's: the 9:00 pm dose was not administered on 01/15/23;

* Hydromorphone 2 mg ½ tablet three times a day for pain: the 9:00 pm dose was not administered on 01/15/23; and

* Lorazepam 0.5 mg two tablets three times a day for anxiety: the 9:00 pm dose was not administered on 01/15/23.

On 01/25/23 at 3:00 pm, the surveyor and Staff 19 (MT) observed/checked the MARs and medication supply. Staff 19 was unable to verify if the above orders had been followed.

The need to ensure orders were carried out as prescribed was reviewed with Staff 15 (Executive Director) and Staff 16 (RCC) on 01/25/23 at 3:10 pm. They reviewed the MARs with the surveyor and acknowledged the findings. Both stated the MTs would receive additional training on medication administration and documentation.

2.  Resident 7 was admitted in 2020 with diagnoses which included Alzheimer's.

Physician orders and MARs, reviewed from 12/01/22 through 01/25/23, revealed the following orders were not followed:

* Donepezil (Alzheimer's medication) 10 mg one tablet once a day was not administered on six occasions;

* Memantine (Alzheimer's medication) 14 mg one capsule once a day was not administered on 12/13/22; and

* Morphine ER 15 mg one tablet every 12 hours for pain was not administered on 01/15/23 at 9:00 pm.

On 01/25/23 at 3:00 pm, the surveyor and Staff 19 (MT) observed/checked the MARs and medication supply. Staff 19 was unable to verify if the above orders had been followed.

The need to ensure orders were carried out as prescribed was reviewed with Staff 15 (Executive Director) and Staff 16 (RCC) on 01/25/23 at 3:10 pm. They reviewed the MARs with the surveyor and acknowledged the findings. No further information was provided.

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 #7 - Facility is completing a thorough medication reconciliation with cart to MAR to Chart review and will send updated physician orders' to resident #7's provider(s) for signature.  Facility will ensure resident #7 has all medications in stock, by coordinating with the resident's physician and facility pharmacy.

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 or designee will review and ensure that all orders are carried out as written by provider(s).

e. Facility nurse or designee will be the last (3rd) review of all physician orders to ensure accuracy of MAR, and to oversee that all medication is in the 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 RCC 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 RCC will ensure coordination of care with physicians and pharmacy when a medication is not in the 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 RCC and Facility LN will be responsible for correction and ongoing compliance.

Based on interview and record review, it was determined the facility failed to notify the physician 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 clinical records and MARs/TARs were reviewed during the survey.

The resident had signed physician orders to take Tylenol 500 mg powder packet every 6 hours. The MAR indicated that the resident refused the medication 17 times from 05/1/22 through 05/23/22.

The facility failed to provide documentation of notifying the physician after each refusal or documentation of how often the physician would like to be notified of the refusals.

On 05/25/22, the need to ensure the facility notified the physician when a resident refused an order was discussed with Staff 1 (Executive Director). She acknowledged the findings.

C 305 - Systems; Resident Right to Refuse

1. Resident #1's medication administration record will be reviewed and all refused medications/treatments will be faxed to resident's physician.

2. Facility will ensure that all residents have orders from their PCP to indicate when they would like to be notified of medication/treatment refusals and/or missed medications. Facility will add frequency to each resident record to ensure care staff are aware of when to notify provider of refusals/missed medications.

3. Facility will audit refusal of medications and/or missed medications, at least once weekly, when completeing MAR audit, additionally, facility will ensure that all refusals have been faxed to resident(s) provider per MD instructions.

4. Facility Administrator (or designee) will be responsible for ensuring that this system is monitored and in compliance.  

Based on observation, interview and record review, it was determined the facility failed to ensure MARs included medication-specific instruction to direct non-licensed staff for 1 of 2 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to:  

Resident 2 moved into the facility in 02/2022 with diagnoses including insulin-dependent diabetes. S/he had orders for Humalog sliding scale insulin TID after meals in varying amounts based on results of the CBGs (blood sugars).

