The findings of the re-licensure survey, conducted 02/07/22 through 02/08/22, 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 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 re-visit, to the re-licensure survey of 02/08/22, conducted 05/09/22, 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 second revisit to the re-licensure survey of 02/08/22, conducted 08/04/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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

1. Resident 1 was admitted to the facility in December 2020 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 02/03/22 service plan, Temporary Service Plans, Observation Notes and Care Reports from 11/01/21 through 02/07/22, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution in the following areas:

* Behaviors;

* New medications and medication changes; and

* Episode of unresponsiveness resulting in a hospital visit.

2. Resident 2 was admitted to the facility in May 2020                                             with diagnoses including multiple sclerosis.

Observations of the resident, interviews with staff, review of the resident's 02/01/22 service plan, Temporary Service Plans, Observation Notes and Care Reports from 11/01/21 through 02/07/22, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution in the following areas:

* Fall;

* Rashes;

* Pain in the mouth; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly was reviewed with Staff 1 (Administrator). She acknowledged the findings.

C 270 OAR 411-054-0040 (1-2) Change of condition and monitoring.

1.(a) RN will complete a comprehensive nursing assessment  related to resident # 1's short term changes including behaviors, new medications and unresponsive episode which resulted in hospital visit.  RN will determine and document the resident specific action or interventions that are needed to address the resident's changes. Ongoing weekly RN monitoring will be completed to evaluate the effectiveness of current interventions for goal to support the resident until back at baseline, or a new baseline is established.

(b) RN will complete a comprehensive nursing assessment related to resident # 2's short term changes including fall, rashes, pain in mouth, new medications and medications changes. The RN will determine and document the resident specific action or interventions that are needed to address the resident's changes. Ongoing weekly RN monitoring will be completed to evaluate the effectiveness of current interventions for goal to support the resident until back at baseline, or new baseline is established.

2. Staff will receive in-servicing specific to monitoring for short term change of condition, significant of condition and appropriate documentation related to the change and when to notify the nurse.

Staff will be provided training for short term monitoring / communication system for any resident identified to have a  change of condition such as UTI, missed medication, return from the hospital, or fall for an example. When a change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician. The staff will be aware of what to report to the nurse / physician per the temporary care plan (TCP) that has been put in place, which correlates with the resident change of condition. The TCP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TCP.

Staff should monitor resident status until resident condition resolves and they are back to their baseline.

24-hour book / process will be reviewed daily as a means of identification of potential change that needs to be assessed by the RN.

3.The system will be reviewed daily, weekly, monthly and quarterly to ensure compliance is maintained.

4.The Administrator/designee and Licensed Nurse will be responsible to ensure the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in December 2020 with diagnoses which included dementia.

Residents 1's physician's orders and 01/01/22 through 02/07/22 MARs were reviewed.

Resident 1 had physician's orders for Losartan 50 mg twice daily, taking blood pressure prior to administration and reporting blood pressure outside defined parameters.

Resident 1's blood pressure was outside the defined parameters three times in January 2022. There was no documented evidence the prescriber had been informed.

2. Resident 2 was admitted in May 2020 with diagnoses including multiple sclerosis.

Residents 2's physician's orders and 01/01/22 through 02/07/22 MARs were reviewed.

Resident 2's January and February MARs included:

*Milk of Magnesia oral suspension 30 cc on the fourth day of no bowel movement; and

* Nicotine Polacrilex Gum one piece 4 times daily as needed for smoking cessation.

There were no signed orders for the medications.

Neither of the PRN medications had been used in 2022.

The need for signed physicians' orders for all medications the facility was responsible to administer and following orders was reviewed with Staff 1 (Administrator). She acknowledged the findings.

C 303 OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders.

1.  A comprehensive MAR review will be completed to enure all current medication & treatment orders are accurate and being carried out as prescribed, including parameters, notification for parameters and current signed physicians orders will be in place for resident # 1 & 2, as well as the remaining residents in community

2. Staff training will be provided regarding medication and treatment instructions and the need to follow all parameters including notification if outside of written parameters.

3. The area needing correcting will be reviewed on a weekly basis per MAR audit. All orders will be reconcilled quarterly prior to physician orders sent for MD review.

4. The Licensed Nurse, administrator or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs included resident specific parameters and instructions for PRN medications, for 1 of 1 sampled resident (#1) whose MARs included multiple PRN medications used to treat the same condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in December 2020 with diagnoses which included dementia.