Observations during mealtimes from 05/24/22 through 05/26/22 revealed the resident was not eating very much.

In an interview on 05/25/22, Staff 3 (Care Partner/Med Tech) indicated that she observed the resident's meal intake. Depending on the amount eaten, she would then administer or hold the insulin. When asked if there were any instructions related to the resident's meal intake, she confirmed there were no instructions for staff to follow.

The MARs, reviewed from 05/01/22 through 05/23/22, lacked medication-specific instructions for unlicensed staff regarding holding the sliding scale insulin or adjusting the amount based on the resident's meal intake.

The need to ensure the MAR provided medication-specific instructions related to insulin administration was discussed with Staff 1 (Executive Director) on 05/26/22. She acknowledged the findings.

C310 - Systems; Medication Administration

1. Resident #2's Insulin order (Humalog sliding scale) will be thoroughly reviewed by facility RN, and all appropriate medication instructions will be added and/or updated. All findings will be communicated to resident's physician.

2. Facility RN will review all new physician orders to ensure accurate and clear instructions for resident medications. Facility will also review medication and treatment instructions when completing MAR audit to ensure orders have medication-specific instructions. Facility RN will also review all insulin orders prior to delegations, to ensure appropriate medication-specific instructions are in place for care staff/med-techs.

3. Facility will review all physician orders daily, via triple check system, with facility LN being the final check. MAR audit will be completed weekly, and all delegated insulin orders will be reviewed, as required, prior to delegations.

4. Facility RN will be responsible for overseeing appropriate medication-specific instructions are in place for resident(s) and Facility Administrator will be responsible for ensuring compliance in this area.  

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's evaluation and service plan for 1 of 1 sampled resident (#6) who had siderails on their bed. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 12/2022.

On 01/25/23 at 10:30 am, the resident's bed was observed to have bilateral half-length siderails in the up position.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.

The above information was discussed with Staff 15 (Executive Director) on 01/26/23 at 8:40 am. He acknowledged the resident's record lacked an assessment by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation in the evaluation and service plan.

OAR 411-054-0060  Restraints and Supportive Devices

1.  The following actions are being taken to correct each violation per example given:

a. Resident #7 - Facility or Home Health RN or PT will complete a thorough assessment of device (s) which will include documentation of less restrictive alternatives evaluated prior to use of assistive device.

b.  The facility will ensure the Service Plan is reflective of resident utilizing device and include clear, specific instructions for staff on the correct use and precautions related to use of the device.

2.  This system is being corrected as follows:

a.  100% room to room audit will be completed by facility LN to ensure all devices with restraining qualities have been assessed by an RN, PT or OT

b. Residents above who are utilizing a device with restraining qualities evaluations and service plans will reflect device, intent, appropriate use and clear staff instructions for correct use and precautions related to use of the device.

3.  The system will be evaluated as follows:

a.  Facility will implement a tracking tool to appropriately  reflect which residents have a device with restraining qualities which will be updated weekly by the community LN.

b.  Devices with restraining qualities will be scheduled to be assessed quarterly in addition to PRN in the case the resident experiences a significant change of condition.  

4.  The facility Administrator will be responsible for oversight of correction and ongoing maintenance of this system.  

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics, including pre-service dementia training, was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 5, 7 and 8). Findings include, but are not limited to:

Staff training records were reviewed on 05/25/22.

* Staff 8 (Care Partner), hired 04/08/22, lacked documented evidence pre-service orientation in abuse reporting requirements and standard precautions for infection control had been completed prior to beginning job duties; and

* Staff 5 (Cook/MT) hired on 03/17/22 and Staff 7 hired on 03/24/22 (Care Partner/MT), both lacked documented evidence of completing all required elements for pre-service dementia training prior to assuming job duties.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Executive Director) on 05/26/22. She acknowledged the findings.

C370 - Staffing Requirements & Training; Caregiver Requirements

1. (a) Staff #8 will complete the following training: Abuse reporting requirements, and standard precautions for infection control.