Residents 1's physician's orders and 01/01/22 through 02/07/22 MARs were reviewed.

Resident 1 had orders for:

*Senna 8.6 mg 1 tablet every night as needed for constipation;

*Milk of Magnesia give 30 cc by mouth on 3rd day of no bowel movement; and

*Bisacodyl 10 mg suppository as needed for constipation.

There were no resident specific parameters and instructions for which PRN medication to use first.

The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator). She acknowledged the findings.

C 310 OAR 411-054-0055 (2) Systems: Medication administration

1. Resident # 1 medication and treatment records will be updated to reflect PRN medications / treatment orders with clear resident specific parameters, and order of administration with clear directions / instructions for staff to follow.

2. All resident medications and treatments records will

be audited to ensure clear resident specific

parameters, and order of administration

with clear directions / instructions for staff to follow.

3. The system will be reviewed with all new resident

prescribed orders. Training with medication technicians

will be provided for who to alert when new precribed medications or treatment orders lack PRN order of administration or resident specific parameters. Additionally, a quarterly medication reconillation will be completed for each resident to ensure PRN medications and treatments have clear resident specific parameters, order of administration with clear directions and instructions for staff to follow.

4. The Administrator and/ or designee and Licensed

Nurse will be responsible to ensure the system is corrected and monitored.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to providing services to residents for 2 of 2 newly hired staff (#s 8 and 9) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 05/09/22.

Staff 8 (Universal Worker), hired 04/01/22, and Staff 9 (Universal Worker/MT), hired 04/27/22, lacked documented evidence of having completed pre-service dementia training prior to beginning job responsibilities.

Staff 8 lacked documented evidence of completing pre-service orientation prior to beginning job responsibilities.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Administrator) on 05/09/22. She acknowledged the findings.

C 370

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

1.Staff # 8 completed preservice dementia training 5/20/22, preservice orientation in progress, staff member is off the schedule until completed. Staff # 9 completed preservice dementia training 5/22/22. An audit of training records will be conducted, any staff lacking preservice dementia training or preservice orientation will be removed from the schedule and required to complete training before being placed back on the schedule .

2. To ensure the system is corrected and staff remain in compliance with all training requirements, the administrator will be provided additional training on all staffing requirements including preservice, initial orientation, 30 day, 60 day and 90 day training as well as tracking of requirements to ensure compliance. At time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program.

3. Staff training records be evaluated on a monthly basis through administrative audit.

4. The Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired caregiving staff (#s 4 and 5) were trained in First Aid within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 02/08/22.

There was no documented evidence Staff 4, hired 11/04/21, and Staff 5, hired 11/17/21, had been trained in First Aid by a certified trainer.

The need to ensure staff had been trained in First Aid by a certified trainer within 30 days of hire was reviewed with Staff 1 (Administrator). She acknowledged the findings.  

C 372 OAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff

1. An audit of staff training records will be completed, any staff without the required training in First Aid will be provided the training.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program as well as given options for first aid training by Licensed nurse certified in first aid, scheduled in person or on line training programs.

3. Staff training records will need to be evaluated on a weekly basis for new hires and monthly basis ongoing after completing required new hire training.

4. Administrator and/or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 caregiving staff (# 8) demonstrated satisfactory performance in all required areas within 30 days of hire and was trained in First Aid and abdominal thrust. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 05/09/22.

There was no documented evidence Staff 8 (Universal Worker), hired  04/01/22, had demonstrated competency in all required areas within 30 days of hire including:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation.

There was no documented evidence Staff 8 had been trained in First Aid and abdominal thrust.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and were trained in First Aid and abdominal thrust was reviewed with Staff 1 (Administrator) on 05/09/22. She acknowledged the findings.  

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

1. Staff # 8 and any current staff members lacking First Aid and abdominal thrust will be trained by a certified RN on First Aid and abdominal thrust on 5/25/22.

2. To ensure the system is corrected and staff remain in compliance for First Aid and abdominal thrust, the administrator will be provided additional training on all staffing requirements within 30 days of hire and tracking of requirements to ensure compliance

3. Staff training records will be evaluated on a monthly basis through administrative audit.

4. The Administrator or designee will be responsible to see that the corrections are completed and monitored.   

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

Refer to C372.

C455

Inspections and Investigtion: Insp Interval

Refer to C370 and C372