(b) Staff #5 and Staff #7 will complete all required elements for pre-service dementia training.

2. Facility will ensure that all pre-service training and orientation are assigned at time of hire and completed prior to care staff providing care. Facility will keep an on-going training document with required components to ensure all trainings are up-to-date.

3. Facility will audit trainings at least once monthly, with updates made to internal training grid.

4. Facility Administrator is responsible for overseeing compliance for all staf training.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics, including pre-service dementia training, was completed prior to providing services to residents for 1 of 1 newly hired staff (# 14). This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 09/21/22.

Staff 14 (Care Partner), hired 07/06/22, lacked documented evidence of completing the following required elements of the pre-service orientation and pre-service dementia training prior to assuming job duties:

* Resident rights and values of CBC care;

* Standard precautions for infection control;

* Techniques for understanding, communicating and responding to behaviors and reducing use of antipsychotics; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering and use of person-centered approach.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 11 (ED) and Staff 13 (HR operation support manager) on 09/21/22. They acknowledged the findings.

C370 - OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

1.) The following actions will be taken to correct this violation for each example given: Facility will ensure staff member # 14 receives all required pre-service training including: Resident rights and values in CBC care, Standard precautions for infection control, techniques for understanding, communicating, and responding to behaviors and reducing use of antipsychotics, and specific aspects of dementia including addressing pain, providing foods/fluids, preventing wandering and use of person-centered approach. All pre-service training will have documented evidence of training and placed in employees' file.

2.) The following correcting will be made to eliminate future violations as follows:

a. Facility administrator will create a training grid with all required pre-service, within 30 days, and annual on-going training requirements, for each staff member with dates completed and dates of training coming due.

b. Facility will audit existing employees to ensure each staff member has all required training completed.

c. As part of new-hire orientation, facility will ensure that each employee has required trainings set-up for each new employee, and staff members will not begin direct resident care until all pre-service training is completed.

3.) This system will be evaluated as follows:

a. Facility admin will review training grid at least once monthly during QA meeting.

b. Facility administrator will review all new-hire orientation and training, at least once monthly to ensure compliance.

c. Facility administrator will bring staff training grid to once monthly QA to review with IDT.

d. Facility will schedule new-hire orientation at least once monthly, to ensure all pre-service training is completed.

4.) Facility administrator will be responsible for corrections and ongoing oversight to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired direct care staff (# 14) had demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 09/21/22.

There was no documented evidence Staff 14 (Care Partner), hired 07/06/22, demonstrated competency in all assigned job duties within 30 days of hire in the following areas:

* Role of service plans in providing individualized care:

* Providing assistance with ADLS;

* Changes associated with normal aging;

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

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

* General food safety, serving and sanitation.

The need to ensure newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 11 (ED) and Staff 13 (HR operation support manager) on 09/21/22. No further documentation was provided.

C372 - OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1.) The following actions will be taken to correct this violation per each example given: Facility will ensure that employee #14 has completed a return demonstration with competency checklist in all assigned job-duties.

2.) This system will be corrected as follows:

a. Facility will audit all employee training files to ensure all direct carestaff have demonstrated competency for all assisgned job duties. Competency will be documented and kept in employee file(s).

b. Facility will ensure that there is an on-going training grid that is reflective of each employees required training, dates of completion, and upcoming training that is coming due.

c. All new-hire employees will be scheduled for new-hire orientation to ensure all applicable training - including competency checklists, are scheduled and handed out.

3.) This system will be evaluated as follows:

a. Admin will review and update training grid at least once monthly, with new-hire orientation.

b. All direct carestaff will have competency checklists with return demonstration completed within 30 days of hire and retured to administrator.

c. Facility admin will review training grid at least once monthly during QA meeting.

4.) Facility administrator will oversee corrections and will be responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure that Fire and Life Safety including drills and instruction were conducted in accordance with Oregon Fire Code. Findings include, but are not limited to:

Review of Fire and Life safety records on 05/24/22, for November 2021 through April 2022 lacked documentation of the following:

* Fire drills conducted and recorded every other month at different times of the day; and

* The facility failed to relocate or evacuate residents during fire drills. Therefore, documentation regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated was incorrectly documented.

On 05/25/22, the need to ensure fire drills were completed on alternate months and fire drills were being correctly documented was discussed with Staff 1 (Executive Director). She acknowledged the findings.

C420 Fire and Life Safety; Safety

1. Facility will conduct a fire drill and document the following: Date, time of day, residents who were relocated/evacuted during drill, escape route used, residents who resisted or failed to participate in the drill, evacuation time period needed, and number of occupants evacuated.

2. Facility will conduct and provide documentation of unannounced fire drills at least every other month, at different times of the day, evening, and night shift. Facility will provide Fire & Life Safety instructions to staff on alternate months.

3. Fire drill and Fire and Life Safety instruction documentation will be filed in the Fire Drill/Fire and Life Safety Binder, in order of month. This binder will be reviewed at least monthly by facility administrator (or designee).

4. Facility Administrator (or designee) is responsible for overseeing compliance for Fire and Life Safety.

Based on interview and record review, it was determined the facility failed to ensure that Fire and Life Safety including drills were conducted and documented in accordance with Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:

Review of Fire and Life safety records on 09/21/22, for July 2022 through September 2022 lacked documentation of the following:

* Fire drills conducted on 07/26/22 noted the facility failed to relocate or evacuate residents during fire drills. Therefore, documentation regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated was not documented.

The need to meet all requirements for fire drills was reviewed with Staff 11 (ED) and Staff 13 (HR operation support manager) on 09/21/22. They acknowledged the findings.

Surveyor: McKay, Matt

C420 - OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1.) The following actions will be taken to correct this violation per example given: Facility will schedule an upcoming fire drill for residents that will include the following required documentation: Evacuation or relocation of residents, documentation regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated. This fire drill will have thorough documentation and will be kept in the fire and life safety binder.

2.) This system will be corrected as follows:

a. Facility will review current fire drill document, and will ensure that all required components are listed.

b. Facility maintenance director will receive updated training on the requirements of fire drills and fire and life safety.

c. Facility Maintenance director will be bring all fire and life safety documentation, including fire drill records, to once monthly QA meeting, for facility administrator to review.

d. Facility administrator will review fire & life safety binder to ensure compliance.

3.) The system will be evaluated as follows:

a. Facility administrator will review fire drill documentation at least once monthly during QA meetings to ensure compliance.

b. Facility administrator will review fire & life safety binder at least once monthly during QA meetings to ensure compliance.

4.) Facility administrator and facility maintenance director will be responsible for corrections and ongoing compliance.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually.  Findings include, but are not limited to:

Review of the facility fire and life safety records indicated that the facility lacked documentation that residents were being instructed on fire and life safety procedures annually.

In an interview on 05/25/22 with Staff 1 (Executive Director), she reported that the facility lacked any documented evidence of providing fire and life safety instruction to residents for the previous year.

On 05/25/22, the need to ensure Fire and Life Safety instruction for residents was being conducted annually was discussed with Staff 1. She acknowledged the findings.

C422 - Fire and Life Safety; Training for Residents

1. Facility administrator will complete a thorough audit for each resident to ensure that Fire and Life Safety training was provided. All residents missing annual Fire and Life Safety training will receive training, as required, in the following areas: General safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area.

2. Facility will ensure that all residents receive Fire and Life Safety training within 24hrs of admission, and annually thereafter. All resident Fire and Life Safety trainings will be documented and kept on file, and will include: content of training sessions, & resident attendance.

3. Facility Administrator will audit all Fire and Life Safety resident training(s) at least monthly to ensure appropriate trainings were provided to resident and documented.

4. Facility Administrator is responsible for oversight and compliance for Fire and Life Safety.  

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 260, C 303, C 370 and C 420.

C455 - OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

Please refer to C260, C 303, C370, and C420.

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

Refer to C260 and C303.

Refer to POC.